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Asthma Flashcards

1
Q

Classification of asthma

A
  1. Intermittent - < 2 days a week, not everyday. Lung function tests normal
  2. Mild persistent- > 2 days a week, not everyday. Lung function tests normal when person is not having an attack
  3. Moderate persistent- symptoms daily. Need to use short acting inhaler every day. Lung function tests abnormal
  4. Severe persistent- symptoms throughout each day. Severely limits daily activities. Lung function tests abnormal
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2
Q

Phases of asthma

A

Acute phase - excessive secretion of mucus that may clog the bronchi and bronchioles

Chronic phase - inflammation, followed by fibrosis, edema and necrosis of bronchial epithelial cells

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3
Q

Status asthmatic/refractory asthma?

A

Acute exacerbation of severe asthma that does not respond to standard treatments of bronchodilators

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4
Q

Risk factors and triggers

A

Stress
obesity
Drugs ( b blockers, aspirin)
Acetaminophen ( paracetamol)

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5
Q

Diagnosis of asthma

A

Spirometry - reduced Fev1, fev1/fvc ratio, and PEF

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6
Q

What is produced on initial exposure to allergens

A

IgE by plasma cells

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7
Q

IgE binds to what receptors?

A

High affinity receptors (FCeR-1) on mast cells

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8
Q

Re- exposure to allergens releases?

A

Mediators stored in mast cells. The histamine , tryptase, leukotrienes C4 and D4 and prostaglandin D2.

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9
Q

The mediators released cause?

A

Smooth muscle contraction and vascular leakage causing bronchoconstriction. EARLY ASTHMATIC RESPONSE

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10
Q

Late asthmatic response is mediated by?

A

TH2 cells (T lymphocytes)

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11
Q

What does TH2 cells secrete?

A

Interleukins (IL) 4,5 & 13, GM-CSF

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12
Q

What does the IL secreted by TH2 cells do?

A
  1. These cytokines attract and activate eosinophils.
  2. Stimulate IgE production by B lymphocytes
  3. Stimulate mucus production by bronchial epithelial cells
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13
Q

Early vs late response summary

A

EARLY
1. mast cell degranulation mediated by IgE.
2. Smooth muscle spasms, vasodilation

LATE
1. Initiated by cytokines produced by TH2 lymphocytes
2. Mucosal edema, mucosal secretion (by bronchial epithelial cells), more IgE production, activation of eosinophils

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14
Q

Treatment of asthma

MOA of Bronchodilators vs Controllers

A

Bronchodilators- relaxation of airway smooth muscle

Controllers- inhibit underlying inflammatory process

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15
Q

Classes of bronchodilators and examples

A
  1. Selective B2 agonists - Salbutamol, Salmeterol, Formoterol terbutaline, Bambuterol
  2. Non- selective sympathomimetics - epinephrine, ephedrine, isoprenaline, orciprenaline
  3. Anticholinergics / muscarinic antagonists - ipratropium bromide, tiotropium bromide
  4. Methylxanthines - theophylline, aminophylline, diprophylline
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16
Q

Mechanism of action of bronchodilators

SYMPATHOMIMETICS

A

Act on B2 adrenergic receptors of bronchial smooth muscles

Increase cAMP, causing bronchodilation

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17
Q

Mechanism of action of bronchodilators

METHYLXANTHINES

A

Decrease cAMP destruction.

By inhibiting Phosphodiesterases, causing bronchodilation

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18
Q

Mechanism of action of bronchodilators

MUSCARINIC RECEPTOR ANTAGONIST OR ANTICHOLINERGICS

A

Competitive antagonist of acetylcholine (ACH) at postganglionic nerve receptors, leading to smooth muscle relaxation and bronchodilation

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19
Q

B1 receptors found?

A

Cardiac and intestinal smooth muscles

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20
Q

B2 receptors found?

