Block 2 Flashcards
(242 cards)
1
Q
What is the cause of hepatic encephalopathy?
A
Accumulation of substances that cant be cleared via liver
Changes in astrocytes which causes brain edema
Substances: Ammonia, glutamate, benzodiazepine receptor AGONISTS, manganese
2
Q
What is Grade I HE?
A
Day/Night Inversions
MILD confusion
Irritability
Tremors
3
Q
What is Grade II HE?
A
Lethargy
Disorientation
Inappropriate behavior
4
Q
What is Grade III HE?
A
Somnolence
SEVERE confusion
Aggressive behavior
5
Q
What is Grade IV HE?
A
Coma
Also the only one that DOESN’T have asterixis
6
Q
What dietary changes can you make for HE?
A
Limiting protein intake to 10-20g/day
Max is 0.8-1g/kg/day or 40g/day
7
Q
What causes the constipation in HE patients?
A
Not eliminating ammonia
8
Q
What causes the hypokalemia and acidosis in HE pts?
A
Diuretics and diarrhea
9
Q
What are the pharmacologic Tx for HE (just non-Abxs)?
A
Lactulose (nonabsorbable disaccharide)
Initially: 15-45mL every 1-2hrs until BM
Continue at 15-45mL 2-4x a day and titrate to 3-5 BMs/day
Enema: 300mL in 700mL water and retain for 1 hr
Watch for signs of dehydration
10
Q
What are the Abx used for HE?
A
Flagyl
Neomycin
Rifaximin
11
Q
What is the dose and AE of Flagyl for HE?
A
Flagyl 250mg every 8-12hrs
**dont use for long-term due to peripheral neuropathy
12
Q
What is the dose and AE of Neomycin for HE?
A
Neomycin 500-1000mg every 6hrs or 1% solution enema in 100-200mL NS
**risk for ototoxicity and nephrotoxicity with an increased risk in renal damaged pt
13
Q
What is the dose and AE of Rifaximin for HE?
A
Rifaximin 550mg 2x or 400mg 3x a day
**nausea and peripheral edema
14
Q
What are the main causes of cirrhosis?
A
EtOH
Hepatitis B, C, D
Nonalcoholic diseases due to diabetes or metabolic syndrome
15
Q
What are the less common causes of cirrhosis?
A
Autoimmune hepatitis
Primary cholangitis
AAT deficiency
Hemochromatosis
Wilson disease
16
Q
What Rx cause cirrhosis?
A
I MAMBAS
Isoniazid
Methyldopa
Amiodarone
Methotrexate
Black cohosh
APAP
anabolic Steroids
17
Q
What are the lab values for cirrhosis?
A
Decreased albumin
Decreased cholesterol
Increased PT/INR
Increased bilirubin
18
Q
What are the signs of compensated cirrhosis?
A
Fatigue, weakness, wt loss (>50%)
40% are asymptomatic
19
Q
What are the signs of decompensated cirrhosis?
A
RUQ pain
Ascites, variceal bleed, jaundice, encephalopathy
20
Q
What gives pt 1 point for cirrhosis?
A
No encephalopathy or ascites
<2 bilirubin
> 3.5 albumin
PT = 1-4
21
Q
What gives pt 2 points for cirrhosis?
A
Mild/moderate encephalopathy
Slight ascites
2-3 bilirubin
Albumin 2.8-3.5
PT = 4-6
22
Q
What gives pt 3 points for cirrhosis?
A
Severe encephalopathy or coma
Moderate ascites
> 3 bilirubin
<2.8 albumin
> 6 PT
23
Q
What is class A cirrhosis?
A
5-6 points
100% 1 yr survival
85% 2 yrs survival
24
Q
What is class B cirrhosis?
A
7-9 points
81% 1 yr survival
57% 2 yrs survival
25
What is class C cirrhosis?
10-15 points
45% 1 yr survival
35% 2 yrs survival
26
What is the MELD score used for in cirrhosis?
Transplant listing
Higher score = sicker and will receive transplant sooner
27
What should be screened for patients who have cirrhosis?
Hepatocellular carcinoma with liver ultrasound and alpha fetoprotein every 6 months
28
What causes portal HTN?
Fibrosis due to cirrhosis causes resistance to blood flow in portal vein
Increased vasoconstriction by decreasing NO, and increased endothelin-1 and ATH
29
How is portal HTN diagnosed?
Pressure gradient >10mmHg between portal vein and inferior vena cava (normal = 3)
Clinical complications: esophageal and gastric varices
Imaging
30
What kind of BB are used in portal HTN? How does that work?
