Asthma Therapy

Question 1

First line for mild intermittent asthma

Answer 1

Albuterol inhaler alone. If attacks are infrequent, there is no need for inhaled glucocorticoids

Question 2

First line for mild persistent asthma

Answer 2

Albuterol inhaler plus corticosteroid inhaler

Question 3

In well-controlled asthma, a SABA should not be needed more than __ per week.

Answer 3

In well-controlled asthma, a SABA should not be needed more than two days per week.

Question 4

Epinephrine hydrofluoroalkane

Answer 4

Available over-the-counter in an inhaled form as a SABA in place of albuterol or levalbuterol

Used for intermittent asthma only. Costs less than perscription inhalers.

If asthma is worsening, these patients should be switched to albuterol or levalbuterol for rescue and started on a maintenance therapy

Question 5

Ipratropium bromide for intermittent asthma

Answer 5

Can be used off-label for intermittent asthma when patients cannot tolerate SABAs

Question 6

Preferred Treatment Guide by asthma severity

Answer 6

Question 7

Ciclesonide and beclomethasone dipropionate vs other inhaled corticosteroids

Answer 7

Ciclesonide and beclomethasone dipropionate are prodrugs that are activated only in the lungs, and so they have less on-target side effects in the oropharynx.

However, they still predispose to the development of thrush at a rate of about 5%.

Question 8

LABAs for asthma maintenance therapy

Answer 8

Always in addition to, NEVER instead of, an inhaled corticosteroid

Salmeterol and Formoterol are the preferred agents

Question 9

First line for moderate persistent asthma

Answer 9

Daily AND PRN low-to-medium dose inhaled corticosteroid and formoterol

Question 10

Why is LABA monotherapy contraindicated?

Answer 10

LABA monotherapy increases the risk of asthma-related death

Question 11

“Three drug inhaler”

Answer 11

Contains the ICS fluticasone furoate, the LAMA umeclidinium, and the LABA vilanterol (Trelegy Ellipta)

Approved for both COPD and persistent asthma. Shows benefits in lung function compared to ICS + LABA therapy alone, but no deacrease in frequency of asthma exacerbations.

Question 12

Where do montelukast and zafirlukast fit in asthma therapy?

Answer 12

They can be an alternative to low-dose ICS for those in whom this is contraindicated, but are less effective.

They can also be added on to therapy in individuals who are already on ICS and LABA.

Question 13

Zileuton

Answer 13

5-LOX inhibitor

Many side effects compared to leukotriene receptor antagonists. Reserved as an add-on for severe asthma therapy.

Question 14

Black box label for leukotriene receptor antagonists

Answer 14

For neuropsychiatric symptoms

Increased risk of completed suicide

Question 15

Theophylline in asthma

Answer 15

It is occasionally used in patients whose asthma is not controlled with an ICS and a LABA alone, however montelukast has generally taken this role

It has largely been replaced by safer alternatives due to its risk of arrhythmias.

Question 16

Oral corticosteroids in asthma

Answer 16

Used in severe asthma exacerbations, and may even be required as maintenance therapy in those with very severe persistent asthma

Question 17

In whom is omalizumab indicated?

Answer 17

Those with:

1. Moderate to severe persistent asthma not well controlled on an ICS
2. Documented allergens, such as mold, pollen, or pet dander

Question 18

Ironically, omalizumab carries a black box warning for ___

Answer 18

Ironically, omalizumab carries a black box warning for anaphylaxis

This is unrelated to on-target IgE activity and appears to be a true allergic reaction to the structure itself.

Question 19

Mepolizumab and Resolizumab

Answer 19

Anti-IL-5 monoclonal antibodies

An add-on treatment for severe eosinophilic asthma. Quite effective in these patients, reducing rates of asthma attacks by ~50-60%.

Question 20

Treating eosinophilic asthma

Answer 20

• Characterized as elevated blood eosinophils (>3%) or elevated sputum eosinophils
• Does not respond well to inhaled ICS
• Rather, responds to oral corticosteroids and anti-IL-5 therapy

Question 21

Dupilumab

Answer 21

Anti-IL-4 subunit (effectively anti-IL-4 and anti-IL-13)

Add-on maintenance treatment of moderate to severe asthma with an eosinophilic phenotype or oral corticosteroid-dependent asthma

Can decrease the rate of attacks by 50-70% in oral corticosteroid dependent asthma

Question 22

Adverse reactions to dupilumab

Answer 22

Eosinophilic pneumonias and EGPA-like (Churg-Strauss-like) vasculitis have been reported, but causal link has not been established