A

Bronchial, uterine and vascular smooth muscles Increase cAMP

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21
Q

B- adrenergic receptors action

A

Acts on b2 receptor (a G protein coupled receptor) > activates adenylyl cyclase > increase cAMP destruction > activates pkA > bronchodilation

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22
Q

Short acting b2 agonists (SABA) and function

A

Salbutamol
Terbutaline

For quick reversal of bronchospasm
(bronchodilation)

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23
Q

Long acting b2 agonists (LABA) and function

A

Salmeterol
Formeterol

Not used for treating acute attacks

Used for treating nocturnal attacks

Preventing asthma attacks along with steroids

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24
Q

Adverse effects of selective b2 agonists

A

Muscle tremor and palpitations

Mild hypokalemia

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25
The Non-selective sympathomimetics ?
Epinephrine Ephedrine Isoproterenol Isoprenaline Orciprenaline
26
Side effects of non-selective sympathomimetics
Muscle tremor Tachycardia Palpitations Hypokalemia Restlessness
27
MOA of anticholinergics / antimuscarinic agents
Binds M3 receptors on airway smooth muscles, preventing the action of acetylcholine released from parasympathetic nerve - bronchodilation Does not cross BBB - devoid of CNS side effects
28
Side effects of anticholinergics/ antimuscarinics
Dryness of mouth GI distress
29
Use of anticholinergics/ antimuscarinics
DOC for bronchospasm caused by beta blockers BRONCHODILATOR OF CHOICE in COPD
30
What are the short and long acting anticholinergic
Short-acting - Ipratropium Long-acting - Tiotropium
31
The Methylxanthines?
Theophylline Aminophylline Diprophylline (DAT)
32
MOA of Methylxanthines
1. Inhibits Phosphodiesterase enzyme (PDE-III & IV) > elevating camp concentration leading to bronchodilation 2. Blocking adenosine receptors > inhibiting bronchoconstriction (Adenosine constricts bronchus smooth muscles via adenosine receptors) Methylxanthines are NOT given to pt. with supraventricular tachycardia
33
Side effects of methylxanthines and plasma level
Plasma level > 20ug/mg - CNS stimulant effects Plasma level > 40ug/mg - Tremors followed by seizures, agitation, arrhythmias Side effects - Common: vomiting, headaches, nausea, diuresis, palpitations High doses: arrhythmia, seizures & death
34
Methylxanthines drug interactions
CYP450 enzyme INDUCERS - rifampicin, phenytoin. Decreases theophylline CYP450 enzyme INHIBITORS - cimetidine, ciprofloxacin. Increases plasma levels and prolongs half-life of theophylline
35
What are the controller therapies and use?
1. Corticosteroids (inhalation and systematic) 2. Mast cell stabilizers 3. Leukotriene antagonists 4. Monoclonal IgE antibody Use - INHIBIT the underlying INFLAMMATORY process
36
Names of Corticosteroid Drugs and their route of use
Oral - Prednisolone, Prednisone, Methylprednisolone Parenteral - Methylprednisolone, Hydrocortisone Inhalation - Beclomethasone, Fluticasone, Triamcinolone, Budesonide
37
MOA of Corticosteroids
‘CONTROLLERS’ - provide long-term stabilization of symptoms due to their anti-inflammatory effects Enhances the effectiveness of b2 receptors on the airway INHIBITS THE RELEASE OF INFLAMMATORY MEDIATORS - prevents smooth muscle contraction, vascular permeability and airway mucus secretion INHIBITS THE FORMATION AND RELEASE OF CYTOKINES thus prevents proliferation and activation of leukocytes
38
ICSs Use
Most effective controllers Least absorbed into systemic circulation ICS along with b2 agonist - FIRST CHOICE of drug for CHRONIC ASTHMA
39
Side effects of ICSs
Dryness of mouth Voice changes ORAL CANDIDIASIS or THRUSH
40
Systemic corticosteroids
Prednisone, methylprednisolone, hydrocortisone
41
Use of systemic corticosteroids
Reserved for patients who require urgent treatment (SEVERE CHRONIC ASTHMA, STATUS ASTHMATICUS)
42
Side effects of systemic corticosteroids