Nonspecific BB
B-1: decreases cardiac output
B-2: prevents splanchnic vasodilation
Unopposed alpha-1: splanchnic vasoCONSTRICTION
31
Tx of portal HTN
Include Rx and dose
Nadolol 20mg daily
Propranolol 10mg 3x day
Titrate to 20-25% reduction in resting HR or absolute HR of 55-60 or until no longer tolerated
**increases risk of hepatorenal syndrome
**same dose for varices as well
32
What are varices?
Gastric/esophageal vessels are enlarged due to increased intrahepatic pressure
33
How is varices diagnosed?
Endoscopy (gold standard)
Grade 1: <5mm
Grade 2:>5mm
34
Primary prophylaxis and varices?
Screen EGD in all cirrhotic pt
No varices present? No pharm. ppx
Varices present w/ HIGH risk for bleed (B or C), use nonselective BB
35
What happens if there is a bleed in varices?
d/c BB in acute setting
Manage airway, fluid resuscitation (make sure Hgb>8)
Then endoscopic exam with pharm. agents
36
What form of endoscopy is preferred for bleeding varices?
Endoscopic band ligation over injection sclerotherapy
37
What are the Rx used for bleeding varices?
Somatostatin OR octreotide
Vasopressin AND Nitroglycerin
Cipro, norfloxacin, or ceftriaxone
38
What are the vasoactive drugs used for bleeding varices? Dose?
Somatostatin OR octreotide
Somatostatin 250mcg IV bolus then 250-500mcg/hr for 3-5days
Octreotide 50-100mcg IV bolus then 25-50mcg/hr for 3-5 days
39
Vasoactive drug MOA for bleeding varices?
Reduces splanchnic blood flow by inhibiting glucagon (and other vasoactive peptides) and direct local vasoconstriction
40
Vasopressin and nitroglycerin dose for bleeding varices? AE?
Vasopressin 0.2 - 0.4 u/min
Max of 0.8u/min
Nitroglycerin 40mcg/min to a max of 400mcg.min for 24 hrs
AE of Nitroglycerin and why only 24hrs = ischemia, arrhythmias, HTN
41
Abx used for bleed varices? Dose?
Cipro 400mg IV every 12hrs
Norfloxacin 400mg PO every12hrs x7 days
Ceftriaxone 1g/day if FQ resistant
42
Secondary prophylaxis and varices?
Propranolol 20mg TID
Nadolol 20-40mg PO daily
Titrate to 20-25% reduction in resting HR or absolute HR of 55-60
If BB is not working, add isosorbide MONOnitrate (but not recommend due to AE)
TIPS if medically unresponsive
43
What is ascites?
>25 mL of lymph fluid in peritoneal cavity due to:
1. cirrhosis (liver cant make albumin)
2. low albumin (lymph fluid leaks OUT of cells into peritoneal cavity)
3. Portal HTN (nitric oxide is released, activates RAAS, sodium and water retention and vasoconstriction)
44
SAAG score and Ascites?
>1.1 = fluid accumulation due to portal HTN
<1.1 = other cuase
Serum albumin - albumin in ascetic fluid; found via paracentesis
45
Diet and ascites?
Abstinence from alcohol
Restrict sodium to <2g/day
46
What happens if you remove a lot of fluid found in ascites?
Circulatory collapse, encephalopathy, and renal failure
If >5L of fluid is removed, add 5-8g of albumin/L
47
How do you Tx ascites?
Mild: Spironolactone
Moderate-severe: Furosemide 40mg PO QAM + spironolactone 100mg PO QAM
Doses can be increased PRN but maintain 40:100 ratio
Max Lasix = 160
Max Spironolactone = 400
If spironolactone w/ painful gynecomastia, consider amiloride or triamterene
48
What is the goal of Tx in ascites with the use of diuretics?
Weight loss of 0.5kg/day (no edema) to 1kg/day (edema)
49
Besides diet and diuretics, what else can you do for ascites?
d/c drugs that retain sodium and water like NSAIDs
TIPS (Transjugular Intrahepatic Portosystemic Shunt) ***for those not responsive to diuretics and sodium restriction
50
What are the most common ways to cause Spontaneous Bacterial Peritonitis?
Intestinal bacterial overgrowth (cirrhosis)
Bacterial translocation from lumen to peritoneal cavity
Can spread to mesenteric lymph nodes and into blood
51
What medications cause Spontaneous Bacterial Peritonitis?
