What are the goals of therapy when treating asthma? (3)
1. Reduce the frequency and intensity of asthma symptoms (reduced cough, chest tightness, wheezing, dyspnea, decrease use of rescue short acting beta agonists, reduce night-time symptoms and awakenings, improve quality of life)
2. Prevent exacerbations (to prevent hospitalizations)
3. Prevent long term consequences of poorly controlled asthma
What is well-controlled asthma?
-symptoms no more than twice per week
-night-time symptoms no more than twice per month
-short acting beta agonists should be used less than twice weekly (with the exception of routine use prior to exercise)
-peak flow near normal
-oral steroid no more than once per year
-urgent care visit no more than once per year
Name 3 types of long-acting asthma medications
1. Inhaled glucocorticoids (preferred for long-term control medication for the treatment of persistent asthma)
2. Long-acting inhaled beta2-agonists (preferred for supplementary long-term control for use with inhaled glucocorticoids)
3. Leukotriene modifiers (oral pills)
True or False: Long acting beta agonists (LABA) are first line therapy for treating asthma patients.
False! Inhaled glucocorticoids are first-line therapy. Long acting beta agonists should not be used alone for asthma since it doesn't reduce inflammation! There is an observed increase in asthma-related deaths when LABA is used alone. It has to be combined with an inhaled corticosteroid to control the inflammation component.
What is the anti-IgE medication that can be used to help with allergic asthma?
Omalizumab. This inhibits the binding of IgE to the high affinity IgE receptor on mast cells and basophils. Decreasing bound IgE decreases the release of mediators of the allergic response
What is the anti-IL5 medication that can be given to help with eosinophilic asthma?
Mepolizumab. This decreases IL-5 which is the cytokine responsible for the growth and differentiation, recruitment, activation, and survival of eosinophils.
How can systemic glucocorticoids help with asthma?
Systsemic glucocorticoids (prednisone pills or IV form) can be used to manage severe acute asthma exacerbations by reducing immune response.
What is albuterol? What is it used for?
Albuterol is a common short acting beta2-agonist. It is preferred treatment to relieve symptoms and to prevent exercise-induced asthma.
In treatment of obstructive lung disease, what are anticholinergics used for?
Anticholinergics are used for COPD but not asthma. It is used as a secondary reliever for significant asthma exacerbations.
Explain the stepwise approach for managing asthma from mild to severe.
For mild cases, give a short acting beta agonist (albuterol) which is taken as needed. One step above that would be to give a inhaled corticosteroid. A step above that would be to add a long acting beta agonist to the inhaled corticosteroid. From there, you can increase the dosing of the combination therapy and consider adding omalizumab for patients with allergic asthma.
How do b-adrenergic agonists work?
They stimulate beta-adrenergic receptors which cause bronchodilation via smooth muscle relaxation. It also inhibits the production of respiratory secretions.
What do anticholinergics do? (mechanism of action and beneficial effect)
Anticholinergics inhibit cholinergic receptors. This causes bronchodilation via smooth muscle relaxation and inhibits the production of respiratory secretions.
What is the mechanism of action and beneficial effect for glucocorticoids?
The mechanism of action of glucocorticoids is phospholipase inhibition and inhibition of cytokine synthesis. This is an anti-inflammatory effect which reduces cellular infiltration, particularly eosinophils, mast cells, and lymphocytes. Glucocorticoids also vasoconstrict which reduces edema.
True or False: Inhaled corticosteroids can have a significant effect on growth which can cause children on ICS to fall short of their predicted height.
What is the beneficial effect for leukotriene modifiers?
- anti-inflammatory effect due to leukotriene blocking effect
- Attenuates exercise-induced asthma
What is cromolyn/nedocromil?
Before albuterol, cromolyn was the common inhaled preventative therapy for exercise-induced asthma. It can also prevent allergen-induced pulmonary response. It does this all by inhibiting mast cell mediator release.
What is theophylline?
It is an old medication that inhibits phosphodiesterase. This has a bronchodilator effect and some anti-inflammatory activity.
Theophylline has a narrow therapeutic window which makes it difficult to manage so it's not used frequently anymore.
What is the benefit of inhaled drug administration? (3)
- Medications are delivered directly to the site of action, bypassing hte need for absorption.
- Smaller doses are needed and a more rapid onset of action can be obtained
- Systemic side effects are minimized
Why is particle size important for aerosol medication delivery? What is the desired size?
Large particles will deposit in the pharynx and the walls of the larger airways while very small particles are too small to be deposited and are retained in the airways and exhaled. The desired size is between 1-5 microns so the particles can deposit in the small airways as a result of gravitational sedimentation.
Follow-up is essential when managing asthma. When initiating therapy, monitor at _____ week intervals to ensure asthma control is achieved. Regular follow-ups at _____ month intervals are needed depending on the level of control.
2-6 week, 1-6 month
What is step-down and why is it important?
Step-down is important to identify the minimum dose of medication necessary to control symptoms and prevent adverse effects. Consider stepping down medication if the subject is well-controlled for 3 months. The dose of inhaled corticosteroids should be reduced 20-50 percent every 3 months to achieve the lowest dose possible to maintain control.
What happens with parenchymal destruction?
Parenchymal destruction causes a loss of alveolar attachments and decrease of elastic recoil. This is seen in emphysema
True or False: COPD onset is typically mid-life while Asthma onset is early in life
True or False: COPD symptoms vary from day to day while Asthma symptoms slowly progress
False. COPD symptoms slowly progress while Asthma symptoms change from day to day
Explain the combined assessment of COPD
Combined assessment combines the risk (airflow limitation based on % reduced FEV1) and the frequency of exacerbations.
What are some lifestyle changes that can help COPD patients?
Smoking cessation (w/ support and nicotine replacement if needed), physical activity, and pulmonary rehab (respiratory therapy exercises)
Which patients (A, B, C, D from combined assessment of COPD) is it recommended to start pulmonary rehabilitation?
Patients in categories B, C, and D should start pulmonary rehabilitation. All patients should stop smoking, exercise, and get flu and pneumococcal vaccinations.
Explain the stepwise approach for managing stable COPD
With patients in category A, you can start with a short-acting beta2-agonist or you can start with short acting anticholinergics. In category B, you can do long-acting beta2-agonists or long-acting anticholinergics. In category C, you can do combination therapy with long acting beta2 agonists with inhaled corticosteroids or long-acting anticholinergics.
The difference between treating COPD and asthma is that in COPD you typically try hte long-acting anticholinergics and you can add the other medications to that as symptoms progress.