- Stabilize membrane of Bronchial Mast Cell - Stimulate adenylcyclase enzyme, causing bronchial smooth muscle relaxation

Pulmonary Treatments & Steroids Flashcards by Dylan Null

Principal Antibody Mediator of Asthma

IgE

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Principal Effector Cells of Asthma

Mast Cells

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Most important mediator in Asthma

Histamine

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GINA Guidelines

Frequency of Symptoms
Nighttime Awakenings
Beta-agonist Use
Interference with Activity
Lung Function

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GINA - Severe Persistent
Symptoms:
Nighttime:
Albuterol:
Limitation:
FEV1:

Symptoms: Throughout the Day
Nighttime: Often Nightly
Albuterol: Several Times Per Day
Limitation: Extreme
FEV1: < 60% of Predicted

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GINA - Moderate Persistent
Symptoms:
Nighttime:
Albuterol:
Limitation:
FEV1:

Symptoms: Daily
Nighttime: > 1x per week
Albuterol: Daily
Limitation: Some Limitation
FEV1: > 60 but < 80

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GINA - Mild Persistent
Symptoms:
Nighttime:
Albuterol:
Limitation:
FEV1:

Symptoms: 3+ days per week
Nighttime: 3 - 4x a month
Albuterol: 3+ days per week
Limitation: Minor
FEV1: ≥ 80

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GINA - Mild Intermittent
Symptoms:
Nighttime:
Albuterol:
Limitation:
FEV1:

Symptoms: ≤ 2 days per week
Nighttime: ≤ 2x per month
Albuterol: ≤ 2 days per week
Limitation: None
FEV1: Normal

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What SABA medication is preferred for patients when they are sensitive to Tachycardia?

Levalbuterol (Xopenox)

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LABA Examples

Salmeterol
Formoterol
Vilanterol

(cannot use a LABA as Monotherapy)

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SABA Examples

Albuterol
Levalbuterol

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Can a patient with a sulfa allergy take Albuterol Sulfate?

Yes.
- sulfates are fine and completely unrelated to sulfonamides.
- Sulfonamides = sulfa allergy

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What are adverse drug reactions of both SABAs & LABAs

Tachycardia
Tremor
Hypokalemia

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Sympathomimetics MoA

Stabilize membrane of Bronchial Mast Cell
Stimulate adenylcyclase enzyme, causing bronchial smooth muscle relaxation

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Sympathomimetic that is selective for direct-acting stimulant of Beta-2 receptors causing smooth muscles to relax.
Can also be used in OB to act as a tocolytic and stop contractions

Terbutaline

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Terbutaline Adverse Effects

Acidosis
Rhabdo
Acute Renal Failure
SVT
A-fib
Hypokalemia (IV)

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Medications that block acetylcholine and relax airways. (4 - 6 hours)

SAMA
(Short-Acting Muscarinic Antagonist)

Ipratropium Bromide

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Adverse Drug Reactions of SAMAs

Dry Mouth
Nausea
Metallic Test

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Medications that block acetylcholine and relax airways for a long duration of time.

LAMA
(Long-Acting Muscarinic Antagonist)

Tiotropium
Glycopyrrolate
Umeclidinium

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Adverse Drugs Reactions of LAMAs

Dry Mouth
Constipation
Urinary Retention
Tachycardia
Blurred Vision

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Anti-inflammatory inhaled steroids that reduce swelling and mucus production in airways.

Inhaled Corticosteroids

Fluticasone
Budesonide
Beclomethasone

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What should patients do after using an Inhaled Corticosteroid?

Rinse mouth
- reduces risk of thrush

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Adverse Drugs Reactions of Inhaled Corticosteroids

Oral Candidiasis
Sore Throat
Hoarseness

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ICS + LABA Combinations

Fluticasone + Salmeterol = Advair
Budesonide + Formoterol = Symbicort

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ICS Low Dose Level of Advair Diskus

100/50 - 1 puff 2x daily

ICS Medium Dose Level of Advair Diskus

250/50 - 1 puff 2x daily

ICS High Dose Level of Advair Diskus

500/50 - 1 puff 2x daily

Medications that block leukotrienes which normally cause inflammation and narrowing of the airways.