PPIs and non-selective BB
52
Risk factors of Spontaneous Bacterial Peritonitis?
Ascetic fluid protein <1
Bilirubin >2.5
Variceal hemorrhage**
Prior episode of Spontaneous Bacterial Peritonitis**
**More common in child pugh class C
53
What lab findings confirm Spontaneous Bacterial Peritonitis?
>250 PMNs/mL in ascetic fluid
54
What is the empiric Abx Tx of Spontaneous Bacterial Peritonitis?
Ceftriaxone 1-2g IV daily
Cefotaxime 2g IV q8h
or
FQs PO only if they never had exposure to Rx, no vomit, no shock, no grade II to IV HE, and if dont have SCR>3
Then give Ofloxacin 400mg PO q12h
Duration for all Tx = 5 days
55
Other Tx besides Abx for Spontaneous Bacterial Peritonitis?
Albumin 1.5g/kg on day 1
Then 1g/kg on day 3
56
Who is placed on primary prophylaxis on Spontaneous Bacterial Peritonitis?
Inpatients w/ cirrhosis and other complications that put them at risk for Spontaneous Bacterial Peritonitis (history, GI bleed, ascitic fluid protein <1g)
57
Who is placed on secondary prophylaxis on Spontaneous Bacterial Peritonitis?
Everyone whos had it before, and they get it forever unless they get a liver transplant or full resolution of ascites
58
What meds are used for secondary prophylaxis on Spontaneous Bacterial Peritonitis?
Norfloxacin 400mg PO daily
Cipro 750mg PO qWeekly
Bactrim 1 tab PO 5x week
59
What causes hepatorenal syndrome?
Portal HTN causes splanchnic blood pool
Vasodilation
Low circulating blood activates SNS, RAAS, release of vasopressin
Leads to increased CO and retention of Na/Water but kidneys dont get blood due to vasoconstriction
60
What is type I hepatorenal syndrome?
Acute (<2wks) onset unresponsive to volume expansion
Doubles SCr >2.5 or reduces CrCl by 50% to <20
Survival: 1 month
61
What is type II hepatorenal syndrome?
Slower progression vs I; aka diuretic resistant ascites
Survival: 6 months
62
What are the general Tx recommendations for hepatorenal syndrome?
Albumin 1g/kg up to 100g/day
Hemodialysis or CRRT until transplant
Liver transplant or TIPS may be required
63
What Pharm. Tx are used in hepatorenal syndrome?
Dopamine + albumin
Preferred: Albumin + Octreotide + Midodrine
Norepi + albumin (if they cant PO and must be in ICU)
Vasopressin + terlipressin
64
What are the doses of Albumin + Octreotide + Midodrine for hepatorenal syndrome?
Albumin 10-20g IV qd for 20 days
Octreotide up to 200mcg SQ TID
Midodrine up to 12.5-15mg PO TID to allow 15mmHg BP increase
65
What is the purpose of the liver?
To produce more polar metabolites aka more hydrophilic
Phase 1: oxidative, CYP
Phase 2: conjugation, glucuronyl transferases, etc
66
What are the common Rx that can cause DILI?
Abx
Anti-epileptics
NSAIDs
IBD Rx
Allopurinol, amiodarone, chlorpromazine
Herbal stuff
67
Differences between the characteristics of DILIs
Intrinsic - dose dependent, short onset
Idiosyncratic - not dose dependent, latency period
68
Characteristics of hepatocellular injury?
Increased in LFTs
Metabolic type: Rx binds covalently to intra. proteins
Immune-med.: haptenization leads to immune response
High risk of death
EX: tylenol
69
How does hepatocellular injury present and what are the lab abnormalities?
Usually occurs within 1 yr of Rx initiation
Ab pain, N/V, jaundice later
ALT greatly increases
LDH and bilirubin also increases
70
What is cholestasis?
Reduction or stoppage of bile flow
71
How does cholestasis present and what are the lab abnormalities?
Pruritus, dark urine, jaundice
Alkaline phosphatase greatly increases
May present with vanishing bile duct syndrome, bilirubin and cholesterol will go up as well
72
What is steatosis?
Accumulation of FA in mitochondria
Microvesicular = tiny fat drops that DONT displace nucleus
Macrovesicular = do displace nucleus
Amiodarone causes this kind of damage
73
How does immunoallergic DILI present and what are the lab abnormalities?
Cholestatic injury + immunoallergic
ALT and alkaline phosphatase both greatly increase
Phenytoin causes this damage via HLA-B*1502
74
How do you calculate R value?
