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Flashcards in Asthma Deck (104):
1

Define Asthma.

  • Chronic inflammatory disorder of the airways characterized by variable and reversible airflow obstruction due to bronchial hyper-responsiveness
  • Characterized by paroxysmal or persistent symptoms such as dyspnea, chest tightness, wheezing, sputum production and cough

2

What are the 2 key defining features of asthma? (GINA)

  1. A history of respiratory symptoms such as wheeze, shortness of breath, chest tightness and cough that vary over time and in intensity AND
  2. Variable expiratory airflow limitation

3

What % of the population has asthma?

  • ~7%
    • May develop at any age, although less common as get older

4

What is a differential diagnosis (15) for a cough?

  • Upper Airway Disorders
    • Foreign-body aspiration
    • Tracheomalacia
    • Angioedema and anaphylaxis
    • Vocal cord paralysis
    • Laryngotracheal mass
  • Lower Airway Disorders
    • Asthma
    • Bronchiolitis
    • COPD
    • Bronchiectasis
    • Cystic fibrosis
    • Pneumonia
  • Other (often cough predominant)
    • CHF
    • GERD
    • PE – consider CT if not improving on treatment
    • Churg-Strauss syndrome

5

What is the classic triad on history for asthma?

  • Episodic dyspnea
  • Cough
  • Wheezing

6

At what age can children reliably cough up sputum?

  • +9 years old

7

What are 5 important symptoms to ask about in a patient presenting with asthma?

  • Wheezing – high-pitched whistle sound
    • Cough variant asthma do not wheeze
    • If poor air entry, then cannot wheeze (Status Asthmaticus)
  • Cough worse at night
    • May be only symptom
    • Before age 9 cannot reliably cough up sputum
  • Dyspnea – stops from participating in activities that peers can do
    • Subjective SOB does not correlate with the FEV1 or severity of disease
  • Chest tightness, heavy – rarely sharp
  • Rhinosinusitis 80% associated
    • Treating PND helps with asthma

8

What are 7 potential asthma triggers? (GINA)

  • Exercise
  • Cold air
  • Viral URIs – fever
  • Domestic and Occupational Allergens
    • House dust mite
    • Pollens
    • Cockroach
  • Smoking and 2nd hand smoke
  • Stress
  • Drugs
    • Beta-blockers
    • ASA
    • NSAIDs

9

What is commonly seen in patients with aspirin-exacerbated respiratory disease? (GINA)

  • Severe asthma
  • Nasal polyposis

10

What is important to ask on family history in a patient presenting with asthma?

  • History of Atopy
    • Eczema
    • Asthma

11

What is important to ask an asthma patient about regarding their asthma control?

  • Prior ER visits
  • Doses of prednisone per year
  • ICU admission

12

What are 9 criteria to measure asthma control? (CTS)

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13

Which age group has the highest rate of emergency department visits and hospital admissions for asthma symptoms? (CTS)

  • Preschoolers (1-5 years)

14

In which preschool (1-5 years) children should the diagnosis of asthma be considered? (CTS)

  • Frequent (≥8 days/month) asthma-like symptoms OR
  • Recurrent (≥2) exacerbations (episodes with asthma-like signs)

15

What is required for the diagnosis of asthma in preschoolers? (CTS)

  • Objective documentations of signs (or convincingly reported symptoms) of airflow obstruction
    • Personal atopy (e.g. eczema, food allergy) or family history of asthma increase suspicion but are not necessary for diagnosis
  • Reversibility of airflow obstruction
    • Documented response to SABA (with or without OCS) by health care professionals during an acute exacerbation
    • In children with NO objective signs of airflow obstruction (i.e. only symptoms) then can be determined by either:
      • 3-month therapeutic trial of medium dose inhaled corticosteroids (200 ug to 250 ug) with SABA prn OR SABA prn
  • Absence of an alternative diagnosis
    • Recurrent URTIs with postnasal drip
    • Croup
    • Bronchiolitis (1st episode usually <1 year of age)

16

What is the preferred diagnostic method for asthma in preschoolers? (CTS)

