PT of Bronchial Asthma

Question 1

Goals of treatment:

Answer 1

1. Achieve good control of symptoms
2. Maintain normal activities level
3. minimize risk of asthma related death
4. Minimize exacerbations
5. Minimize S/E

Question 2

Nonpharmacologic therapy

Answer 2

1. Teach self management skill
2. Avoid allergenic triggers
3. Smoking cessation

Question 3

Pharmacotherapy

Answer 3

1. Reliever
2. Controller/preventer

Question 4

Reliever

Answer 4

1. Rapid onset - LABA
2. SABA
3. SAMA
4. Short acting Theophylline

Question 5

Controller/Preventers

Answer 5

1. Corticosteroid
2. LABA
3. Leukotrine Modifier
4. Immunomodulator
5. LAMA
6. Sustained release theophylline

Question 6

SABA

Answer 6

Albuterol (salbutamol), isoproterenol, metaproterenol, terbuline

Question 7

Frequent use of SABA associated with:

Answer 7

1. increase risk of severe exacerbation
2. Hospital admission
3. Increase level of airway inflammation
4. Death

Question 8

Anticholinergic

Answer 8

Effective but not as potent as B2 agonist

Question 9

Example of Anticholinergic SAMA and LAMA

Answer 9

1. Ipratropium bromide - 4-8 H
2. Triotropium bromide - 24 H

Question 10

Inhaled ipratropium bromide- SAMA

Answer 10

1. Only indicated as adjunctive in severe acute asthma
2. does not imrpove outcome in chronic asthma

Question 11

Why Tiotropium- LAMA should not be used as monotherapy (without ICS)

Answer 11

Increase risk of severe exacerbation

Question 12

Adding LAMA to ICS-LABA

Answer 12

-No clinically important benefit for symptom

Question 13

Methylxanthines - Theophylline

Answer 13

Bronchodilator & anti-inflammatory

Question 14

Theophylline : Adverse effect

Answer 14

Potential DDI
-V&M, tachycardia, insomnia, tachyarrythmia
-plasma conc. should be monitored

Question 15

SAMA potential alternative for SABa BUT,

Answer 15

Slower onset of action and higher risk of A/E- Not recommended for routine use

Question 16

Sustained release theophylline

Answer 16

less effective than ICS and no more effective than oral sustained released b2 Agonist , Cromolyn, LT antagonist

Question 17

Management with CS

Answer 17

Most potent and effective anti-inflammatory mdx available

Question 18

Benefit ICS

Answer 18

-reduce symptom
-improve lung function and QOL
-reduce BHR
-reduce exacerbation
-reduce mortality

Question 19

Mild desease

Answer 19

control with twice daily dosing

Question 20

How to initiate CS?

Answer 20

Start with higher / more frequent dose - then tapered down once under control

Question 21

Response to ICS

Answer 21

3-6 weeks

Question 22

ICS adverse effect ?

Answer 22

Oropharyngeal candidiasis (dose dependant)- reduce by gargle after using ICS & dysphonia - minimize using spacer

Question 23

Short term systemic CS are indicated in?

Answer 23

acute asthma/ exacerbation

Question 24

Pt with severe persistent asthma/ require chronic systemic CS…should use

Answer 24

Lowest possible dose-provide most clinical benefit (eg: Budesonide 200-400 mcg)

Question 25

ICS : preffered theraphy should be combined with ..

Answer 25

LABA , formoterol, salmeterol, arformoterol (never used alone)

Question 26

pt with mild asthma should start with...

Answer 26

Low dose ICS - Formeterol

Question 27

Can LABA provide significant protection against EIB?

Answer 27

Yes for 8-12 hours initially. but decrease with chronic regular use

Question 28

Nocturnal asthma is indicator of ?

Answer 28

Inadequate anti-inflammatory treatment

Question 29

Example of MCS

Answer 29

Cromolyn sodium , nedocromil sodium

Question 30

Discontinuation because:

Answer 30

Low efficacy

Question 31

effect of nsaid in asthma

Answer 31

Aspirin and other NSAIDs can induce bronchospasm and, in rare cases, this reaction can lead to death

Question 32

The main types of NSAIDs include:

Answer 32

aspirin ibuprofen. naproxen. diclofenac. mefenamic acid. indomethacin.

Question 33

LT Modifier: LTR. Antagonist. Example?

Answer 33

Zafirlukast and Montelukast (oral), Zileuton

Question 34

Indication?

Answer 34

Reduce proinflammatory and BC effect of LT

Question 35

ICS vs LT modifier?

Answer 35

LTM less effective than ICS

Question 36

Montelukast adverse effect?

Answer 36

Neuropsychiatric events

Question 37

Zileuton

Answer 37

(oral) 5-lipoxygenase inhibitor - inhibit synthesis of LT . used on for 12 and >12 y/o

Question 38

Use of zileuton is limited because :

Answer 38

potential elevated hepatic enzyme and inhibit metabolism of some drugs (eg: theophylline and warfarin)

Question 39

when Use of zileuton, what should be monitored?

Answer 39

serum alanine aminotransferase

Question 40

Other controller : Immunomodulators. Example?

Answer 40

Omalizumab (anti-IgE)

Question 41

Omalizumab: 1. Indication 2. Dosage and Dosage form 3. DISADVANTAGE

Answer 41

1. Monoclonal ab , prevent binding of IgE to basophil and mast cell (used in pt 6/>6 y/o) 2. SC : 150 -375 mg (2-4 weeks interval) 3. High cost (step 5) , combine with high dose ICS and LABA

Question 42

Other controller : Immunomodulators. Example?

Answer 42

Mepolizumab SC, Reslizumab IV, Benralizumab SC (anti-IL5)

Question 43

Indications??

Answer 43

Severe eosinophilic (allergy) asthma

Question 44

Combination ICS + LABA (more effective)

Answer 44

Varied dose ICS + fixed dose LABA

Question 45

Combination theraphy : 1st agent

Answer 45

Budesonide/Formoterol (DPI) 200/6 Relief and maintenance

Question 46

Assessment of Asthma control

Answer 46

-assess risk factor -measure FEV1 at start of tx -->potential risk factor: low FEV1 (<60%) -blood eosinophils -->elevated FeNO ; in pt with allergic asthma taking ICS

Question 47

Types of inhaler: MDI CS (preventer) MDI B2 Agonist (reliever)

Answer 47

Brown Blue

Question 48

DPI

Answer 48

drawn into lung when breath in

Question 49

Exacerbation of Asthma / Acute asthma

Answer 49

... can also happen to pt who dependant on SABA

Question 50

Evaluation of TE outcome: acute asthma

Answer 50

1. monitor morning peak flow 2. lung function --> spirometry/ peak flow --> 5-10 mins after each tx 3. oxygen saturation