(ALT/55) / (Alk Phos/130)
75
How do you interpret R value?
≥5 = heptaocellular
≤2 = cholestatic
2-5 = mixed
76
What is RUCAM?
Exposure to DILI
-9 to 10; higher = more likely of DILI
77
What is Hy's Law?
Mortality risk after DILI, usually within 6 months
78
What are the treatments for overdose on....
```
APAP
MTX
Valproic acid
Pruritus
Coagulopathy
Immune-mediated
```
```
APAP - N acetylcysteine
MTX - Leucovorin
Valproic acid - L carnitine
Pruritus - Cholestyramine/Colestipol
Coagulopathy - Vit. K
Immune-mediated - Corticosteroids
```
79
How is APAP metabolized and how does it cause damage?
Goes thru glucuronidation or sulfation
or
Metabolized by CYP2E1 as a toxic metabolite (NAPQI)
then can go through glutathione conjugation to become a stable metabolite
80
How does N-acetylcysteine treat APAP overdose?
Works on the glutathione conjugation part
81
How does Valproic acid overdose work?
Mitochondrial toxicity, causes hyperammonemia
Lower carnitine levels, causes mitochondrial dysfunction
82
When should you rechallenge in DILI cases?
Only if DILI is questionable, serious, no other Tx is available, AND they have no signs/symptoms
Reduce dose by 1/2 and titrate up slowly
83
How do you treat DILI?
D/c offending agent, give antidote if possible
84
Pulmonary Gas Exchange, what goes in/out of alveoli?
CO2 in
O2 out (to blood)
85
What antibody is present in the defenses of the lung?
IgA and serum immunoglobulins
86
What makes up total lung capacity?
IRV + TV + ERV/RV
87
What makes up the lung capacity that we can breathe in/out ourselves?
VC (vital capacity)
88
Tidal volume + IRV = ???
IC (inspiratory capacity)
89
What is FEV1?
Volume of air exhaled during the first second of FVC (forced volume capacity)
Diminished by decreased total lung capacity or lack of effort
90
What is FEV1/FVC?
Measure of airway obstruction w/ or w/o restriction
Normally ≥75%
Anything ≤70% suggest OBSTRUCTION (INDEPENDENT of size or TLC)
91
ERV + RV = ???
FRC (functional residual capacity)
92
What cant the spirometry measure?
Anything with RV in the equation
1. RV
2. TLC
3. FRC
93
Bronchospasm vs Emphysema
Reduced diameter of airways...
Bronchospasm
94
Bronchospasm vs Emphysema
Reduction in elastic recoil/lung elasticity...
Emphysema
95
In obstructive lung disorders, what volumes are increased/decreased?
Decreased: VC, IRV, ERV
Increased: RV, FRC, RV, TLC
96
Pulmonary fibrosis is an example of obstructive/restrictive disease?
Restrictive
97
Restrictive disease and FEV1/FVC, how is it affected?
Normal
98
In restrictive lung disorders, what volumes are increased/decreased?
Pretty much everything decreases except FEV1/FVC
99
What disease states should and shouldn't have normal DLCO (diffusing capacity of CO)?
Normal levels that affect airways only (like asthma and bronchitis)
Abnormal that cause parenchymal disease (like interstitial lung disease or emphysema)
100
Risk factors of asthma?
Genetics; ATOPY is the biggest factor, others include, obesity and male
Endogenous factors; low exposure to childhood infections, Th2 overproduction
Environmental (typical stuff, but also APAP :o)
101
What are triggers? what are some triggers for asthma?
Something that makes an ESTABLISHED disease worse
URTI, exercise, cold air, irritant gases, rx such as non-selective BB, NSAIDs
102
How does an allergen cause early phase reaction of acute asthma?
Allergen activates IgE, activates mast cells and macrophages, airway contraction/mucus secretion/vasodilation
103
How does late phase acute asthma work?
6-8hrs after early phase
Recruits eosinophils, CD4 T cells, neutrophils, and macrophages, releases cytokines and recruits inflammatory cell recruitment
104
How does chronic asthma work?
Pretty much late phase acute asthma + fibroblasts and bronchial smooth mucles
Releases cytokines and growth factors
Remodeling of lungs, causes greater decline in lung function in non-asthma pt
105
Main symptoms of asthma?
Episodic dyspnea which can go and stop anytime
Chest tightness
**unless its acute severe asthma, then they can only say a few words, unresponsive to quick relief meds
106
Spirometry findings of Asthma?