  • Recurrent (≥2) episodes of asthma-like symptoms AND WHEEZING ON PRESENTATION
  • Direct observation of improvement with inhaled bronchodilator (with or without OCS) by a physician or trained health care practitioner confirms the diagnosis

17

Why is a minimum 3-month trial of moderate dose ICS suggested to diagnose asthma in preschoolers? (CTS)

  • Onset of action within 1-4 weeks
  • Efficacy within 3-6 months

18

Which ICS is recommended for preschoolers with suspected asthma and why? (CTS)

  • Fluticasone
    • Studied most effectively along with budesonide
    • Budesonide only available for use by nebulization in Canada in children
    • MDI preferred route
    • Fluticasone shows less effect on growth than budesonide at equivalent dose

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19

What should be monitored in preschoolers to assess response to a 3-month trial of ICS in suspected asthma? (CTS)

  • Asthma Diary
    • Daytime and nighttime symptoms
    • Rescue SABA use
    • Effort limitation
    • Absenteeism from usual activities
    • Exacerbations requiring unscheduled medical visits
    • Oral corticosteroids and/or hospital admission

20

What should be done for preschoolers in whom there is an unclear response to a trial of ICS for suspected asthma? (CTS)

  • Dechallenge – stopping therapy for a period of observation of 3-6 months or until recurrence of symptoms, whichever occurs first

21

What are 5 reasons to refer to an asthma specialist for consultation or comanagement in preschoolers? (CTS)

  • Diagnostic uncertainty or suspicion of comorbidity
  • Repeat (≥2) exacerbations requiring rescue OCS or hospitalization or frequent symptoms (≥8 days/month) despite moderate (200 ug to 250 ug) daily doses of ICS
  • Life-threatening event such as an admission to the ICU
  • Need for allergy testing to assess the possible role of environmental allergens
  • Other considerations (parental anxiety, need for reassurance, additional education)

22

What % of children with asthma become asymptomatic by the age of 6? (CTS)

  • 60%

23

What is the normal FEV1/FVC ratio in adults and children? (GINA)

  • Adults > 0.75-0.80
  • Children > 0.90

24

What is the gold standard for diagnosis of asthma?

  • PFTs – Reversible Obstruction
    • FEV1/FVC <0.8
    • >12% (and 200 mL improvement in adults) with bronchodilators

25

What are 3 methods to diagnose asthma? (CTS)

***GINA = average daily diurnal PEF variability is >10% (in children, >13%)

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26

Distinguish between bronchiolitis, croup and foreign body aspiration from asthma and how they would be managed?

  • Bronchiolitis
    • First episode of wheezing in contact of respiratory infection (RSV)
    • Treatment
      • Reassure, hydration, monitor respiratory status
      • SABA or Epinephrine if moderate symptoms
      • No antibiotics
      • Unless atopic child or recurrent, do NOT use prednisone
  • Croup
    • Upper respiratory wheezing – stridor
    • Parainfluenza virus
    • Febrile, non-toxic, barking cough
    • Treatment
      • Blow-by humidified oxygen, Dexamethasone
  • Foreign body aspiration
    • History of playing with small object
    • No atopy

27

In a patient with cough as the only respiratory symptom, what is the differential diagnosis? (GINA)

  • Cough variant asthma
  • Chronic upper airway cough syndrome (‘post-nasal drip’)
  • Chronic sinusitis
  • GERD
  • Vocal cord dysfunction
  • Eosinophilic bronchitis

28

What is the most frequent finding on physical examination in patients with asthma? (GINA)

  • Wheezing on auscultation (especially on forced expiration)

29

What is the recommended maintenance therapy and matching step-up therapy for preschoolers, children and adults (12 and over)?

