Drugs for Asthma and Chronic Obstructive Pulmonary Disease

Question 1

Asthma Pathophysiology REVIEW

Answer 1

chronic disorder of airway obstruction with airway inflammation r/t antigen-IgE antibody and mast cell binding ultimately resulting in bronchoconstriction and constant activation of inflammatory mediators

Question 2

What are the management goals for asthma?

Answer 2

Reduce impairment, reduce recurrence risk, DECREASE SABA use.

Question 3

Global Initiative for Asthma (GINA) recommends what for adults and adolescents

Answer 3

NO LONGER recommends treating asthma for adults or adolescents with SABA (short acting broncodialators) alone.

Should also receive symptom driven tx such as daily inhaled corticosteroids PRN to reduce exacerbation risk

Question 4

Adverse effects of regular or FREQUENT use of Short Acting Beta Agonist (SABA)?

Answer 4

B receptor downreg, rebound response, decreased bronchodilator response, increased allergic response, increased inflammation.

Question 5

ACUTE Severe Asthmatic Exacerbation Tx?

“SHOOIM”

Answer 5

Systemic glucocorticoid - reduce inflammation
High dose SABA - nebulized to reduce airflow obstruction
Oxygen - relieve hypoxemia
Oral glucocorticoid - for 5-10 days post exacerbation
Ipratopium - nebulized to reduce airway obstruction
Magnesium IV

Question 6

Inhaled SABA with spacers vs alone?

Answer 6

Spacers INCREASED by 57% reaching lungs from only 10% admin alone

Question 7

Glucocorticoids such as Budesonide or Fluticasone are used for what? MOA?

Answer 7

Asthma: prophylaxis, acute exacerbations, inhaled safer than oral

Suppress inflammation by decreasing mucous production and bronchial activity

MAY increase beta 2 receptors & response

Question 8

Glucocorticoids such as Budesonide or Fluticasone a/e?

Answer 8

INHALED - Adrenal suppression, oral candidas, dysphonia
ORAL - PROFOUND adrenal suppresion - sudden withdrawal could lead to death

LONG TERM USE - both loss (greater with oral)

Question 9

Leukotriene modifiers (Montelukast) can also be used for what? MOA? a/e?

Answer 9

Asthma, can help w/ tx by suppressing effects of leukotrienes

BLACK BOX WARNING - neuropsychiatric effects

Question 10

Montelukast MOA & use?

Answer 10

BLOCKS leukotriene receptors.

Prevent exercise induced bronchospasm - if given 2 hours prior, noctural asthma, improves lung functioning,

Question 11

What medication interacts with Montelukast?

Answer 11

Phenytoin – can DECREASE PLASMA LEVELS of montelukast.

Question 12

A/e of Montelukast?

Answer 12

Can cause…

Neuropsychiatric events – suicide, nightmares and behavioral problems with children.

FDA ADVISES RESTRICTING USE FOR ALLERGIC RHINITIS & CONSIDERING MENTAL HEALTH OF PATIENT PRIOR TO ADMIN

Question 13

Mast Cell Stabilizer (Cromolyn) MOA and Use?

Answer 13

MOA: suppresses inflammation, stabilizing mast cells, prevents histamine

Use: Prophylaxis for seasonal allergies r/t asthma, exercise induced bronchospasm, asthma

SAFEST OF ALL ANTI-ASTHMA MEDICATIONS

Question 14

Omalizumab MOA, use, a/e?

Answer 14

MOA: binds free IgE reducing amount in body

Use: moderate to severe asthma

A/e: Viral infx, URI, anaphylaxis, monitor patients for two hours after first 3 doses

Question 15

Beta 2 Adrenergic Agonists (Bronchodilators) MOA, Use, types?

Answer 15

Use: symptomatic relief of asthma, MOST EFFECTIVE for acute bronchospasm, prevents exercise induced bronchospasm.

MOA: activates beta 2 receptors initiating bronchodilation

LABA – long acting beta 2 agonists (used for increased risk of severe asthma or asmathic related death)
SABA – short acting beta 2 agonists

Question 16

LABAs for Asthma examples?

Answer 16

anything ending in - terol

Salmeterol, Formoterol, Arfomoterol… etc

Question 17

Theophylline MOA, use, a/e?

Answer 17

MOA: relaxes smooth muscle blocking adenosine receptors - decreasing frequency of attacks, LESS EFFECTIVE than beta-2 agonists.

Use: in COPD if patient cannot afford long term therapy.

Question 18

What accelerates/decreases metabolism of Theophylline?

Answer 18

Smoking INCREASES
Fluoroquinolones DECREASE
Phenobarb, Phenytion, Rifampin INCREASE

Question 19

Why would you CLOSELY monitor theophylline plasma levels?