Reduced FEV1/FVC with REVERSIBILITY followed by B2 agonist
107
Exercise induced bronchospasm info?
Likely caused by heat loss/water loss from central airways
Drop in FEV1 of 15%+ from pre-exercise value
108
Nocturnal Asthma info?
Worsening of asthma during sleep
Its a sign of inadequately treated persistent asthma
109
Peak flow meter zones?
Green = 80% of best
Yellow 50-79% of best
Red = <50% of best
Best = Achieved by getting a reading over a 2 wk period
Take readings twice daily for 2-3wks and 15-20 min after SABA use
**used every 1-2yrs to demonstrate reversibility in severe cases
110
Level of asthma symptom control and their levels?
Well controlled = 0 points
Partially controlled = 1-2 points
Uncontrolled = 3-4 points
1. Daytime Sx more than 2x a week?
2. Any night waking due to asthma?
3. Reliever needed more than 2x a week?
4. Any activity limitations due to asthma?
Check every 1-2 yrs
Other risk factors include being intubated, in ICU or having 1+ exacerbation in the last 12 months
111
Mild, Moderate, Severe asthma, what step treatment do they need? **general**
Mild = asthma controlled w/ step 1 or 2
Moderate = 3 or 4
Severe = 5
112
What is Step 1 Tx for asthma?
PRN low dose ICS-formoterol or w/ SABA is taken
113
What is Step 2 Tx for asthma?
Daily low dose ICS or PRN ICS-formoterol
Can take Leukotriene RA
114
What is Step 3 Tx for asthma?
Low dose ICS-LABA
Can take medium dose ICS or low dose ICS+LTRA
115
What is Step 4 Tx for asthma?
Medium dose ICS-LABA
Can take high dose ICS, addon tiotropum or LTRA
116
What is Step 5 Tx for asthma?
High dose ICS-LABA
Refer to phenotypic assessment
Can add tioproium, anti-IgE,IL5,IL4
Can also add OCS (watch for AE)
117
What are risk factors for obstructive disease?
External factors
Smoking
Endogenous factors (AAT deficiency - emphysema)
118
If obstructive is neutrophil driven, what is it in asthma?
Eosinophils and mast cells
119
If asthma is eosinophils and mast cell driven, what is in obstructive disease?
Neutrophils
120
What are the main physiological changes in obstructive disease?
Mucus secretion via goblet cell hypertrophy
Air trapping
Diaphragm is flattened, impaired inspiration
121
What are the subtypes of COPD?
Emphysema
Chronic bronchitis
122
What is emphysema?
Destruction of airways distal to terminal bronchioles
Cant oxygenate blood well
Compensates by hyperventilating
123
What is chronic bronchitis?
Excessive mucus production
No damage to pulmonary capillary beds
Compensates by decreasing ventilation and increasing cardiac output
124
Asthma vs COPD, which one requires spirometry for diagnosis?
Only COPD
125
What is the GOLD classification of COPD?
FEV1/FVC <70 for all pt
Based on FEV1 values:
Mild ≥80%
Moderate 50-79%
Severe 30-49%
Very severe <30%
126
What is the MMRC scale?
For COPD
0 = not trouble unless on strenuous exercise
1 = SOB when hurrying on level or walking up hill
2 = walks slower for same aged ppl due to breathlessness or has to stop when walking with pace
3. Stops after 100m or a few min on level
4. Too breathless to leave house or breathless when dressing up/down
Theres also a CAT scale (>10 or <10)
127
What is the COPD assessment and classification step?
Assessment of severity with C....D then A....B
D = most severe
A = least severe
Exacerbation history = 1 w/ hospital or ≥2 = C or D line
= 0 or 1 not leading to hospital = A or B line
MMRC and CAT score of 0-1 or <10 = A C line
≥2 or ≥10 = B D line
128
Besides B2 receptor agonists and inhaled corticosteroids, what antagonist can help with bronchodilation and is effective in COPD?
Muscarinic receptor antagonists
129
B2 receptor agonist MOA?
B2 adrenergic receptors couples to Gs protein and stimulates adenylyl cyclase which increases cAMP
cAMP stimulates phosphorylation of an enzyme that NEGATIVELY regulates excitation-contraction, which leads to smooth muscle relaxation
Also decreases release of inflammatory mediators and bronchoconstrictors from mast cells
130
Albuterol, Salmeterol, Formoterol
Which one is given PRN?