Leukotriene Receptor Antagonists - Montelukast (Singulair)

Benefits of Montelukast (Singulair)

Taken once at bedtime 1 year and older Few interactions

Downsides of Montelukast

NOT a rescue therapy for acute asthma attack - Headache (most common) - NVD - Abdomen Pain - Flu-like symptoms

Small doses of allergens under the tongue to build up tolerance to allergens.

Sublingual Immunotherapy - Grass Pollen = Grazax - Ragweed Pollen = Ragwitek

Monoclonal Antibody for IgE

Omalizumab

Monoclonal Antibody for IL-5

Mepolizumab

Monoclonal Antibody for IL-4

Dupilumab

Indications for Monoclonal Antibody Treatments

Moderate to Severe Asthma - Subq every 2 - 4 weeks

Adverse Drug Reactions of Monoclonal Antibodies (Biologics)

Black Box Warning - Anaphylaxis Injection Site Reactions Very Expensive

Medications that is rarely used and seen mostly in the hospital setting for severe refractory asthma. - Inhibits phosphodiesterase (catalyzes cAMP degradation) and induces release of epinephrine.

Theophylline

ADRs of Theophylline

NARROW THERAPEUTIC INDEX - seizures and arrhythmias - close monitoring

Theophylline Considerations

Smoking Increases Elimination LOTS OF DDIs - 3A4 Substrate

Asthma Treatment: Step 1

Low-dose ICS + LABA (PRN)

Asthma Treatment: Step 2

Low-dose ICS (Maintenance) Low-dose ICS+LABA (PRN)

Asthma Treatment: Step 3

Low-dose ICS + LABA (Maintenance) + LTRA + SLIT or medium-dose ICS

Asthma Treatment: Step 4

Medium-dose ICS + LABA (Maintenance) + LAMA + LTRA + SLIT or high-dose ICS

Asthma Treatment: Step 5

High-dose ICS + LABA (Maintenance) + LAMA + LTRA + Low-dose oral steroids + Biologicals

Asthma Medications that are SAFE during Pregnancy

Albuterol Budesonide

Asthma Medications that are SAFE for Children + Infants

Leukotriene Modifiers Pulmicort Nebs

Sign of imminent respiratory failure in children

Grunting

Mild Asthma Peak Flow (PEFR)

> 80% = Green

Severe Asthma Peak Flow (PEFR)

< 50% = Red - Talks in Words - Usually accessory muscle use

Moderate Asthma Peak Flow (PEFR)

50 - 80% = Yellow

Asthma Exacerbation Treatment - Home

Albuterol Inhaler (every 3 - 4 hours) Oral Corticosteroids

Asthma Exacerbation Treatment - Emergency Department or Inpatient

Oxygen > 90% Continuous DuoNeb (every hour) Oral or IV Steroids

What medication increased the risk of asthma-related deaths when used as a monotherapy.

Salmeterol (LABA)

Blue Bloater

Chronic Bronchitis

Pink Puffer

Emphysema

COPD: Gold 1

FEV₁ ≥ 80%

COPD: Gold 2

FEV₁ 50-80%

COPD: Gold 3

FEV₁ 30-50%

COPD: Gold 4

FEV₁ < 30%

COPD Post Bronchodilator FEV₁/FVC

< 70%

Breathless with strenuous exercise (mMRC)

No Dyspnea - Grade 0

Shortness of breath when hurrying or walking up slight hill (mMRC)

Slight Dyspnea - Grade 1

Slower than normal pace on a level surface due to Shortness of Breath. Or has to stop to catch breath if walking normal pace. (mMRC)

Moderate Dyspnea - Grade 2

Stops to catch breath after walking 100 yards, or after a few minutes on a level surface. (mMRC)

Severe Dyspnea - Grade 3

Too Short of Breath to leave house or becomes short of breath while dressing or undressing. (mMRC)

Very Severe Dyspnea - Grade 4

Medication used for severe or very severe COPD that is not controlled with inhaled bronchodilators and in patients that are at high risk for exacerbations. Always used as adjunct to inhaled therapies (daily oral tablet)

Phosphodiesterase IV Inhibitors (PDE-4) - Roflumilast

ADRs of Roflumilast (PDE-4 Inhbitor)

Weight Loss Neuropsychiatric Effects

Tiotropium vs. LABA

Tiotropium Wins (mechanistic advantage of drying up secretions)