Answer 19

Narrow therapeutic index (can see adverse effects with >30 mcg/ml causing V-fib and/or convulsions

Question 20

Anticollinergic Medications that can help with Asthma? MOA? a/e?

Answer 20

MOA: block muscarinic receptors in brochi preventing bronchospasm

Use: Ipratropium approved for COPD, off label asthma
LESS EFFECTIVE than beta agonists
SHORT duration

a/e: Increased IOP, CV events

Question 21

DPI and MDI are an ancronym for?

Answer 21

dry powdered inhaler (DPI)

metered dose inhaler (MDI)

Question 22

Tiotropium (anticholinergic) is used for what? A/e?

Answer 22

Used off label for asthma use, long lasting, long term maintenance

A/e: dry mouth

Question 23

Aclidinium bromide (bronchodilator) is used for what?

Answer 23

COPD Bronchospasm, long term maintenance

Question 24

Umeclidinium (bronchodilator - anticholinergic) is used for what?

Answer 24

NOT asthma, used for COPD

Question 25

Patients with asthma and COVID-19 considerations...

Answer 25

1. Continue taking inhaled/oral corticosteroids & biological therapy 2. Written asthma plan if symptoms worsen 3. Prescribed a short course of oral corticosteroids if exacerbations occur 4. ENSURE WHEN THEY KNOW WHEN TO SEEK MEDICAL HELP!!!! (What to do when it gets worse?!) 5. Avoid nebulizers & spirometry with confirmed covid-19

Question 26

Can patients have both COPD and asthma?

Answer 26

YES!!!! Not a single ailment, but a descriptor for overlapping conditions.

Question 27

What are special considerations for patients w/ Asthma?

Answer 27

NEVER tx with bronchodilators solely alone ( THIS CAN INCREASE RISK FOR EXACERBATIONS, HOSPITALIZATION AND/OR DEATH!!!)

Question 28

What are special considerations for patients w/ COPD?

Answer 28

START tx with LABA (long acting beta 2 agonist) w/o ICS (inhaled corticosteroids)

Question 29

What are special considerations for patients w/ COPD & Asthma concurrently?

Answer 29

More likely to die/hospitalized w LABA vs ICS & LABA! HIGH doses of ICS may be needed for SEVERE asthma, but if COPD is present it can increase risk of pneumonia!

Question 30

Why is LABA treatment ALONE dangerous?

Answer 30

It can MASK certain disease processes such as asthma exacerbations not addressing the underlying inflammation with delay in addressing the real problem THUS using LABA & ICS is important to help decreasing inflammation as well as relaxing smooth muscle.

Question 31

COPD diagnosis is determined with what?

Answer 31

Spirometry! A post-bronchodilator FEV1/FVC < 0.70 confirms presence of persistent airflow limitations confirming COPD

Question 32

When would you advise against ICS treatment?

Answer 32

Repeated pneumonia events Blood eosinophils <100 cell/uL Hx of mycobacterial infxs

Question 33

COPD Exacerbation Treatment recommendations?

Answer 33

SABA Inhalation (preferred for bronchodilation) Oral glucocorticoids Abx if infection is present O2 Supp (Keep 88-92%)

Question 34

Roflumilast (phosphodiesterase type 4 inhibitor [PDE4]) MOA, use, a/e?

Answer 34

MOA: PED4 breaks down cyclic adenosine monophosphate preventing inflammation, decreasing lung damage, improving pulmonary function Use: SEVERE COPD w/ chronic bronchitis COMBO with Tiotropium A/e: psychiatric effects (worsens depression, insomnia, HA).

Question 35

Purpose of asthma tx?

Answer 35

Decrease impairment & decrease risk of asthma

Question 36

Purpose of a pulmonary function test for asthma and COPD?

Answer 36

Used with spirometer to assess lung function

Question 37

Forced expiration volume (FEV1) is what? Forced vital capacity (FVC) is what?

Answer 37

FEV1: Most useful test in a hospital setting Inhale completely, forcefully exhale into spirometer Value is based on sex, age, height, weight Reported in a percentage FVC: total volume of air which can be exaled after full inhalation FEV1/FVC = you want HIGHER than 70-85% <70% is consistent with COPD diagnosis

Question 38

Pneumonic for Initial tx of asthma? "ILLS"

Answer 38

ICS #1 place to start for for tx Leukotriene mods LABA SABA

Question 39

What is the go-to drug for asthma?

Answer 39

ICS (budesonide) as inflammation is the key common factor of asthma

Question 40

Common side effects for ICS? PNEUMONIC "HOCUS"

Answer 40

Hoarseness Oral thrush Cough URI Soreness