All of them, but with ICS
131
How often is salmeterol and formoterol given in prophylaxis of asthma?
q12hrs daily
Can be used PRN w/ ICS
132
What is the GINA 2019 recommendation Tx on SABAs?
Use ICS + SABA
or
ICS/LABA
133
B2 receptor agonist AE?
Tremors, Tachycardia
Hypokalemia
Hyperglycemia
Restlessness
134
B2 receptor agonist DDI?
Salmeterol w/ azoles
Formoterol with mesoridazine
^^Both have increased % of QT prolongation^^
Albuterol with atomoxetine, increases BP/HR
135
What are the inhaled muscarinic receptor antagonists?
Ipratropium and tiotropium
136
Ipratropium and tiotropium MOA?
Muscarinic Receptor Antagonists
ACh stimulates and constricts smooth muscle in lung. These drugs block that
Limited role by itself and in asthmatics
137
Corticosteroid MOA?
Positively/negatively regulates gene transcription ***takes time***
Inhibit production/release of cytokines, lipolytic/proteolytic enzymes. Decrease mobilization of leukocytes to area of injury + fibrosis
138
Can ICSs be used for acute exacerbation?
Nope
139
What is the first line anti-inflammatory therapy for asthma?
ICS, must pair it with B2 agonist per GINA
140
ICS, regardless of asthma severity, reduces asthma exacerbation and what else?
Reduces hospitalizations, death, and improves overall lung function
141
ICS is used for their glucocorticoid/mineralocorticoid effects
Glucocorticoid effects only
142
Examples of ICS?
Beclomethasone, budesonide, mometasone, fluticasone
143
Can ICS reach systemic circulation?
Yes, a significant fraction is swallowed and can reach GI tract
144
If ICS dose is high, which one is preferred?
Any except beclomethasone
145
Which ICS is a pro-drug?
Beclomethasone
146
How do you reduce the amount of ICS being swallowed?
Gargle and rinse. Use spacer if aerosolized
147
ICS AE?
Local - candidiasis (use spacer and rinse), dysphonia, cough.
Systemic - growth retardation (beclomethasone), skin thinning and capillary fragility. Osteoporosis if used with oral and ICS steroids
148
Oral corticosteroid AE?
Only in burst doses (high doses in short time ie 5-14 days) = insomnia, PUD, pancreatitis
149
For asthma, what should be used prophylactically vs episodic use vs exacerbation?
Prophylactic (daily) ICS or ICS w/ LABA.
Episodic use = ICS w/ SABA/LABA (prn).
Exacerbation = ORAL corticosteroid for 5-14 days or inj corticosteroids
150
What are the leukotriene inhibitors?
Montelukast
151
Montelukast should be used in (asthma/COPD)
Asthma only, leukotrienes don’t exist in COPD
152
Montelukast MOA?
LTD4 antagonist. Not as effective as ICS, just an add-on. Good for kids
153
Montelukast AE?
Hepatic issues and Churg-Strauss syndrome
154
Pharmacophore for B2 agonists?
Substituted phenethylamine (NH-R group at the end with an R-N)
155
B2-agonist general structure?
Benzene ring with 2 -OHs and 2 carbons to the right with another -OH group and NH-R
156
Purpose of -OH groups in B2 agonists?
Direct action to B2 receptors
157
Purpose of R groups in B2 agonists?
Gives it B selectivity. Larger = greater and longer
158
What is the key structure in ACh?
CCOORN
159
Which compound for asthma/COPD contains quaternary ammonium group?
Anticholinergics; cant cross BBB because of it unlike atropine
160
What is the goal of Asthma Tx per GINA?
Achieve and maintain CONTROL and REDUCE risk
161
What is the asthma management cycle parts?
Review/Response. Assess. Adjust
162
What is the preferred reliever for asthma?
Regardless of what step they're in, use ICS-formoterol
163
Which Rx are used for quick-relief of bronchoconstriction, cough, chest tightness, and/or wheezing?
SABAs, anticholinergics, systemic corticosteroids
164
What is the typical dosing regimen for SABAs?
Albuterol and levalbuterol = 90mcg/actuation = 1-2 inhalations q4-6hrs PRN
165
Brand name of levalbuterol?
Xopenex
166
Brand name of albuterol?
AccuNeb, Proventil, Ventolin, ProAir
167
Pearls of SABAs?
AE are predictable and dose-dependent, desensitization due to frequent use
168
What is the preferred "reliever medication" and what is the max dose/day?