  • Can try intermittent high dose (750 mg Flovent) for children with recurrent viral associated wheezing (if persistent, trial daily therapy)
    • Low-medium dose is not effective

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30

Name 11 potentially modifiable independent risk factors for asthma exacerbations? (GINA)

  • Uncontrolled asthma symptoms (e.g. daytime symptoms, night waking, reliever needed >2x/week, activity limitation)
  • ICS not prescribed; poor ICS adherence; incorrect inhaler technique
  • High SABA use (with increased mortality if >1x200-dose canister/month)
  • Low FEV1, especially <60% predicted
  • Major psychological or socioeconomic problems
  • Exposures: smoking, allergen exposure if sensitized
  • Comorbidities: obesity; rhinosinusitis; confirmed food allergy
  • Sputum or blood eosinophilia
  • Pregnancy
  • Ever being intubated or in ICU for asthma
  • Having 1 or more severe exacerbations in the last 12 months

31

Define an asthma flare-up or exacerbation and what terminology is preferred. (GINA)

  • An acute or sub-acute worsening in symptoms and lung function from the patient’s usual status
  • ‘Flare-up’ is preferred

32

How would acute management in the ER differ for mild, moderate, severe and near death asthma attacks and how would they present?

Assessment

 

Clinical

Treatment

Mild

-Exertional SOB/cough

-Nocturnal symptoms

-Increased SABA use with good response

- Speaks in sentences

 

  • FEV1 >60% predicted
  • PEF >300L/min
  • Oxygen
  • SABA
  • Consider steroids

Moderate

-SOB at rest

-Cough

-Partial relief from SABA

-SABA use >8x/day

-Chest tightness

-Speaks in phrases

 

  • FEV1 40-60% predicted
  • PEF 200-300L/min
  • Oxygen
  • SABA
  • Anticholinergics
  • Steroids

Severe

-Laboured breathing

-Difficulty speaking

-Agitated

-Diaphoretic, Tachycardic

-No relief from SABA

-Speaks in words

 

  • O2 sat <90%
  • FEV1 <40% predicted
  • PEF <200L/min
  • 100% O2
  • Continuous SABA
  • Anticholinergics
  • IV Steroids
  • IV 2g Magnesium sulfate as a last ditch
  • IV SABA
  • Telemetry, O2 sat, ABG, CXR
  • Consider BI-PAP, must be awake, monitor for barotrauma and hypotension
  • Consider Inubation
  • Consider IM Epi

Near Death

-Exhausted

-Confused

-Diaphoretic, cyanotic

-Failing heart rate

-Near death

-Can't speak

  • O2 sat <90%
  • FEV1 and PEFR not appropriate
  • Ventolin 4-8 puff or 2.5-5mg (0.15mg/kg/dose, min 2.5mg) in 3cc neb q20min x3
  • Atrovent 4-8 puffs or 250-500mcg (<2 years 125mcg/dose) in same neb q20min x3
    • Delayed effect. No benefit to greater than 3 treatments.
  • Prednisone 50mg or 1mg/kg x 3-10 days. First dose within the hour at the ER. No taper needed with doses less than 10 days

 

 

33

What steroid is best for the treatment of pediatric asthma exacerbations and why? (TFP)

  • 1-2 doses (2 days) dexamethasone 0.6 mg/kg (safe and effective, no difference in relapse rates as 5-day course of prednisone)
  • NNT = 20 for reduced vomiting compared to prednisone

34

What finding on examination would be most concerning for an asthma exacerbation and how should it be treated? (GINA)

  • Silent chest
    • Inhaled SABA
    • Inhaled Iptratropium bromide
    • Oxygen
    • Systemic corticosteroids

35

What criteria would allow a patient with asthma to be discharged home from the ER after an asthma attack?

  • Ventolin longer than q4h
  • Never had a prior ICU admission
    • Must be admitted regardless
  • No recurrent ER visits or admissions
  • PEF > 300, or >70%, never if less than 200 or 40%
  • Improvement on steroids
    • If not improvement by 6h, unlikely to occur
  • Nothing trumps clinical judgement
  • Use Ventolin q4h for 48h with aerochamber and steroids

36

What investigations would you consider performing in a patient with an asthma attack in the ER?

