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Flashcards in Asthma And COPD Deck (55):
1

Causes of airway narrowing in asthma exacerbation

Contraction smooth muscle
Mucus plugs in lumen
Thickening / edema of bronchial mucosa
Cellular infiltration

2

Most easily reversible cause of asthmatic airway obstruction

Contraction of smooth muscle (edema / infiltration is covered with sustained anti-inflammatories)

3

Short term control of asthma is achieved with

Relaxation of airway smooth muscle with
B agonists
Sometimes can use Theophylline (methylxanthine) or antimuscarinics

4

Long term control of asthma most effectively achieved with

Anti-inflammatory agent like ICS
Or:
LTRA (leukotrine pathway antagonist)
Cromolyn or Nedocromil (mast cell de granulation inhibitor)
Omalizumab (monoclonal Ab targeted against IgE)

5

Bronchoconstriction in asthma can be IgE mediated or non IgE mediated. Name a few of non IgE mediated reasons

ASA
cold air
Exercise

6

Name 3 inflammatory cells involved in pathophysiology of airway inflammation

Lymphocytes
Mast cells
Eosinophils
Neutrophils
Macrophages
Dendritic cells
Airway smooth muscle

7

Name 3 inflammatory mediators involved in asthma

Chemokines
Cytokines
Cysteinylleukotriens
Nitric oxide
IgE

8

Name 6 comorbidities and complicating factors of asthma

Allergies
Viral or bacterial infections
Nonselective B blockers
Air pollution
ASA/ NSAID sensitivity
Food sensitivity
GERD
OSA
OBesity
Stress/ depression

9

Step 1 Asthma Tx

SABA PRN

10

Step 2 asthma TX (0-4 years)

Preferred: low-dose ICS
Alternatives:
Cromolyn
LRTA (Singulair)

11

Step 2 asthma Tx (5-11 years)

Preferred:
Low-dose ICS
Alternative:
Cromolyn/Nedocromil
LRTA
theophylline

12

Step 2 asthma Tx (12 + years)

Preferred:
Low-dose ICS
Alternative:
Theophylline
Cromolyn, Nedocromil
LRTA

13

Clinical presentation of asthma

Reversible bronchoconstriction
SOB
chest tightness
Wheeze
Eosinophilic or lymphocytic inflammation of bronchial mucosa
"Remodeling" of bronchial mucosa (hyperplasia)

15

Step 3 Asthma Tx (12+ years)

Preferred:
Low-dose ICS & LABA
OR
MED-dose ICS
Alternatives:
Low-dose ICS & THeophylline;
Low-dose ICS & LRTA
Low-dose ICS & Zileuton (also an LRTA)

16

Step 4 asthma Tx (0-4 years)

Preferred: MED-dose ICS &
Either LABA or Singulair

17

Step 4 asthma Tx (5-11 years)

Preferred:
MED-dose ICS & LABA
Alternatives:
MED-dose ICS & LTRA;
MED-dose ICS & theophylline

18

Step 5 asthma tx (0-4 years)

Preferred:
HIGH DOSE ICS &
EITHER
LABA OR SINGULAIR

19

Step 5 asthma Tx (5-11 years)

Preferred:
HIGH DOSE ICS & LABA
alternatives:
HIGH DOSE ICS & theophylline;
HIGH DOSE ICS & LRTA

20

Step 5 Asthma Tx (12 + years)

Preferred:
HIGH DOSE ICS & LABA
alternatives:
Consider Omalizumab for pets with allergies

21

Step 6 asthma Tx (0-4 years)

HIGH DOSE ICS & LABA
Or HIGH DOSE ICS & Singulair
AND
ORAL STEROIDS

22

Step 6 Asthma Tx (5-11 years)

HIGH DOSE ICS & LABA & ORAL STEROID
Alternatives:
HIGH DOSE ICS & theophylline & oral steroid;
HIGH DOSE ICS & LRTA & oral steroid

23

Step 6 Asthma Tx (12+ years)

