Asthma, COPD & Infectious Diseases

• These study notes cover key concepts related to asthma, COPD, and various infectious diseases, including their treatments, medications, and guidelines.

Estrogen and Asthma

• Estrogen replacement during menopause can worsen asthma, especially without progesterone.
• Decreases in estrogen levels during PMS may also exacerbate asthma.

Non-Selective Beta Blockers

• Propranolol and similar drugs don't cause bronchospasm but can prevent its reversal, reducing the effectiveness of albuterol.

Aspirin Allergies

• Inhaled Corticosteroids (ICS) are the primary preventative treatment for asthma in patients with aspirin allergies.

Acute Asthma Exacerbation Treatment

• Treatment includes:
  • SABA (Albuterol)
  • Systemic Corticosteroids (Prednisone, Prednisolone, Methylprednisolone, Dexamethasone)
  • Inhaled Ipratropium (anticholinergic)
  • Intravenous Magnesium Sulfate
  • Oxygen

Acute Asthma Exacerbation Severity

• Severe cases may require intravenous steroids and magnesium, along with ICS.
• Mild to moderate cases typically use oral corticosteroids.

ICS for Chronic Asthma

• Mometasone Furoate DPI:
  • Low dose: 110-220 mcg
  • Medium dose: 220-440 mcg
  • High dose: >440 mcg
• Budesonide (Symbicort) 90-180 mcg/dose DPI:
  • Doses can be adjusted using the same inhaler.
  • Adults: max 12 inhalations/day
  • 12-17 y/o: 11 inhalations/day
  • 4-11 y/o: 8 inhalations/day
• Advair (Fluticasone and Salmeterol)
  • Diskus: 1 inhalation BID for ages 4-11 and 12+
  • HFA: 2 puffs BID for ages 12+

Montelukast (Singulair)

• Leukotriene Receptor Antagonist (LTRA)
• Reduces airway edema and smooth muscle contraction by reducing leukotriene production.
• Approved for exercise-induced asthma and chronic asthma.
• Available in chewable, granules, and tablets.
• Administered at night.
• Dosage based on age:
  • 12 months to 5 years: 4 mg once daily
  • 6-14 years: 5 mg once daily
  • 15 and up: 10 mg once daily

Asthma Treatment Based on GINA Guidelines

• Treatment is determined by assessing which step the patient is in and choosing the appropriate therapy.
• Examples of medications used:
  • Symbicort (Budesonide/Formoterol)
  • Mometasone
  • Advair (Fluticasone and Salmeterol)

Asthma/COPD Counseling Points and Devices

• Asthma Products:
  • Prime new or unused SABA inhalers with two pumps if not used in 7 days (have to prime it)
  • Wait 15-30 seconds between SABA puffs.
  • No waiting time needed between puffs for other inhalers.
  • Inhale with the inhaler slightly outside the mouth, with a spacer, or with the whole mouth on it.
  • Spacers are typically used for children under 6.
• COPD Products:
  • Spiriva Respimat and Combivent:
    • TOP – Turn, Open, Press (soft mist inhalers)
    • Expiration: 3 months after opening
    • Spiriva- Tiotropium (antimuscarinic aka anticholinergic)
    • Combivent- Ipratropium and Albuterol
  • Spiriva Handihaler:
    • Capsule device
    • DPI – breath it in on your own
    • Expiration: 6 weeks after opening
    • Tiotropium (antimuscarinic) with possible side effects.
  • Advair Diskus:
    • DPI
    • Fluticasone and Salmeterol
    • Rinse mouth with water after use.
    • Expiration Date: 1 month after opening
    • Capsule
  • Trelegy:
    • Fluticasone Furoate, Umeclidinium, and Vilanterol
    • DPI
    • Rinse mouth after use.
    • Expiration Date: 6 weeks

ICS Therapy Adjustment

• Step down ICS doses by 25-50% every 3 months if feasible and safe.
• Avoid stepping down therapy during pregnancy.

Drugs for Acute Exacerbation of Asthma

• Albuterol and Corticosteroids:
  • Prednisone
  • Methylprednisolone
  • Prednisolone
  • Dexamethasone
• Anticholinergics:
  • Ipratropium Bromide nebulizer and MDI
  • Usually combined with albuterol (Duoneb)
• Albuterol and Levalbuterol:
  • Nebulizer and MDI

Nebulizer Albuterol Use

• Continuous nebulization is recommended for patients with an unsatisfactory response (less than 50% normal FEV1 or PEF) after the initial 3 doses (every 20 minutes).
• Also recommended for patients initially presenting with PEF or FEV1 less than 30% of the predicted value.