Budesonide + Formoterol. 72mcg formoterol (12 inhalations) is the max
169
In which case can you use SABAs by itself for asthma?
Never! Increases risk of severe exacerbations
170
What is the onset of action and duration for albuterol/levalbuterol and formoterol (w/ ICS)?
Onset of action for albuterol/levalbuterol = 5 min. Duration of action for those two = <4hrs.
Onset of action of formoterol + ICS is about 5 min (peaks at 15), however the duration is 12 hrs
171
Brand name of Ipratropium?
Atrovent
172
Brand name of Ipratropium w/ albuterol?
Combivent, DuoNeb
173
A B2 agonist has a big R group due to what other characteristics?
High lipophilicity + resistance to MAO/COMT metabolism
174
For systemic corticosteroids, what functional group increased anti-inflammatory effects?
6-methyl, but decreases mineralocorticoid effects
175
For the ICS, what functional groups increased anti-inflammatory effects?
9-Cl,F, but increases mineralocorticoid effects
16,17 ester/cyclic ester groups decrease mineralocorticoid effects, but increase binding affinity
176
Which Rx are alpha-1-antitrypsin?
Prolastin
Aralast
Zemaira
**COPD only, targets protease
177
Which Rx are methylxanthines?
Theophylline
Targets PDE
178
Which Rx are mast cell stabilizers?
Cromolyn
Targets calcium channel
179
Which Rx are anti-IgE?
Omalizumab
180
Which Rx are anti-IL5?
Mepolizumab
181
Which Rx are PDE4 inhibitors?
Roflumilast
182
What are the other leukotriene modifiers besides Montelukast?
Zafirlukast
Zileuton
183
What is the onset of action and duration of ipratropium?
Onset = 15 min
Duration 3-5 hrs
184
When is ipratropium utilized in asthma?
Quick relief of ACUTE bronchospasm in combo w/ albuterol in ED
185
What is the typical dosing of ipratopium?
Neb = 0.5mg q20min for 3 doses
MDI = 8 inhalations q20min PRN up to 3 hrs
186
Corticosteroid onset and duration of action?
Onset = 1-2hrs (IV) and 2hrs (PO)
Duration = 18-36hrs
187
Albuterol AE?
Tachycardia, tremors, hypokalemia
188
Levalbuterol vs albuterol, what is the benefit of taking levalbuterol?
Possibly less tachycardic issues, but not by much
189
Formoterol + ICS AE?
Tachycardia, tremors, hypokalemia, anxiety, dizziness
190
Ipratropium AE?
Dry mouth
191
Corticosteroid AE?
Hyperglycemia, fluid retention, wt gain, GI issues
192
Response of ICS on body and time?
Just know that symptomatic improvements dont go into effect until 1-2weeks and baseline FEV1 and PEF improvements in 3-6wks
193
At what age can you take zafirlukast, zileuton, and montelukast?
≥5 - zafirlukast
≥12 - zileuton
≥1 - montelukast
194
AE of zafirlukast, zileuton, and montelukast?
Eosinophilia and vasculitis - zafirlukast + montelukast (+ neuropsychiatric events)
Hepatotoxicity (monitor ALT x3months) - zileuton
195
DDI of zafirlukast, zileuton, and montelukast?
May increase theophylline concentration + 1A2 inhibitors - zafirlukast and zileuton
May increase gemfibrozil + 2C8, 2C9 inhibitor
196
Dosing consideration for zafirlukast, zileuton, and montelukast?
Empty stomach, 1hr before or 2 hrs after meals - zafirlukast
1 hr after AM and PM meals - zileuton
evenings, may dissolve in certain things - montelukast
197
Which LABA has the quickest onset?
Formoterol (5min, peak in 15min)
Others are salmeterol (30min) and vilanterol (15-30min)
198
What are the durations for LABAs?
Salmeterol and formoterol = 12hrs
Vilanterol = 24hrs
199
Which LABA is a combo product?
Vilanterol; comes with fluticasone
200
What is the approved age for LABAs?
>4 = salmeterol
>5 = formoterol
>18 = vilanterol
201
When can you use LABAs by itself?
Never, should always be used w/ ICS
202
What is an example of a long-acting anticholinergic?
Tiotropium
203
What are the anti-IL5 agents for asthma?
MRB
Mepolizumab
Reslizumab
Benralizumab
204
Which immomodulators for asthma are anti-IL4R alpha?