HIGH-DOSE ICS & LABA & ORAL STEROID
AND
Consider Omalizumab for pts with allergies

24

Name a SABA - action, dose, side effects and contraindications

Albuterol
AKA Ventolin or Proventil
Action: bronchial smooth muscle relaxation
Onset: 15 minutes
Duration: 3-4 hours
Dosing: 0.15 mg/kg/dose (MAX: 5 mg/ DOSE)
OF 0.5% solution: 0.01-0.05 ml/kg/dose (MAX: 1 ml/ DOSE)
Premixed 0.083% solution 1 vial= 2.5 mg in 3 ml NS (= standard adult)
Premixed 0.63 mg/3ml NS and 1.25mg/3ml (=peds)

25

Albuterol pregnancy category / lactation?

Category C and lactation compatible

26

Levalbuterol (Xopenex):
Difference between this and albuterol;
Why you might choose;
Dosing and side effects

As effective as Albuterol without cardiac side effects;
R-isomer of Albuterol
S/E: tachycardia, palpitations, tremor, insomnia, nervous, nausea, headache
Dosing: 0.31 to 0.63mg

27

Atrovent:
what it is, how it works, when indicated

AKA Ipratroprium Bromide
Inhibits effects of acetylcholine at muscarinic receptors> > bronchodilation
* enhances bronchodilation of Albuterol
Duoneb or Combivent = combined form of Albuterol and Atrovent

28

Inhaled corticosteroids:
Names
🎯HOW HELPS asthma
🎯Advantage of ICS RX over oral steroid RX

Fluticasone, Beclomethasone, budesonide;
Works by reducing bronchial inflammation and reactivity
ADVANTAGE OVER SYSTEMIC CORITCOSTEROIDS: avoids the systemic SE's

29

Methylxanthines:
method of action (MOA)
Examples
What is VERY IMPORTANT to monitor..
SE's and signs toxicity

MOA: inhibits cAMP -induced bronchoconstriction
Examples: theophylline (aminophylline; theobromine; caffeine)
Must monitor Theophylline levels (narrow therapeutic window!!)
SE's: N/V; H/A.....(neuro and GI-related)
Toxicity: arrhythmias, seizures in addition to N/V and H/A

30

Tx of "mild intermittent" asthma

Ie, sx

31

Tx of moderate persistent

ie for daily sx but not continuous/ > 1x /week/ night
ICS + LABA
PEDS: ICS + LTRA

32

Cromolyn and Nedocromil:
MOA
Use
Dosing
SE's

anti inflammatory / blockade Cl channels/ modulate mast cell release and eosinophil recruitment;
Not preferred for persistent asthma but can be used for prophylaxis;
QID dosing preferred
SE's: cough, dry mouth, 🎯ANGIOEDEMA

33

How does the flu affect asthmatics?

Exacerbations!

34

Immunomodulators: Omalizumab / Xolair-
MOA
INDICATIONS

Inhibits binding of IgE
K mm

35

Step 3 asthma TX (age 0-4)

Med-dose ICS

36

Step 3 TX asthma (5-11 years)

Either:
Low-dose ICS & LRTA; or low-dose ICS & LABA; or low-dose ICS and theophylline
OR:
Med-dose ICS

37

LABA's:
Names
MOA
Duration and 🎯lipophilic or hydrophilic?
SE's
Adverse events/ warning

Salmeterol /Serevdnt (partial agonist), Formoterol/ Foradil (full agonist)
Selective B agonists that achieve their long duration of action via their lipid solubility
Duration:5-12 hours
NEVER recommended as monotherapy for asthma!
Use LABA & ICS per NIH guidelines

38

What stage asthma do we start to see LABA use?

Stage 3

39

Leukotreine inhibitors:
Names
MOA
When indicated
SE's
Warning! 🎯 what to monitor while on these?