  • CXR if not improving, moderate to severe symptoms or comorbidities
  • Potassium – can get low with repeated dosing of Ventolin
  • PEF pre and post treatment

37

Why should regular daily controller treatment be initiated as soon as possible after the diagnosis of asthma is made? (GINA)

  • Early treatment with low dose ICS leads to better lung function than if symptoms have been present for more than 2-4 years
  • Patients not taking ICS who experience a severe exacerbation have lower long-term lung function than those who have started ICS

38

For which patients (3) is regular low dose ICS recommended? (GINA)

  • Asthma symptoms more than 2x per month
  • Waking due to asthma more than 1x per month
  • Any asthma symptoms plus any risk factor(s) for exacerbations (e.g. needing OCS for asthma within the last 12 months; low FEV1; ever in ICU for asthma)

39

What are 5 lifestyle management suggestions for the chronic management of asthma?

  • Reduce allergen exposure – animal dander, dust, pollen, mold, pollution
  • No smoking
  • ASA induced, nasal polyps and rhinosinusitis triad
    • Avoid NSAIDs – blocking PG synthesis shifts the pathway towards bronchoconstrictors
  • Immunizations – Flu and Pneumococcal
  • Inhaler technique

40

When would you consider stepping down asthma treatment and what is NOT advised? (GINA)

  • Symptoms controlled for 3 months + low risk for exacerbation
  • Ceasing ICS is NOT advised

41

How should ICS dose be stepped down when asthma is well controlled? (GINA)

  • Reduce ICS dose by 25-50% at 2-3 month intervals

42

Should LABAs be used as monotherapy for asthma in any age group? (CTS)

  • NO

43

If low-dose ICS is not adequate to maintain asthma control, what is the next step in children 6-11 years old and adults 12+ years? (CTS)

  • 6-11 – Increase to Medium-dose ICS
  • 12+ - Add a LABA to low-dose ICS

44

If medium-dose ICS is not adequate to maintain asthma control, what is the next step in children 6-11 years old? (CTS)

  • Addition of either a LABA or LTRA

45

If LABA+ICS is not adequate to maintain asthma control, what is the next step in adults 12+ years? (CTS)

  • Consider addition of LTRA
  • Consider referral to specialist

46

What is the recommended controller therapy by age? (CTS/DFCM)

 

6-11 years old

>12 years old

First-line

Low dose ICS

Low dose ICS

Second-line

Medium dose ICS

Low dose ICS + LABA

Third-line

Medium dose ICS + LABA

OR

Medium dose ICS + LTRA

Medium dose ICS + LABA

OR

Medium dose ICS + LABA + LTRA

47

What would management options be for asthma in patients < 6 years old?

  • Can only suspect diagnosis and confirm based on response to treatment
  • Same management as ages 6-11, but consider referral 1 step before
  • Use lowest effective dose

48

What would management options be for asthma in patients 6-11 years old?

  • Lifestyle management – decrease allergens, no humidifier, action plans
  • Intermittent asthma
    • SABA prn
      • QID standing with viral respiratory illness for 24h
  • Persistent daily asthma
    • Low dose ICS
      • Second line LTRA if allergic component
    • Medium dose ICS – consult if not controlled
    • Add LABA or LTRA
    • Prednisone

49

What would management options be for asthma in patients >12 years old?

  • Lifestyle management – decrease allergens, no humidifier, action plans
  • Intermittent asthma
    • SABA prn
      • QID standing with viral respiratory illness for 24h
  • Persistent daily asthma
    • Low dose ICS
      • Second line LTRA if allergic component
    • Add LABA – consult if not controlled
    • Add LTRA if not done already
    • Anti IgE (Omalizumab) or Prednisone

50

For purely seasonal allergic asthma, how should ICS be prescribed? (GINA)

  • Start ICS immediately and cease 4 weeks after end of exposure

51

What is the 5-step approach for adjusting asthma treatment? (GINA)

  • Step 1 – as-needed SABA with no controller
    • Symptoms are rare, no night waking due to asthma, no exacerbations in the last year
    • Normal FEV1
  • Step 2 – regular low dose ICS plus as-needed SABA
  • Step 3 – low doses ICS/LABA either as maintenance treatment plus as-needed SABA, or as ICS/formoterol maintenance and reliever therapy
  • Step 4 – low dose ICS/formoterol maintenance and reliever therapy, or medium dose ICS/LABA as maintenance plus as-needed SABA
  • Step 5 – refer for expert investigation and add-on treatment

52

What would management options be for asthma in patients >18 years old?

