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Pharm N895 > Asthma > Flashcards

Asthma Flashcards

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1
Q

Asthma Triggers

A
  • Environment
  • Respiratory infection
  • Allergens
  • Emotions
  • Exercise
  • Drugs/preservatives
  • Occupational stimuli
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2
Q

What are the most important asthma triggers?

A

Environmental:

Cold air, fog, ozone, sulfur dioxide, nitrogen dioxide, tobacco smoke, wood smoke

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3
Q

Define Asthma

A

Widespread, reversible narrowing of bronchial airways w/marked increase in bronchial responsiveness to inhaled stimuli

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4
Q

Asthma: pathophysiology of bronchoconstriction

A
  • Irritant stimulates vagal nerve pathways –> postganglionic fibers release acetylcholine at muscarinic receptors on bronchial smooth muscle cells –> BRONCHOCONSTRICTION
  • Irritant also stimulates release of chemical mediators from mast cells in lungs –> BRONCHOCONSTRICTION
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5
Q

Diagnostic criteria: asthma

A
  • Detailed med Hx
  • PE
  • Spirometry (age ranges, but typically FEV1/FVC <70% is a problem)
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6
Q

Components of severity classification: asthma

A
  • Frequency of symptoms
  • Nighttime awakening
  • Days/wk SABA used for Sx control
  • Interference w/normal activity

*use the highest classification

Intermittent or Persistent (mild, moderate, severe)

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7
Q

Asthma treatment goals

A

Reduce impairment: prevent chronic & troublesome Sx; prevent frequent use of rescue meds, 2+/week; maintain near normal pulmonary function & normal activity

Reduce Risk: prevent hosp, prevent loss lung fx, provide optimal pharm w/minimal AEs

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8
Q

Asthma medications

A

SHORT ACTING B2 AGONISTS

LONG ACTING B2 AGONISTS

INHALED CORTICOSTEROIDS

LEUKOTRIENE INHIBITORS

CROMOLYN (INTAL®)

METHYLXANTHINES

IMMUNOMODULATORS

ORAL CORTICOSTEROIDS (OCSs)

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9
Q

Most effective long-term control medication

A

Inhaled corticosteroids: reduces impairment and risk of exacerbations

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10
Q

B2 Receptor Agonists, Short Acting (SABAs): agents

A
  • Albuterol (ProAir, Proventil)
  • Levalbuterol (Xopenex)
  • Pirbuterol (Maxair)
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11
Q

B2 Receptor Agonists, Short Acting (SABAs): MOA

A

selectively activate β-2 adrenergic receptors in the smooth muscles of the lungs, promoting bronchoconstriction

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12
Q

B2 Receptor Agonists, Short Acting (SABAs)​: indications

A

Indications: acute bronchospasm (“rescue inhaler”) and prevention of exercise-induced asthma

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13
Q

B2 Receptor Agonists, Short Acting (SABAs) and long acting (LABAs): ADRs

A

inhalation –> minimal systemic effects; tremors/shakiness

-oral –> possibility of activated β-1 receptors with high dose –> tachycardia; angina; tremors

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14
Q

significance of albuterol and levalbuterol as enantiomers

A

enantiomers are chemical mirror images; theoretically, levalbuterol may have a lower risk of bronchial hyperresponsiveness because it does not contain the S-isomer; however albuterol is still more frequently rx’ed due to the availability of a generic

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15
Q

Albuterol (ProAir, Proventil): onset & duration

A

Onset: ~10min, duration 3-4h

(SABA)

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16
Q

Albuterol (ProAir, Proventil): formulations

A

MDI, Neb

(SABA)

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17
Q

Albuterol (ProAir, Proventil): available generic?

A

Available generic, least $

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18
Q

SABA w/most and least clinical evidence

A

Most: Albuterol (ProAir, Proventil)

Least: Pirbuterol (Maxair) - least B2 potency

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19
Q

Levalbuterol (Xopenex): onset & duration

A

Onset: ~10min, duration 3-4h

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20
Q

Levalbuterol (Xopenex)​: formulations

A

MDI, Neb

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21
Q

Levalbuterol (Xopenex): available generic?

A

no

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22
Q

Pirbuterol (Maxair): onset & duration

A

Onset: ~30min, duration 5h

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23
Q

Pirbuterol (Maxair): formulations

A

MDI

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24
Q

Pirbuterol (Maxair): available generic?

A

no!