Montelukast/ singular
Zafirlukast/ accolate
[zileuton/zyflo= 5 lip oxygenase inhibitor]
MOA: interrupt leukotreine pathways
SE's: insomnia/ dream abnormalities, N/V/D, elevated LFTS, vasculitis, cramps, eosinophilia
Warning! SINGULAIR may increase suicidal thinking/ mood changes (2008 FDA)

40

Systemic corticosteroid-
Memorize dosing

Prednisone/ prednisolone 1-2 mg/kg /day

41

Oral steroids:
MOA
Indications
SE's

For most severe cases
Suppresses, controls, reverses inflammation
SE's related to dose....
Adrenal suppression
Growth suppression
HTN
Cushings
Osteoporosis
Dermal thinning
StriAe
Muscle weakness
Weight gain
Cataracts
Glaucoma
Increased risk infection!

42

COPD -definition

Common
Preventable
Progressive
Treatable disease
Characterized by increased inflammatory response in lungs
Exacerbations contribute to overall severity

43

COPD:
Forms

Chronic bronchitis: chronic cough x 3 mo/ 2 years in a row

Emphysema: permanent enlargement airspaces distal to terminal bronchioles
+ destruction airspace walls
(Fibrosis in early stages)

Asthma: airway obstruction reversible + wheeze + tightness+ broncho reactivity

44

COPD:
Patho

- chronic inflammation
-excessive lysis of elastin and other structural proteins of lung matrix
-Changes to acinar ... Permanent dilation / destruction
-destruction of alveoli (loss of capillary bed)
-hyperplasia

45

Differential DX

Asthma
Bronchiectasis
CHF
panbronchitis
Obliterating bronchitis
Pulm HTN
TB
Pneumonia
Pleural effusion

46

Tiotroprium/ Spiriva:
MOA
Duration
INDICATIONS🎯

Antimuscarinic; longer acting than Atrovent
Duration: 24 hours

47

GOLD 1-4

1: mild airflow limitation
2: moderate

48

GOLD ABCD

A: less SX / less airflow limitations / 0-1 hospitAlizations
B: MORE SX / less airflow limits / still 0-1 hospitAlizations
C: less SX / more airflow limits / 2+ exacerbations with 1+ hospitalization
D: MORE SX / more airflow limits / 2+ exacerbations with 1+ hospitAlization

49

Romufilast:
Indications
Duration
MOA
SE's🎯
C/I's

Indicated in COPD
duration 24 hours
MOA: selectively inhibits PDE4>> antiinflammatory effect via suppression of cytokine release; inhibition of neutrophil infiltration, and attenuation of pulmoNary remodeling
SE's: 1st 6 months- diarrhea and weight loss! 🎯
h/a, n/v, dizziness, back pain
C/I: severe hepatic dz; substrate of CYP1a2,
Pregnancy categoryC / passes into breAstmilk

50

Atrovent SE's: 🎯

Dry mouth, constipation, urinary retention

51

Risk fx for COPD

A-1 anti trypsin deficiency (genetic)
Fam hx
Smoking
Female
Prematurity of lungs
Teen smokers
Poorly controlled asthma
Lots of lower resp infections before age 6
Pollutants
Occupational exposure

52

ICS
Names
WhAt they do
What decreases their effectiveness

Pulmicort, Flovent, Asmanex, Aerobid, QVAR
-less SX
-better quality life
- better PEF
-less exacerbations
Less effective in:
-smokers
African am peds with poorly controlled asthma
Neutrophil predominant inflammation

53

What organisms cause exacerbations in COPD

H. FLU!
M catarrhal is
S pneumonia
Viruses

54

ICS
SE's

Thrush
Dysphonia
Reflex cough
Slower growth
Bone mineral density down
Varicella
Thin skin/ bruising
Cataracts, glaucoma
Glucose metabolism effects
HypothAlamic-pituitary-adrenal axis function (issue with higher doses)

55

COPD pts: increased risk of ... (R/T meds) and how to address

increased risk of bone fractures; need Vitamin D + Ca+

56

Use caution when prescribing Atrovent (anticholinergic) to

pts with glaucoma or urinary outflow issues