  • In moderate to severe asthma, can monitor sputum eosinophilia as a measure of asthma control

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53

What should patients with asthma be educated about?

  • Consider allergy testing if appear to be predominant feature
  • Make a trigger log and avoid triggers
  • Progressive decline in lung function if not controlled and can be minimized if start effective treatment
  • YouTube videos for inhaler technique
  • No beta-blockers

54

How often should PFTs be performed to monitor patients with asthma? (GINA)

  • FEV1 at start of treatment
  • FEV1 after 3-6 months of controller treatment to record personal best lung function
  • Periodically for ongoing risk assessment

55

What should be included in a written asthma action plan? (GINA)

  • The patient’s usual asthma medications
  • When and how to increase medications and start OCS
  • How to access medical care if symptoms fail to respond

56

How should patients be told to increase their controller in written asthma action plans? (GINA)

  • Rapid increase in ICS component up to max 2000 mcg BDP equivalent
  • Type of ICS Controller

    Dose Increase

    ICS

    At least double dose

    Maintenance ICS/formoterol

    Quadruple maintenance ICS/formoterol dose (max formoterol dose 72 mcg/day)

    Maintenance ICS/salmeterol

    Step up at least to higher dose formulation; consider adding separate ICS inhaler to achieve high ICS dose

    Maintenance and reliever ICS/formoterol

    Continue maintenance dose; increase as-needed ICS/formoterol (maximum formoterol 72 mcg/day)

57

How should patients be told to increase OCS in the written asthma action plans? (GINA)

  • Adults – prednisolone 1 mg/kg/day up to 50 mg, usually for 5-7 days
  • Children – 1-2 mg/kg/day up to 40 mg, usually for 3-5 days
  • Tapering not needed if treatment has been given for less than 2 weeks

58

For children being given OSA, what should practitioners ensure the child is immunized against? (CTS)

  • Chickenpox

59

How would you educate patients with asthma on using a MDI, Diskus, Turbuhaler and Handihaler?

  • MDI (require SPACER)
    • Shake and then attach aerochamber – take at least 6 breaths if can’t hold their breath or are children
    • Breathe out all the way, press MDI, then breathe in and breathe several breaths through aerochamber – repeat in 5 min
    • Must wait 1 min between puffs
    • Must prime dose with 1 puff (if not used in the last few days)
    • Must reshake MDI after 2 puffs
  • Diskus and Turbuhaler
    • Do NOT require spacer
    • <6 years CANNOT generate required inspiratory force necessary to use
    • When breathing out, do so away from the inhaler
  • Handihaler (Spiriva)
    • Must inhale 2x for each dose

60

What should be included in an action plan for patients with asthma?

  • When symptoms increase:
    • Allow patients to self-titrate medications with worsening symptoms
    • Give patients clear indications of when to seek help

61

When would you consider a referral for a patient with asthma?

  • < 6 years – not controlled on low dose ICS
  • < 12 years – not controlled on moderate ICS
  • ≥12 years – not controlled on ICS/LABA
  • Frequent oral steroids

62

At what age are children unlikely to have the required inspiratory force to use inhalers other than an MDI?

  • < 6 years

63

What forms does salbutamol come in and at what dose?

  • Ventolin HFA (MDI) – 100 mcg
  • Ventolin Diskus – 20 mcg

64

What are potential adverse effects of salbutamol use?

  • Tachycardia
  • Nervousness
  • Headache
  • Dizziness
  • Tremor
  • Palpitations
  • Increased QT
  • Decreased K
  • Tachyphylaxis
  • Hyperglycemia in DM

65

How would you prescribe salbutamol for acute and chronic asthma in adults and children <12?

