Asthma

Question 1

Intermittent Asthma Severity

Answer 1

• Daytime sxs =< 2d/w
• SABA rescue inhaler use: =< 2 d/w
• Recommend Step 1 Therapy initially

Question 2

Mild Asthma Severity

Answer 2

• Daytime sxs >2 d/w but not daily
• SABA rescue inhaler use >2 d/w but not daily or >1x/d
• Recommend Step 2 Therapy initially

Question 3

Moderate Asthma Severity

Answer 3

• Daytime sxs daily
• SABA use daily
• Recommend Step 3 Therapy initially

Question 4

Severe Asthma Severity

Answer 4

• Daytime sxs throughout the daily
• SABA use several times per day
• Recommend Step 4/5 Therapy initially

Question 5

Asthma Guidelines

Answer 5

• NHLBI’s EPR (Expert Panel Report)

- GINA

Question 6

Well-Controlled Asthma

Answer 6

• Sxs/use of SABA =< 2 d/w
• Nighttime awakening =<2x/month
• No limitations to normal activity
• Maintain current treatment, if controlled at least 3 months, can consider step down tx

Question 7

Not Well-Controlled Asthma

Answer 7

• Sxs/use of SABA > 2d/w
• Nighttime awakening 1-3x/week
• Some limitations to normal activity
• Step up 1 level of tx

Question 8

Very Poorly Controlled Asthma

Answer 8

• Sxs/use of SABA daily
• Nighttime awakening >4d/week
• Normal activity extremely limited
• Step up 1-2 levels of tx, consider systemic steroid course

Question 9

Step 1 Asthma Tx

Answer 9

• PRN low dose ICS-formoterol

- SABA + Low-dose ICS (taken with SABA)

Question 10

Step 2 Asthma Tx

Answer 10

• PRN low dose ICS-formoterol

- SABA + Daily low-dose ICS

Question 11

Step 3 Asthma Tx

Answer 11

• Low-dose formoterol + Low-dose ICS + formoterol

- SABA + Low-dose ICS + LABA

Question 12

Step 4 Asthma Tx

Answer 12

• Low-dose ICS/formoterol + Medium-dose ICS/formoterol

- SABA + Medium-dose ICS-LABA

Question 13

Step 4 Asthma Tx

Answer 13

• Low-dose ICS/formoterol + High-dose ICS/formoterol

- SABA + High-dose ICS/LABA

Question 14

Albuterol

Answer 14

• SABA
• Proair HFA/Respiclick, Ventolin HFA, Proventil HFA
• 90 mcg/inh
• PO forms available but NOT recommended
• Dose: 1-2 inh Q4-6h PRN
• Most contain 200 inh/canister, Ventolin HFA has 60 inh/canister option as well
• Clean by rinsing under water at least once weekly, air dry

Question 15

SABA Information

Answer 15

• SE: Nervousness, tremor, tachycardia, palpitation, cough, HYPERglycemia, HYPOkalemia
• Shake HFA products (MDI) well before use
• EIB: 2 inh 5 minutes prior to exercise

Question 16

Xopenex HFA

Answer 16

• SABA

- Levalbuterol, R-isomer of albuterol

Question 17

Asthmanefrin Refill

Answer 17

• SABAA
• Racepinephrine
• Don’t use since non-selective
• OTC

Question 18

Primatene Mist

Answer 18

• Epinephrine
• OTC
• FDA-approved for mild sxs in intermittent asthma ONLY
• Generally not a preferred SABA for reliever

Question 19

Serevent Diskus

Answer 19

Salmeterol

• LABA
• Monotherapy option (NEVER use in asthma, only COPD)
• Combinations: Advair or AirDuo (Fluticasone) - use in maintenance only

Question 20

LABA Information

Answer 20

• Box warnings: Increased risk of asthma-related deaths (only give if receiving AND uncontrolled on long-term asthma control medications (ICS), increased asthma hospitalization in pediatric/adolescent patients
• NOT for acute bronchospasm (long onset)