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25
LONG-ACTING BETA-2 RECEPTOR AGONISTS (LABAs): agents
Salmeterol (Serevent) Formoterol (Foradil)
26
LABAs: indication
indicated for long term control of asthma; preferred adjunctive therapy ***in combination* with ICS**
27
LABAs: BBW
LABA use alone can increase the risk of asthma-related death!; should ALWAYS be combined with an ICS
28
Salmeterol (Serevent): onset/peak, duration
up to 2h, Duration: 12h
29
Best clinical evidence for LABAs
Salmeterol (Serevent)
30
Salmeterol (Serevent): generic available?
Yes!
31
Formoterol (Foradil): onset/peak & duration
Onset/Peak: up to 2h, Duration: 12h
32
Formoterol (Foradil)​: formulations
Aerosol powder for inhalation
33
Formoterol (Foradil)​: generic available?
no
34
inhaled corticosteroids: agents
- beclomethasone dipropionate - fluticasone - mometasone furoate Advair®, Symbicort® and Dulera® are combination corticosteroid + β-2 adrenergic agonist formulas -SONE
35
inhaled corticosteroids: MOA
direct local anti-inflammatory activity; reduce airway hyperresponsivenes; inhibit inflammatory cell migration and activation ## Footnote
36
Inhaled/Oral corticosterois: ADRs
* inhalation --\> oral candidiasis (use spacer and gargle afterwards); dysphonia * intranasal --\> drying; itching; sore throat; epistaxis * systemic effects --\> cataracts; glaucoma; hyperglycemia; PUD (oral only); bone loss; adrenal suppression * slowed growth in children and adolescents
37
ICS: considerations for effectiveness
* Consider lung delivery % if delivery to site of action is an issue (think pediatric pts.) --\> beclomethasone and flunisolide have highest lung delivery %
38
ICS: Special administration instructions
* Oral rinse with water after use * Onset of improvement within 1 week of initiation --\> tell pt. not to d/c after a few days of use
39
ICS: concerns w/systemic availability
* Systemic adverse effects * ?Decreased growth velocity
40
ICS: monitoring parameters?
growth velocity in pediatrics – may ↓ GV if systemic absorption
41
LEUKOTRIENE INHIBITORS: MOA
interfere with the production of chemical mediators by eosinophils and mast cells --\> ↓ plasma exudation, mucus secretion, bronchoconstriction and eosinophil recruitment
42
LEUKOTRIENE INHIBITORS: Indications
Indications: moderate to severe persistent asthma;
43
LEUKOTRIENE INHIBITORS: recommendations - when and with what
recommended in combination with high-dose ICS + LABA; \*\*considered prior to initiation of chronic corticosteroid therapy
44
LEUKOTRIENE INHIBITORS: agents
Leukotriene Receptor Antagonist: * Montelukast (Singulair®) Leukotriene Receptor Antagonist: * Zafirlukast (Accolate®) 5-Lipooxygenase Inhibitor: * Zilueton (Zyflo CR®)
45
Montelukast (Singulair®): dosing
4-10 mg PO QHS Leukotriene Receptor Antagonist:
46
Montelukast (Singulair®): ADRs
\*H/A (up to 25%) Leukotriene Receptor Antagonist
47
Zafirlukast (Accolate®): dosing
10-20 mg PO BID Leukotriene Receptor Antagonist
48
Zafirlukast (Accolate®): ADRs
transaminitis Leukotriene Receptor Antagonist
49
Zafirlukast (Accolate®): C/Is
Hepatic impairment Leukotriene Receptor Antagonist
50
Zilueton (Zyflo CR®): dosing
1200 mg PO BID 5-Lipooxygenase Inhibitor
51
Zilueton (Zyflo CR®): ADRs
transaminitis 5-Lipooxygenase Inhibitor
52
Zilueton (Zyflo CR®): C/Is
C/I: Hepatic impairment also $$$ 5-Lipooxygenase Inhibitor:
53
CROMOLYN (INTAL®): indication
alternative agent for mild persistent asthma --\> effective in providing symptom control for exercise induced bronchospasm (EIB); inferior to ICS in improving outcomes
54
CROMOLYN (INTAL®): dosing & formulations
MDI or nebulizer; 20 mg inhalation up to 4 times daily
55
CROMOLYN (INTAL®): MOA
MOA: mast cell stabilizer ## Footnote
56
CROMOLYN (INTAL®): Onset of response to therapy
2 to 6 weeks
57
CROMOLYN (INTAL®): ADRs
Good tolerability and safety profile
58
METHYLXANTHINES: Agents
only theophylline (Elixophyllin ®)
59
METHYLXANTHINES: Indications
alternative step up therapy for mild persistent asthma or as adjunctive therapy with ICS
60
theophylline (Elixophyllin ®):​ dosing
\*\*narrow TI drug, with goal serum concentration of 5-15 mcg/mL (30 min after loading dose) * Initial loading dose generally required * Time to peak serum concentration 1-2 h for PO, within 30 min for IV METHYLXANTHINE
