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Flashcards in Pharm 4 Resp pt4 Deck (24)
1

Leukotriene Inhibitors
Mechanism, Indications

Mechanism:
5-LO modifier
Cysteinyl leukotriene receptor antagonist
Indications:
Long-term control therapy in mild-persistent asthma
Improves lung functions (PF and FEV1)
Reduces need for short-acting beta2-agonists
Prevents acute exacerbations

2

*Clinical Pearl: what patients would you consider putting on a Leukotriene inhibitor?

the individual who has more of an allergic component (rhinitis) will be the person who sees the greatest improvement with a Leukotriene Inhibitor

3

the 4 steps of asthma therapy
Step down when possible, up when necessary.
Consider specialist at steps 3-4

Step 1: Quick-relief meds, no daily long-term control needed
PRN max. 1-2 times weekly
Step 2: Daily long-term control: low-dose ICS (or long-acting beta2-agonist depending upon symptoms)
Step 3: Daily long-term control: medium-dose ICS AND long-acting beta2-agonist
Step 4: Daily long-term control: medium- to high-dose ICS and long-acting beta2-agonist and leukotriene inhibitor or Mast cell wall stabilizer; oral steroids.

4

PA: How many canisters of Albuterol did you use last year?
Pt: Three.
PA: That’s too many. We need to add another medication, ______
Pt: Great. Goodbye!

ICS

5

NIH Guidelines indicate that you should step up from Step 1 to Step 2 whenever your patients are using albuterol more often than:

1-2x week

6

How many puffs/doses is in a canister of albuterol?

200 puffs/100 doses
2 puffs per use

7

Managing Exercise-Induced Bronchospasm (EIB)
Short term (1), long term (2)

Consider short-acting beta2-agonists immediately before exercise
Alternatively, depending upon severity of exacerbations consider:
long-term MAST cell wall stabilizer therapy
long-term long-acting beta2-agonist therapy which may control EIB better than short-acting agents

8

Managing Seasonal Asthma Symptoms

Just before allergy season begin (or step-up) anti-inflammatory therapy
During allergy season, use Step Therapy (take max dose) to control symptoms

9

If their asthma worsens with seasonal allergies. Have them escalade their therapy, but for how long?

Only during that period of time

10

Asthma often presents atypically (no wheezes). What's the most common atypical presentation of asthma?

Cough - and cough-variant asthma or cough as the initial presenting symptom of asthma is much more common than previously recognized

11

Mechanism of beta-adrenergic agonist bronchodilators

stimulates -receptors, which in turn increases the cyclic AMP, producing functional antagonism to the broncho-constriction, ultimately relaxing the smooth muscle of the airways and causing bronchodilation

12

4 b-Adrenergic Agonists

Albuterol (short acting)
Levalbuterol
Metaproterenol
Salmeterol (long acting)

13

Relief, prevention of bronchospasm w/ reversible obstructive airway disease; prevention of exercise-induced asthma

Albuterol
(short acting)

14

Bronchodilator for bronchial asthma, reversible bronchospasm associated with COPD

Metaproterenol

15

MAINTENANCE treatment of asthma, prevention of bronchospasm in patients with reversible obstructive airway disease, prevention of exercise-induced bronchospasm

Salmeterol
(long acting)

16

Prototypical Short-Acting b2-Agonist
Example
Indication
Forms it exists as
How long does it work?

Albuterol
Indicated in: bronchospasm
Available as: Inhaler or Syrup
5-8 hours

17

What would make you want to prescribe a syrup Albuterol instead of a MDI Albuterol?

If there’s a 9 month old child who needs an MDI.
Doses must be in mg instead of mcg

18

What's useful in an acute/early phase bronchospasm?
What about late phase?

Acute/Early phase: Albuterol
Late: ICS

19

Albuterol
Contraindications, Precautions, Side Effects

Avoid excessive use
Discontinue w/ paradoxical bronchospasm (wheezing/breathing gets even worse), cardiac effects occur
Caution in CAD, htn, arrhythmias
Pregnancy Cat. C (breathing is pretty important though..)
Nursing mothers: not recommended
Avoid MAOIs, TCAs w/in 14 days
Antagonizes b-blockers
Monitor digoxin levels
May cause tremor, h/a, nervousness, insomnia, tachycardia, hypokalemia

20

A patient with mild asthma should use their albuterol no more often than (2)

1-2x week
or
4 puffs per week

21

If a patient uses albuterol two time a week, their prescription should last how long?

1 year
When a patient gets refills more than once a year, their asthma is not well-controlled

22

Prototypical Long-Acting b2-Agonist
Example
Indications

Salmeterol
Indications: Maintenance treatment in asthma (esp. noctural asthma), bronchospastic disease including COPD-associated bronchospasm

23

Details of Salmetrol

Very selective b2 over b1 (therefore far fewer side effects, unlike albuterol)
Slow onset of action of > 30 minutes or longer
Used to treat late-phase response
Long duration of action (12 hours) may result in significant bronchodilation in spite of not using short-acting agents and block symptomatic expression
Not a substitute for steroids

24

Salmeterol
Contraindications, Precautions, Side Effects

Not for use of acute attacks
Caution in CAD, hypertension, seizure disorders, arrhythmias
Pregnancy Cat. C
Nursing mothers: not recommended
Avoid MAOIs, TCAs w/in 14 days
Antagonized by b-blockers
Caution with potasium-depleting diuretics
May cause h/a, sore throat, GI disturbances, tremor, local upper respiratory irritations