Recommended Vaccines

• Flu: every year during fall
• Tdap: every 10 years
• RSV: one dose
• COVID-19: with flu
• Pneumonia:
  • 19-50 with COPD
  • Shared decision-making after 65
  • After 50 you need an extra vaccine

Guidelines

• IDSA for bacterial infections
• AAP for Acute Otitis Media
• RSV
• GOLD
• GINA

Asthma and COPD Medications

• LABA drugs are not recommended for monotherapy in asthma per GINA guidelines.
• SABA:
  • Albuterol and levalbuterol inhibit immediate hypersensitivity mediators from mast cells
  • Epinephrine (OTC)
• Corticosteroids:
  • Reduce synthesis and release of pro-inflammatory cytokines, reduce inflammatory cell activation, and may affect beta receptors
  • Beclomethasone, Budesonide, Ciclesonide, Flunisolide, Fluticasone, Mometasone (all inhaled)
• Anticholinergics:
  • Competitive inhibitors of muscarinic receptors; blockade of M2 receptors allows further release of presynaptic acetylcholine and may antagonize the bronchodilator effect
  • SAMA:
  • Ipratropium + Albuterol (Duoneb)
  • LAMA:
  • Tiotropium (Spiriva Respimat)
  • Spiriva handihaler not for asthma
• Leukotriene Modifiers:
  • Reduction of production or action of leukotrienes in inflammation and allergy; reduces airway edema and smooth muscle contraction
  • Montelukast
  • Zafirlukast (rare hepatotoxicity)
  • Zileuton (5-lipoxygenase inhibitor catalyzes the formation of leukotrienes from arachidonic acid)
• Biologics:
  • Omalizumab: recombinant anti-IgE antibody -> decreases inflammatory mediator release (anaphylaxis, injection site reactions, increased risk of infection, dosing based on weight and IgE levels, 2-4 week dose interval)
  • Dupilumab: Interleukin 4 antagonist – decreases inflammatory mediator release (same adverse effects) Il 5 antagonists: Benralizumab, Mepolizumab, and Reslizumab
• Additional asthma medications:
  • Cromolyn (mast cell stabilizer)
  • Methylxanthines (Theophylline and Aminophylline - phosphodiesterase inhibitor to reduce bronchodilation, inhibition of release of mediators from mast cells and leakocytes)

COPD Medications

• Can still use SABA and SAMA
• LABA:
  • Salmeterol (DPI)
  • Formoterol (nebulized)
  • Arformoterol (nebulized)
  • Indacaterol (DPI)
  • Olodaterol (SMI)
• LAMA:
  • Tiotropium (SMI and DPI)
  • Aclidinium (DPI)
  • Glycopyrrolate (nebulized or DPI)
  • Umeclidinium (DPI)
  • Revefenacin (nebulized)
• Corticosteroid:
  • ICS monotherapy not recommended for COPD
  • ICS/LABA not recommended – go for LAMA/LABA or triple therapy
• Phosphodiesterase 4 (PDE4) inhibitor:
  • Relaxation of airway smooth muscle cells and decreased activity of inflammatory cells and mediators such as TNF and IL-8
  • Roflumilast (Don’t give with theophylline due to similar MOA, neuropsychiatric effects, may be used If triple therapy doesn’t work)
• Phosphodiesterase 3 and 4 inhibitor:
  • Ensifentrine
• Macrolides:
  • Azithromycin (increased risk of hearing loss, QTC prolongation, and don’t use while smoking)
• A1- Antitrypsin Replacement Therapy:
  • Expensive
• Mucolytics:
  • Guaifenesin (lack of evidence)
• Opioids:
  • Morphine (end-stage dyspnea)

Symbicort

• GINA guidelines recommend it for MART therapy (only one).
• One inhaler for acute and one for maintenance.
• Total daily dose considerations.
• Budesonide (Symbicort + Formoterol) 90-180 mcg/dose DPI:
  • Doses can be adjusted using the same inhaler.
  • Low-medium = 80 mcg
  • Med-high = 160 mcg
  • Maintenance: 1-2 inhalations one or twice daily
  • Adults: max 12 inhalations/day
  • 12-17 y/o: 11 inhalations/day
  • 4-11 y/o: 8 inhalations/day

COPD Vaccinations Recommendatons

• 19-50 Pneumococcal vaccine.
• 50 + get an additional vaccine.

Short- and Long-Term Effects of Steroids

• Special points for geriatrics (cataracts, osteoporosis, skin thinning).

COPD Patient Scenarios

• CAP or MMRc: identify the group and selective therapy; if therapy fails which options would you want to do.

