Asthma Management and Treatment

Estrogen Effects on Asthma

• Estrogen alone may affect asthma.
• Estrogen replacement during menopause without progesterone can worsen asthma outcomes.
• Estrogen may exacerbate asthma during premenstrual syndrome (PMS).

Non-Selective Beta Blockers

• These drugs do not cause bronchospasm.
• These drugs can reduce the effectiveness of albuterol when taken together.

Aspirin Allergies

• Inhaled Corticosteroids (ICS) are the primary preventative treatment.

Acute Asthma Exacerbation Treatment

• Short-Acting Beta Agonist (SABA) such as albuterol is the first step.
• Systemic corticosteroids, like prednisone, prednisolone, methylprednisolone, or dexamethasone, are used depending on severity.
• Other options are inhaled ipratropium (anticholinergic), intravenous magnesium sulfate, and oxygen (O2).
• Severe cases may need IV steroids, optional IV magnesium, and optional ICS.
• Mild to moderate cases use an oral route for steroids.
• Severe cases may need an IV route if the airway is closing.
• Recommended dosage is age-based.

ICS for Chronic Asthma

• Mometasone furoate DPI dosages:
  • Low: 110-220
  • Medium: 220-240
  • High: >440
• Budesonide (Symbicort) 90-180 mcg/dose DPI:
  • The same inhaler is used when stepping up or down in dosage.
  • Adults: max 12 inhalations/day.
  • Adolescents (12-17 y/o): 11 inhalations/day.
  • Children (4-11 y/o): 8 inhalations/day.
• Advair (LABA/ICS) contains fluticasone and salmeterol.
  • Diskus: 1 inhalation BID for ages 4-11 and 12+.
  • HFA: 2 puffs BID for those 12+.

Montelukast (Singulair)

• Montelukast is a leukotriene receptor antagonist (LTRA).
• LTRA reduces leukotriene production/action in inflammation and allergy, reducing airway edema and smooth muscle contraction.
• Montelukast is approved for exercise-induced asthma and treats chronic asthma.
• LTRA is referenced in GINA guidelines.
• It comes in chewable tablets, granules, and tablets.
• Administer at night and adjust the dose based on age.
• Doses:
  • 12 months to 5 years: 4 mg once daily
  • 6-14 years: 5 mg once daily
  • 15+ years: 10 mg once daily

Asthma Patient Therapy

• Therapy is determined with GINA guidelines, which are used to decide the step the asthma patient is in.
• Options include Symbicort (budesonide), Mometasone, and Advair (fluticasone and salmeterol).

Asthma Products Counseling Points

• If priming is needed, two pumps are required if the inhaler is new or hasn't been used in 7 days.
• For SABAs, wait 15-30 seconds between puffs.
• Spacers are often used for patients under 6.
• For others, waiting between puffs is not required.
• Inhaling can be done with the inhaler slightly outside the mouth, with a spacer, or with the whole mouth on it.

COPD Products

• Spiriva Respimat and Combivent
  • TOP is used, which means Turn, Open, and Press (soft mist inhalers).
  • Expiration: 3 months after opening.
  • Spiriva Tiotropium is a (antimuscarinic aka anticholinergic).
  • Combivent includes ipratropium and albuterol.
• Spiriva Handihaler
  • It is a capsule device.
  • Dosage form is DPI, so breath in on your own.
  • Expiration: 6 weeks after opening.
  • It includes Tiotropium (antimuscarinic).
  • Side effects exist.
• Advair Diskus
  • Dosage form is DPI
  • Contains fluticasone and salmeterol
  • Mouth should be rinsed after use
  • Expiration: 1 month after opening
  • It is a capsule.
• Trelegy
  • Contains fluticasone furoate, umeclidinium, and vilanterol.
  • Dosage form is DPI
  • Mouth should be rinsed after use
  • Expiration: 6 weeks

ICS Therapy

• How to step up and down:
  • Step down ICS doses by 25-50% at 3-month intervals if feasible and safe.
  • Avoid stepping down therapy during gestation in pregnancy.

Drugs for Acute Exacerbation of Asthma:

• Albuterol and corticosteroids are options.
  • Corticosteroids include prednisone, methylprednisolone, prednisolone, and dexamethasone.
• Anticholinergics:
  • Ipratropium bromide nebulizer and Metered Dose Inhaler (MDI).
  • Usually given with albuterol (Duoneb).
  • Albuterol and levalbuterol can be administered via nebulizer or MDI.