Primary Goal of COPD Management

Smoking Cessation

Oxygen Treatment for COPD

Resting Paₒ₂ < 55 mm Hg Saₒ₂ < 88% - must be used at least 15 hrs a day Walking Study Positive in Office - 6 min walk < 88% Goal > 90-92%

3 Cardinal Symptoms of COPD

↑ Dyspnea ↑ Sputum Purulence ↑ Sputum Volume

COPD Exacerbation Staging

1 Symptom = Mild 2 Symptoms = Moderate 3 Symptoms = Severe

< 4 exacerbations per year No comorbid illness FEV₁ > 50%

Uncomplicated

Age 65+ > 4 exacerbations per year Antimicrobial use in past 3 months Severe COPD ( FEV₁ < 50%) Comorbid Illness

Complicated

Recent Hospitalization (past 90 days) Chronic Steroid Use Resident of Nursing Home > 4 courses of ABX in past year Known Pseudomonas infection in past

Risk for P. aeruginosa

COPD ABX Recommendations

Recommended if: 2/3 cardinal symptoms are present and one of the symptoms includes ↑ Sputum Purulence or 3/3 Cardinal Symptoms

Usual Pathogens of COPD

S. pneumoniae M. catarrhalis H. influenzae

Usual Duration of COPD ABX

5 - 10 days

Common ABX for COPD

Bactrim Augmentin Doxycycline Clarithromycin Azithromycin

ABX for P. aeruginosa (COPD)

Levofloxacin (750 mg) Zosyn Cefepime

Prodrug to Prednisolone - Inhibits expression and secretion of CRH and vasopressin in hypothalamus - Suppresses release of ACTH from pituitary, reducing cortisol production

Prednisone

Only Mineralcorticoid we learned about

Fludricortisone

Prednisone (Intermediate Acting) Equiv. Potency (mg)

Methylprednisone (Intermediate Acting) Equiv. Potency (mg)

Dexamethasone (Long Acting) Equiv. Potency (mg)

0.75

Fludricortisone Equiv. Potency (mg)

125

Steroid Dose Equal to Amount Secreted Daily by Adrenal Cortex - Allows HPA Axis to function properly

Physiologic Dosing Prednisone ≤ 5 mg/day

Low Supra-physiologic Dosing (Steroids)

10 mg

Supra-physiologic Dosing (Steroids)

30 mg

High Supra-physiologic Dosing (Steroids)

60 mg

Short Term High-dose Steroids ADRs

Hyperglycemia Leukocytosis Insomnia Na + Water Retention GI Bleed

Hyperadrenocorticism

Cushing's Syndrome

Exogenous Cause of Cushing's Syndrome

Corticosteroids - high doses - long term therapy

How is Cushing's Syndrome diagnosed?

Dexamethasone Challenge - high levels of ACTH in morning blood draw

Features of Cushing's Syndrome

Moon Face Buffalo Hump Striae Hypertension Osteoporosis Amenorrhea Hirsutism

Primary adrenal insufficiency

Addison's Disease

Possible long-term exogenous steroid administration (> 14 days) might lead to what?

Secondary Adrenal Insufficiency

Most commonly caused and seen in chronic use of exogenous glucocorticoids and ABRUPT WITHDRAWAL causing HPA axis suppression

Addisonian Crisis (Adrenal Crisis)

What is the agent of choice for Addisonian Crisis?

Hydrocortisone

Average Adult Production of Cortisol

10 - 30 mg/day

Courses of Corticosteroids for what period of time pose a risk for HPA-axis suppression?

> 2 weeks (possible suppression)

Symptoms of Rapid Reduction in Corticosteroid Levels

Anorexia Nausea + Vomiting Weight Loss Lethargy Headache Fever Muscle and Joint Pain Postural Hypotension

Corticosteroid Tapering Therapy used frequently in Asthma + COPD Exacerbations

Burst Therapy - no taper required if < 14 days

Taper quickly over a 2 week period

Short-term Taper

Patients who have been on chronic therapy should be tapered over months toward physiologic dose

Long-term Taper

Corticosteroids ADRs

Peptic Ulcers Hypertension Hypokalemia Insomnia Hyperglycemia Osteoporosis Infection

Patients that are taking long-term dosing of Steroids and undergo severe stress such as Accidental Trauma or Surgery may need what?

Tenfold Dosage Increase for 48-72 hours

Pulmonary Treatments & Steroids Flashcards

(107 cards)