Adverse Effects of Drugs

• Monoclonal antibodies
• Beta agonist
• Anticholinergics
• Azithromycin: increased risk of hearing loss for people with COPD

Acute COPD Exacerbation Treatment

• Recommended antibiotics, steroid, or both.
• 3 cardinal symptoms: dyspnea, cough, or sputum production: Mild: Bronchodilator only 2 or 3 cardinal symptoms : Bronchodilator + Prednisone 40 mg Qday x 5-7 days
• Uncomplicated (less than 4 exacerbation in a year: Azithromycin, cefdinir, doxycycline)
• Complicated (>4 exacerbations in a year or 65 and up with comorbidities: Augmentin or Levaquin)

• 14 days of OCS, hospitalization or IV Abx in the past 90 days, or live in long term care: PO Levaquin or IV Piperacillin / tazobactam or cefepime

Theophylline

• Narrow therapeutic index (5-15 mcg/mL).
• Toxicities ( >20 mcg/mL) causing arrhythmias and seizures.
• Drug interactions – CYP 1A2, CYP 3A4 caused by Fluoroquinolones (decreases clearance and smoking and CYP 3A4 inducers (Increase clearance)
• Oral beta agonist (theophylline and albuterol syrup) not preferred for use in Asthma per GINA guidelines

Smoking Cessation Products

• NRT contraindicated with recent (in past two weeks) stroke or MI.
• Bupropion SR (avoid with PMH of seizures or eating disorders).
• Nicotine gum
• Nicotine patches
• Varenicline (MOA: partial agonist on nicotinic receptors)
• Other: Tricyclic antidepressants, behavioral therapy, hypnosis.

Bacterial Antibiotic Overview

• Diagnosis, treatment, second-line options, allergic reactions
• Dosage and duration of each

Community Acquired Pneumonia

• For CAP with pneumococcal resistance rates, patient allergy info, and past medical history
• Review CURB-65 score and appropriate drugs and dosages.
• Severe CAP:
  • Treat empirically for MRSA or Pneumonia. 3+ minor or 1 major is severe CAP.
  • Major: Septic shock with need for vasopressors or Respiratory failure requiring mechanical ventilation.
  • Minor: Hypotension, Uremia 20+, Confusion, Resp rate 30+, PaO2/flo2
• Empiric Therapy for Inpatients with CAP
  • Ceftriaxone + Azithro or levo
  • or monotherapy (Levo or moxi) (not cipro)
    • Vanc/zosyn/ceftaroline (MRSA)
    • Bactrim (PJP)
• Outpatient treatment
  • macrolides or doxy
• If had prior IV ABX in last 3 months, can’t use doxy or macrolides

Therapy for influenza

• Goal <48 hours (PO Oseltamivir 75 mg QID x 10 days)
• Give within 48 hours

Exception: If flu and pneumonia and have been sick for more than 48 hours, they will treat you with Oseltamivir.

• Nursing homes- on Tamiflu for a long time

Acute Otitis Media Treatment

• Recommended treatment for patients with acute otitis media – age (6 months-12 years old), fever (102.2), ear pain greater than 48 hours
• 1st line:
  • Amoxicillin 80-90 mg/kg/day BID
  • Augmentin 90 mg/kg/day BID only if patient has taken Abx in the past 90 days, purulent conjunctivitis, history of recurrent infection, unresponsive to amoxicillin
  • Cefdinir for type II PCN allergy or Clindamycin for type I.
• Therapy failure after 48-72 hours:
  • Augmentin
  • Clindamycin + or – cefdinir
• Duration:
• 5-7 days mild-moderate, 10 if severe in patients 6 years and older.

Bacteria Associated with Infections

• S. Pneumonia: Acute Bacterial Rhinosinusitis and Pneumonia.
• H. Influenzae: Acute Bacterial Rhinosinusitis and Pneumonia.
• M. Catarrhalis: Acute Bacterial Rhinosinusitis.
• Klebsiella: Pneumonia in alcoholics.
• E. Coli: Pneumonia.
• P. Aeruginosa: Pneumonia.
• S. Pyrogens (Group A): Strep Throat (Pharyngitis).

Neuraminidase Inhibitors

• Inhibit the release of new viral particles from host cells by stopping catalyzing the cleavage of linkages to sialic acid
• Oseltamivir:
  • Capsule and solution
  • 5-day treatment, preferred drug for influenza
  • Can take 2 weeks old and up, can take while pregnant and lactating
  • Renally dosed
• Zanamivir:
  • Diskhaler, 5-day treatment
  • Not renally dosed, 7 years and up
• Peramivir:
  • 2 years and up, IV, 1-day treatment, renally dosed

CURB-65 Score

• Confusion
• Uremia (BUN > 20)
• Respiratory rate = or > 30
• Blood pressure (less than 90/60)
• = or > 65 years old

Key concepts related to asthma, COPD, and infectious diseases. Includes treatments, medications, and guidelines. Estrogen replacement, beta blockers, and aspirin allergies are discussed. Also covers acute asthma exacerbation treatments.