61
theophylline (Elixophyllin ®): Dosage forms
ER tablet (Theo-Dur®), capsule (Theo-24®), oral solution, IV solution METHYLXANTHINE
62
theophylline (Elixophyllin ®): MOA
* Bronchodilation*: non-selective phosphodiesterase (PDE) inhibitors --\> ↑ cAMP and cGMP concentrations * Anti-inflammatory*: activation of histone deacetylase --\> ↓ proinflammatory gene expression METHYLXANTHINE
63
Factors that ↓ theophylline clearance
cimetidine; macrolides; quinolones; systemic viral illness; zileuton; propranolol METHYLXANTHINE
64
Factors that ↑ theophylline clearance:
\*phenytoin; rifampin; carbamazepine; smoking; phenobarbital; high protein diet METHYLXANTHINE
65
theophylline (Elixophyllin ®): ADRs
Dose-related adverse effects: tachycardia; H/A; hypotension; N/V; hematemesis; hyperglycemia; hyperkalemia; seizures
66
IMMUNOMODULATORS: agents
only omalizumab (Xolair ®)
67
omalizumab (Xolair ®): indications
alternative agent for patients with sensitivity to relevant allergens in severe persistent asthma IMMUNOMODULATOR
68
omalizumab (Xolair ®): dosing and administration
solution for subcutaneous injection [$1000 per dose]; dosing based on pre-tx IgE levels and body weight; 150-300 mg Q4 weeks; must be adjusted if significant weight change IMMUNOMODULATOR
69
omalizumab (Xolair ®): pathophysiology
IgG monoclonal antibody that inhibits IgE receptor binding on mast cells and basophils; long-term use shows ↓ exacerbations and corticosteroid use IMMUNOMODULATOR
70
omalizumab (Xolair ®): ADRs
anaphylaxis reported in \< 0.2% patients; injection site RXNs IMMUNOMODULATOR
71
ORAL CORTICOSTEROIDS (OCSs): Indications
last resort!; short course (up to 2 weeks) indicated for pts. w/ poor asthma control; reduces sx duration, prevents hospitalizations and ↓ likelihood of relapse post-exacerbation
72
Metered Dose Inhalers (MDI): how to use
* Shake the inhaler well before use; remove cap * Exhale away from inhaler * Bring the inhaler to your mouth. * Place it in your mouth between your teeth and close you mouth around it. * Start to breathe in **slowly**. * Press the top of you inhaler once and keep breathing in slowly until you have taken a full breath. * Remove the inhaler from your mouth, and hold your breath for about 10 seconds, then breathe out.
73
Diskus (Dry powder inhaler): how to use
* Hold Diskus in palm of hand (sandwich) * Push thumb grip until it clicks into place * Slide lever away from you * Place it in your mouth between your teeth and close you mouth around it. * Start to breathe in **deeply and rapidly**. * Remove the inhaler from your mouth, and hold your breath for about 10 seconds, then breathe out. * Always check the number in the dose counter window to see how many doses are left
74
Twisthaler (Dry powder inhaler): how to use
* Twist white cap counter clockwise * Exhale away from Twisthaler * Hold horizontally * Place it in your mouth between your teeth and close you mouth around it. * Start to breathe in **deeply and rapidly**. * Remove the inhaler from your mouth, and hold your breath for about 10 seconds, then breathe out. * Replace cap and twist clockwise. * Make sure it clicks to completely close it. * Rinse mouth and gargle
75
Spacers: benefit
* Enhanced drug delivery, highly recommended with ICS for pediatrics * Canister holds drug in place. Can inhale at own pace – good for pedi who may not have high lung capacity
76
Asthma: Step-Up Pharmacotherapy for Well Controlled
Well controlled * Frequent follow up (1 – 6 month intervals)
77
Asthma: Step-Up Pharmacotherapy for Not well controlled ## Footnote
Step up 1 step and re-evaluate (2 – 6 weeks)
78
Asthma: Step-Up Pharmacotherapy for Poorly controlled ## Footnote
Step up 1 or 2 steps and re-evaluate Consider short course of oral corticosteroids
79
How does pregnancy affect asthma?
* Worsens in one-third of pregnant females
80
Asthma and pregnancy: preferred rescue agent
Albuterol: Preferred rescue agent
81
Asthma and pregnancy: preferred maintenance agent
Budesonide: Preferred maintenance agent
82
Asthma and pregnancy: agents to avoid
Long-acting beta agonists Omalizumab Zileuton

Pharm N895 (13 decks)

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