Truncal obesity Bruising Osteoporosis Diabetes Hypertension Gastric ulceration Cataracts Adrenal insufficiency Cushing syndrome
43
Mast cell stabilizers
Sodium cromoglycate, Nedocromil
44
Use of Mast cell stabilizers
Not bronchodilators, non-steroidal drugs Used for PROPHYLACTIC TREATMENT of bronchial asthma Prevention the degranulation and release of chemical mediators from mast cells Used solely for PROPHYLAXIS. NOT for acute asthma attacks To prevent bronchospasm associated with exposure to known precipitating factors, such as cold, dry air or allergens
45
Side effects of Mast cell stabilizers
Throat irritation Dryness of mouth Headache
46
Moa of leukotriene
Mediators of inflammation - causes bronchoconstriction and mucus production
47
Effects of leukotriene can be prevented by? And med?
1. Inhibiting leukotriene synthesis By inhibiting the 5-lipooxygenase enzyme - ZILEUTON 2. By blocking their stimulatory effects on Cys-LT receptors - ZAFIRLUKAST, MONTELUKAST
48
Uses of leukotriene antagonists
As an adjuvant with ICS in poorly responding patients Prophylaxis and treatment of chronic asthma Used for prophylaxis of mild to moderate asthma in children NOT meant for the management of acute asthmatic attacks
49
Moa and adverse effects of leukotriene antagonists
ZILEUTON - CONTRAINDICATED in liver disease - Hepatotoxicity ZAFIRLUKAST - FOOD DECREASES BIOAVAILABILITY - administer 2 hours before meals (12hrs interval) Adverse effects- git distress & headache MONTELUKAST - Administer once daily Bioavailability is not affected by meals
50
Monoclonal anti-IgE antibody?
Omalizumab
51
Moa of Monoclonal anti-IgE antibody
Recombinant human monoclonal antibody which inhibits the binding of IgE to mast cells and basophils Inhibits the activation of IgE that is already bound to mast cells and prevents its degranulation
52
Management of Chronic Asthma
Mild intermittent - short-acting b2 agonist as required for symptom relief Mild persistent - short-acting b2 agonist as required for symptom relief + Low dose ICS Moderate persistent - short-acting b2 agonist as required for symptom relief + Low dose ICS + LABA Severe persistent - short-acting b2 agonist as required for symptom relief + High dose ICS + LABA Very Severe persistent - short-acting b2 agonist as required for symptom relief + High dose ICS + LABA + OCS
53
Treatment of Acute Severe Asthma
A high conc. of OXYGEN, given by face mask to achieve oxygen saturation of >90% The mainstay of treatment are HIGH DOSES of SABA
54
Treatment of Acute Severe Asthma in severely ill pt. with impending respiratory failure
IV B2 agonist may be given A NEBULIZED ANTICHOLINERGIC MAY BE ADDED if there is not a satisfactory response to b2 agonist alone
55
Treatment of Acute Severe Asthma for pt. with respiratory failure
INTUBATE and INSTITUTE VENTILATION
56
Treatment of Acute Severe Asthma in severely ill pt. with chest infection
Treated with intensive antibiotic therapy Correct dehydration and acidosis
57
CHRONIC BRONCHITIS
Chronic productive cough and excessive sputum Enlargement of mucus glands Increase in mucus production Thickening of the bronchial wall Dyspnoea, bronchospasm and respiratory tract infections
58
Complications of CHRONIC BRONCHITIS
Pt. suffers from RT-sided heart failure (corpulmonale: pulmonary hypertension, RT Ventricular hypertrophy, RT Heart failure)
59
EMPHYSEMA
Enlargement of air spaces Destruction of lung parenchyma Loss of elasticity and closure of small airways
60
Management of COPD
COPD - Irreversible dz.l, drugs only relieve the symptoms without treating underlying pathophysiology
61
Management of COPD Aims of the treatment
To lessen the airflow obstruction Reduce respiratory symptoms and improve quality of life Prevent secondary complications like hypoxaemia, infections and corpulmonale
62
Treatment of COPD
Stop smoking FIRST LINE DRUG THERAPY - BRONCHODILATORS - to reduce bronchospasm and wheezing Methylxanthines - to improve respiratory muscle functions Corticosteroids O2 therapy

Pharmacology (8 decks)

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