Dupilumab
205
Dupilumab MOA?
anti-IL4R alpha
206
Benralizumab MOA?
anti-IL5
207
Reslizumab MOA?
anti-IL5
208
Mepolizumab MOA?
anti-IL5
209
Omalizumab MOA?
anti-IgE
210
Which immunomodulator for asthma is IV only?
Reslizumab (Cinquair), the rest are SQ
211
When is omalizumab approved for use?
≥6 yrs old w/ step 4/5 ALLERGIC asthma
positive skin test
inadequate controlled w/ ICS and LABA
IgE level before treatment and body weight required for dosing
212
Omalizumab AE?
Anaphylaxis and delayed anaphylaxis, required that pt wait 2 hours after SQ inj
213
When is Mepolizumab approved for use?
≥12 yrs old w/ severe eosinophilic phenotype asthma
214
Mepolizumab AE?
Hypersensitivity/anaphylaxis
Herpes zoster infection
215
When is Reslizumab approved for use?
≥18 yrs old as an add-on Tx with eosinophilic phenotype
216
Reslizumab AE?
Hypersensitivity/anaphylaxis
Malignancy
217
When is Benralizumab approved for use?
≥12 yrs old with severe eosinophilic asthma at steps 4-5
218
Benralizumab AE?
Hypersensitivity/anaphylaxis
Headache
219
When is Dupilumab approved for use?
≥12 yrs old w/ severe eosinophilic type 2 asthma OR requiring maintenance OCS
220
Dupilumab AE
Hypersensitivity/anaphylaxis
Oral HSV
Conjunctivitis
Inj site rxn
221
Methylxanthines have okay bronchodilation or anti-inflammatory properties?
Just okay bronchodilation
222
Theophylline dosing and monitoring?
ER 300mg daily (600 max)
100mg q8h oral solution
Therapeutic range 5-15 (adults) or 5-10 (kids)
223
Theophylline AE?
Therapeutic AE = insomnia, GI issues, hyperactivity
Toxic effects = heart issues, N/V, seizures, hypokalemia
224
Theophylline or aminophylline (IV) can be used for (exercise-induced asthma/nocturnal symptoms)
Theophylline - nocturnal
225
Cromolyn can be used for (exercise-induced asthma/nocturnal symptoms)
Exercise induced asthma
226
Cromolyn vs theophylline, which one has less toxicity issues?
Cromolyn
227
MDI education points?
If you havent used it for 3 days - 4 wks, spray 2-4 times in the air
Shake for 5 sec
Breath in for 5-7 sec as you push the canister and hold for 10 seconds or as long as you can
Wait 1 min between puffs
228
Dry powder inhaler education points?
Never exhale into inhaler
If inhaler uses capsules, make sure its empty (may take 2 inhalations)
229
Nebulizer education points?
Every 4-5 breaths, take a deep breath and hold for a few seconds, then exhale completely
230
Initially, when is someone placed in step 1 treatment?
Sx less than twice a month
231
Initially, when is someone placed in step 2 treatment?
Sx twice a month but less than daily
232
Initially, when is someone placed in step 3 treatment?
Sx most days or waking with asthma once a week or more
233
Initially, when is someone placed in step 4 treatment?
Sx most days or waking with asthma once a week or more AND low lung function
234
After starting treatment for asthma, when should they be reevaluated?
q1-3 months
235
Once stable on their asthma treatment, how often should they be reevaluated?
q3-12 months
236
If pregnant, how often should they be reevaluated for asthma?
q4-6 weeks
237
After an exacerbation, how often should they be reevaluated for asthma?
Within 1 week
238
When should you step up therapy for asthma?
If Sx not controlled using those 4 questions
239
When should you refer to a specialist for asthma?
Step 4 or 5
Not meeting goals after 3-6 months of Tx
>2 oral corticosteroid bursts in a year
Life-threatening exacerbation
Immunotherapy consideration
240
What should you do if you're in the green, yellow, and red zone?
Green - continue maintenance meds
Yellow - use SABA +/- prednisone and contact physician
Red - use SABA + seek medical attention
241
Asthma and ED, how is it treated?
Oxygen at 93-95%
SABA +/- ipratropium (3 Tx every 20-30 min)
Systemic corticosteroids can be used (IV or PO), continue for 5-7 days after d/c
If they have impending respiratory failure, use IV magnesium and high dose ICS
242
What are some risk factors for death from asthma?
≥1 hospitalization due to asthma in the past year
>1 canisters of SABA use/month
Not on ICS
Illicit rx use
Comorbid conditions
Previous severe exacerbation (intubation, ICU admission)
