asthma and allergy

Question 1

most common phenotypes of asthma

Answer 1

• Allergic (or eosinophilic) asthma
• Nonallergic asthma
• Late-onset asthma
• Asthma with fixed airflow limitation
• Asthma with obesity

Question 2

chronic inflammation in asthma

Answer 2

• Inflammation in asthma is a complex process driven by a variety of responses of the immune system
• Exposure of the airway epithelium to triggers releases alarmins which activate inflammatory immune responses

Question 3

most common mechanism leading to airway inflammation of asthma

Answer 3

activation of the type 2 humoral pathway

Question 4

chronic inflammation leads to airway remodeling, which can include:

Answer 4

• Subepithelial fibrosis
• Hypertrophy of the airway smooth muscle
• Angiogenesis

Question 5

two major sources for guidelines for the management of asthma

Answer 5

• National Asthma Education and Prevention Program (NAEPP)
• Global Initiative for Asthma (GINA)

Both advocate for a stepwise approach to asthma medications based on severity of disease

Question 6

NAEPP guidelines discuss two components of asthma severity

Answer 6

impairment and risk

Question 7

impairment as a component of asthma severity

Answer 7

how much the asthma is affecting activities, sleep and objective lung function

Question 8

risk as a component of asthma severity

Answer 8

how often a patient is having significant exacerbations requiring high-risk medications (such as oral corticosteroids)

Question 9

asthma meds are categorized into two classes

Answer 9

quick relief meds and controller meds

Question 10

what are quick relief meds used for?

Answer 10

treat acute symptoms

Question 11

what are controller meds used for?

Answer 11

to achieve and maintain control of persistent asthma

Question 12

quick relief meds in asthma

Answer 12

• SABA
• SAMA
• oral corticosteroid bursts

Question 13

SABA

Answer 13

Short-acting beta2-agonists (SABAs)
- First choice for quick relief of asthma s/s
- Albuterol is the most commonly used SABA

Question 14

SAMA

Answer 14

• Best known is ipratropium
• NAEPP recommends this as an add-on medication to albuterol
• Especially in the management of asthma exacerbations in the ED setting

Question 15

oral corticosteroid bursts for asthma

Answer 15

Recommended if the patient is not responding to bronchodilator therapy during an exacerbation

Question 16

controller meds for asthma

Answer 16

• ICS
• LABA
• LAMA
• leukotriene receptor antagonists
• monoclonal antibody therapies

Question 17

inhaled corticosteroids (ICS)

Answer 17

considered the cornerstone of asthma treatment

Question 18

MOA of ICS

Answer 18

To suppress the generation of cytokines, recruitment of airway eosinophils, and release of inflammatory mediators

Question 19

in asthma

LABAs

Answer 19

• Typically utilized as an add-on medication to inhaled steroids in the treatment of asthma
• Not indicated for use as monotherapy in asthma

Question 20

LAMAs

Answer 20

• Provide long-lasting bronchodilator effects
• Recommended by NAEPP and GINA as add-on therapy for patients requiring additional controlled medications
  EX: tiotropium
• One triple therapy option for asthma is currently available in the US
• Combines an ICS, LABA, and LAMA into a once-daily dry powder inhaler

Question 21

leukotriene receptor antagonists

Answer 21

With airway stimulation from allergens, leukotrienes C4 and D4 are released
- These substances cause contraction of the airway smooth muscle and increase the permeability of the airway vasculature

Question 22

two leukotriene receptor antagonists have indications for treating asthma

Answer 22

• Montelukast (Singlulair)
• Zafirlukast (Accolate)

Question 23

formoterol

Answer 23

has quick onset of action, similar to SABA but effects are long lasting

Question 24

SMART dosing meaning

Answer 24

single maintenance and reliever therapy

Question 25

how to use SMART dosing

Answer 25

Uses an ICS/LABA product containing formoterol as both the controller and quick-reliever In the US, the currently available formulations for SMART therapy are: - Budesonide/formoterol (Symbicort) - Mometasone/formoterol (Dulera)

Question 26

pathophysiology of allergies

Answer 26

In an immediate hypersensitivity reaction, IgE molecules are sensitized to a particular antigen - These molecules are bound to receptors on the surface of basophils and mast cells - With future exposure to the antigen, the IgE molecule is cross-linked, leading to mast cell degranulation When the mast cell breaks down, substances such as histamine, leukotrienes, platelet activating factors, and kinins are released - These chemicals leads to tissue inflammation that manifests as local and/or systemic reactions

Question 27

goals of therapy for allergic rhinitis

Answer 27

goal is to reduce the daily burden of chronic respiratory symptoms and prevent recurrent sinusitis and ear infections

Question 28

goals of therapy for patients with life threatening anaphylaxis

Answer 28

goal is strict avoidance of the triggers - Preparation for accidental exposures with injectable epinephrine devices and an emergency plan always available

Question 29

rational drug selection for patients with life threatening allergic reactions

Answer 29

an epinephrine autoinjector device should be prescribed