  • Adults
    • Acute
      • 4-8 puffs q20min MDI for up to 4 hours, then q1-4h
      • 2.5-5 mg neb q20min for 3 doses, then 2.5-10mg q1-4h
    • Chronic
      • 1-2 puffs QID prn MDI or 1 puff QID prn Diskus
  • Children (< 12)
    • Acute
      • 4-8 puffs q20min MDI x3 doses, then q1-4h
      • 0.15 mg/kg (2.5mg minimum) neb q20min x3 doses, then 0.15-0.30 mg/kg (10 mg maximum) q1-4h

66

What is another type of SABA that can be prescribed for asthma and what is the advantage of it?

  • Terbutaline (Bricanyl Turbuhaler)
  • 1 inhalation, if not effective after 5 minutes may repeat dose
  • Max is 6 inhalations in a 24-hour period

67

What is the difference between salbutamol and terbutaline in regards to age of starting treatment? (DFCM)

  • Salbutamol ≥4-years
  • Terbutaline ≥6-years

68

What is considered regular use of a SABA necessitating adjunct therapy for asthma? (CTS)

  • >3 doses per week

69

Should LABA be used as monotherapy for asthma? Why or why not? (TFP)

  • LABA should NOT be used without ICS
  • Increased risk of serious adverse events
    • FDA meta-analysis of 110 trials found 2.8 extra events (asthma-related death, intubation and hospitalization) per 1000 asthmatic patients treated with LABA inhalers (NNH = 358)
  • No clear increased risk of adverse events with ICS+LABA
    • Not statistically significant (NNH = 3,334)

70

What is a FABA and is it recommended as a reliever for asthma? (CTS)

  • Fast-acting beta2-agonist (FABA) – SABA or fast-acting LABA (e.g. Formoterol)
  • Use of formoterol alone (without an ICS) as a reliever in asthma is NOT recommended and it is not approved for this indication in Canada

71

What is recommended as reliever therapy for asthma in all patients with mild asthma? (CTS)

  • SABA
    • Including individuals not on controller therapy and those on ICS monotherapy)

72

When would BUD/FORM (budesonide/formoterol) be considered as a reliever therapy for asthma? (CTS)

  • Adults (12+ years) with poor controlled on maintenance ICS/LABA

73

What forms does fluticasone come in and at what dose?

  • Flovent HFA (MDI) – 50, 125 and 250 mcg
  • Flovent Diskus – 50, 100, 250 and 500 mcg

74

What are potential adverse effects of fluticasone use?

  • Thrush (Oropharyngeal Candidiasis) – rinse after each use
  • Short-term growth deceleration – achieve adult height but takes longer
  • Dysphonia, cough at time of inhalation, sore throat
  • With high dose – osteoporosis, adrenal suppression, cataracts, glaucoma
  • Flovent Diskus has lactose in it – caution with lactose allergy but not intolerance

75

What can be done to reduce the local adverse effects of ICS? (GINA)

  • Rinse mouth with water and spit out after inhalation

76

What are 3 important points to tell patients when prescribing fluticasone?

  • Need to give 2 puffs BID to achieve required dose
  • Takes 4 weeks to achieve maximal effect
  • If stable, can decrease by 25% q3months if desired

77

What dose should you prescribe fluticasone for asthma based on age?

<12 years old

>12 years old

Low

Medium

Low

Medium

<200

200-400

<250

250-500

78

What is the combination of fluticasone (ICS) and salmeterol (LABA) called?

  • Advair (Purple)

79

What doses does Advair come in and how should it be prescribed?

  • Advair HFA (MDI) – 125/25 and 250/25 mcg
    • Max 2 puffs BID for maintenance
  • Advair Diskus – 100/50, 250/50 and 500/50 mcg
    • Max 1 puff BID for maintenance

80

Is Advair suitable as an on demand reliever for asthma?

  • No

81

What is the max dose that children 4-11 years can use Advair for asthma?

  • 200/100 per day

82

What are side effects of LABAs to warn patients taking Advair for asthma?