Question 21

QVAR Redihaler

Answer 21

Beclomethasone

• Don’t shake before use
• No priming/activation needed

Question 22

Flovent HFA/Arnuity Ellipta

Answer 22

Fluticasone

Question 23

Symbicort HFA

Answer 23

• Budesonide + Formoterol
• Never put in water
• *Preferred 1st line for Asthma, reliever or maintenance (step 2+)**

Question 24

Pulmicort Flexhaler

Answer 24

• Budesonide
• Use respules in jet nebulizer ONLY
• Flexhaler is only DPI that needed to be primed
• Preferred ICS for preggo

Question 25

Advair Diskus

Answer 25

-Fluticasone + Salmeterol | ICS + LABA

Question 26

Breo Ellipta

Answer 26

- Fluticasone + Vilanterol - ICS + LABA - Maintenance only

Question 27

Dulera HFA

Answer 27

Mometasone + Formoterol - Never put in water * *Preferred 1st line for Asthma, reliever or maintenance (step 2+)**

Question 28

ICS Information

Answer 28

- SE: Dysphonia (difficulty speaking), oral candidiasis (thrush), cough - Warnings: Increased fracture risk

Question 29

Alvesco

Answer 29

- Ciclesonide | - MDI that DOESN'T need to be shaken before use

Question 30

MDIs

Answer 30

- HFA, Respimat, RediHaler, or no suffix (Alvesco) - Aerosolized liquid - Some use propellant (HFA) - Slow, deep inhalation while pressing canister (coordination) - Can use spacer in those with less coordination and/or to decrease thrush risk - Must shake prior to use (Exceptions: QVAR Redihaler, Alvesco, and Respimat products) - Prime at first use and if not used for a significant period of time (based on med used - Ex: Ventolin, Symbicort, Dulera, etc.

Question 31

DPIs

Answer 31

- Diskus, Ellipta, Pressair, Handihaler, Neohaler, Respiclick, Flexhaler - Fine powder - No propellant, spacer, shaking or priming needed - Quick, forceful inhalation (no need to press anything)

Question 32

Singulair

Answer 32

- Montelukast - Tablet, chewable tablet, granules - Approved for allergic rhinitis and EIB as well - Dose >14 yo: 10 mg PO QPM - Dose 6-14 yo: 5 mg PO QPM - Dose 1-5 yo: 4 mg PO QPM

Question 33

Leukotriene Modifying Agent Information

Answer 33

- Box warning: neuropsychiatric events (montelukast) - Montelukast granules can be administered directly to mouth or mixed with 5 mL of breast milk/formula OR a spoonful of applesauce, carrots, rice, or ice cream - Use granules w/in 15 mins of opening packet - Zileuton - Zyflo, QID - Zafirlukast (Accolate) must be dispensed in original container (protect from moisture and light) and BID - Z drug - liver toxic

Question 34

Theophylline

Answer 34

- Active metabolites include caffeine and 3-methylxanthine - Dosing based on IBW (actual if underweight) - Therapeutic Range: 5-15 mcg/mL (measure at PEAK) - Michaelis-Menton Kinetics - SE: persistent vomiting, arrhythmias, and seizures associated with toxicity - ATM

Question 35

Xolair

Answer 35

- Omalizumab - Monoclonal antibody that inhibits IgE binding - Indicated for moderate to severe allergic asthma in patients 6yo+ with positive skin test - Given SQ q2-4w - Administer in HC setting with supervision - Box Warning: anaphylaxis

Question 36

Reliever Options

Answer 36

For sudden sxs relief: - ICS + Formoterol: preferred first line - SABA (PRN) - Systemic steroids: for exacerbations or SEVERE asthma

Question 37

Maintenance Drugs for Asthma

Answer 37

Used DAILY to help control sxs: - ICS: first line for ALL patients - LABA: NEVER alone in asthma - LTRA, theophylline, LAMA (Spiriva only in Asthma), monoclonal antibodies: add-ons

Question 38

Interleukin Receptor Antagonists

Answer 38

- Used in severe asthma with eosinophilic phenotype - Ex: all have -li- in name - Reslizumab, mepolizumab, etc. - Anaphylaxis warning!