  • Elevated BP
  • Tachycardia
  • Hypokalemia
  • Caution if epilepsy due to CNS stimulation

83

What forms does budesonide come in and at what dose?

  • Pulmicort Turbuhaler – 100, 200, 400 mcg

84

What dose should you prescribe fluticasone for asthma based on age?

<12 years old

>12 years old

Low

Medium

Low

Medium

<400

400-800

<400

400-800

85

What is the combination of budesonide (ICS) and formoterol (LABA) called?

  • Symbicort

86

What doses does Symbicort come in and how should it be prescribed?

  • Symbicort Turbuhaler – 100/6 and 200/6
    • Maintenance 1-2 puffs BID
    • Maximum 8 puffs daily

87

What is the max dose that children 5-11 years can use Symbicort for asthma?

  • Max 4 inhalations per day (Symbicort 80/4.5)

88

What is SMART for asthma?

  • Symbicort Maintenance and Reliever Therapy
    • Can be used for maintenance and reliever therapy
    • Maintenance: 1-2 puffs BID or 2 puffs once daily
    • Reliever: 1 additional inhalation as needed, may repeat if not relief for up to 6 inhalations total (maximum: 8 inhalations/day)

89

What is recommended for reliever therapy in exacerbation-prone individuals 12 years of age and over with moderate asthma and poor control on a fixed-dose maintenance ICS/LABA combination? (CTS)

  • Budesonide/Formoterol

90

What leukotriene receptor antagonist (LTRA) can be prescribed for asthma or for allergic rhinitis?

  • Montelukast (Singulair)
  • 10 mg tablet once daily

91

At what age can patients with asthma use LTRAs as an acceptable, second-line, daily monotherapy? (CTS)

  • Children 6+

92

When would montelukast be used first line for asthma?

  • Allergy-related – if always allergic trigger

93

What dose of montelukast would you prescribe for asthma based on age?

  • 2-5 years – 4 mg
  • 6-14 years – 5 mg
  • >15 years – 10 mg

94

What should you monitor on patients started on montelukast (Singulair)?

  • Monitor baseline and periodic LFTs

95

When should the maximum effect be seen with montelukast (Singulair)?

  • Maximum effect within 6 weeks
  • Starts within 2 days

96

How do LTRAs compare to ICS and ICS+LABAs for treating pediatric asthma? (TFP)

  • Inferior to ICS monotherapy
    • NNH = 21 for extra exacerbation
  • Inferior as add-on to ICS compared to ICS+LABAs

97

What subgroups of asthma has LTRAs demonstrated some benefit? (TFP)

  • Allergic rhinitis
  • Exercise induced bronchospasm
  • Specific genotypes

98

What is the benefit of adding Tiotropium as add-on therapy for patients with moderate-severe asthma already on an ICS or ICS+LABA? (TFP)

  • Addition of Tiotropium prevents exacerbations for 1 in 18-36 patients over 4-52 weeks

99

What delivery system is recommended for Tiotropium in asthma and what is the potential concern with this? (TFP)

  • Respimat (aqueous solution soft mist inhaler)
  • Possibility of increased mortality with tiotropium delivered via the Respimat inhaler in COPD (particularly those with cardiovascular disease and arrhythmias)

100

How would you prescribe prednisone for asthma exacerbations?

  • 50 mg OR 1-2 mg/kg x3-10 days
  • Watch for acute bone necrosis and glaucoma, osteoporosis, immunosuppression

101

How would you manage pregnant patients with asthma?

  • Treat as needed
  • SABA and ICS safe
  • Less data on LABA and LTRAs – use only if needed
  • Systemic steroids are safe but…
    • Increased risk of pre-eclampsia, hemorrhage, low birth weight, preterm birth and hyperbilirubinemia

102

How often should pregnant patients with asthma be reviewed? (GINA)

  • Every 4-6 weeks

103

What type of preschool children are more likely to have their asthma resolve in childhood?

  • Non-atopic child with minimal symptoms

104

What are 3 symptoms that would make you consider a diagnosis of asthma in the elderly?

  • Dyspnea
  • Wheezing
  • Nocturnal cough