How To Use Nebulized Albuterol

• Continuous nebulization is recommended if there is an unsatisfactory response with less than 50% normal FEV1 or PEF after the initial 3 doses every 20 minutes of aerosolized b-agonist.
• Continuous nebs can be used for patients presenting initially with PEF or FEV1 less than 30% of predicted value.

Guideline Knowledge

• Recommendations for CBC- vaccines.
  • Flu: every fall annually.
  • Tdap: every 10 years.
  • RSV: one dose.
  • COVID: vaccine with flu.
  • Pneumonia:
• Administer the vaccine for those 19-50 yr with COPD!!
• Shared decision-making after 65.
• Those over 50 need an extra pneumonia vaccine.
• IDSA-bacterial infections
• AAP-Acute otitis media
• RSV
• GOLD
• GINA

Long-Acting Beta Agonist (LABA)

• LABAs are not recommended for monotherapy in asthma.

Medication MOA and Class

• Asthma Medications:
• SABA: Albuterol, Levalbuterol, Epinephrine (OTC), work via inhibition of immediate hypersensitivity mediators from mast cells.
• Corticosteroids: Beclomethasone, Budesonide, Ciclesonide, Flunisolide reduce synthesis and release of pro-inflammatory cytokines and reduce inflammatory cell activation. They may have an effect on beta receptors.
• Fluticasone and Mometasone (inhaled)
• Anticholinergics compete with muscarinic receptors. Blockade of M2 receptors leads to the further release of presynaptic acetylcholine which can antagonize the bronchodilator effect.
  • SAMA: Ipratropium, DuoNeb (albuterol and ipratropium).
  • LAMA: Tiotropium (Spiriva Respimat) - do not use Spiriva handihaler.
• Leukotriene modifiers reduce the production/action of leukotrienes in allergy and inflammation to reduce airway edema and smooth muscle contraction.
  • Montelukast and Zafirlukast (rare hepatotoxicity).
  • Zileuton: 5-lipoxygenase inhibitor catalyzes the formation of leukotrienes from arachidonic acid.
• Biologics:
  • Recombinant anti-IgE antibody decreases the release of inflammatory mediastors.
  • Omalizumab can cause anaphylaxis and injection site reactions and increase the risk of infection. Dosage is determined by weight and IgE levels, 2-4 week intervals.
  • Dupilumab is an Interleukin 4 antagonist that decreases inflammatory mediator release. Can have similar adverse effects.
  • II 5 antagonists; Benralizumab, Mepolizumab, Reslizumab.
• Additional drugs used:
  • Cromolyn is a mast cell stabilizer.
  • Methylxanthines (Theophylline and aminophylline): phosphodiesterase inhibitor to reduce bronchodilation, inhibition of release of mediators from mast cells and leakocytes.
• COPD can use SABA, SAMA.
  • LABA: Salmeterol (DPI) and Formoterol (nebulized).
  • Arformoterol - Nebulized and Indacaterol (DPI) Olodaterol (SMI).
• LAMA:
  • Tiotropium (SMI and DPI).
  • Aclidinium (DPI).
  • Glycopyrrolate (Nebulized or DPI).
  • Umeclidinium (DPI).
  • Revefenacin (Nebulized).
• Corticosteroids:
  • ICS monotherapy is not recommended for COPD.
  • ICS/LABA is not recommended - LAMA/LABA or triple therapy recommended instead.
• Phosphodiesterase 4 (PDE4) inhibitor:
  • Relaxes airway smooth muscle cells and reduce activity of inflammatory cells and mediators such as TNF and IL-8.
  • Roflumilast is not to be given with theophylline due to similar MOA.
  • Consider if triple therapy doesn't work.
  • Neuropsychiatric effects.
• Phosphodiesterase 3 and 4 inhibitor -Ensifentrine
• Macrolides:
  • Azithromycin: increased risk of hearing loss, QTC prolongation, don't use while smoking.
• A1- antitrypsin replacement therapy:
  • Expensive 50,000.
• Mucolytics- guaifenesin:
  • Lack of evidence.
• Opioids (morphine):
  • End-stage dyspnea.

Symbicort Info

• Symbicort (ICS/LABA) is used for chronic asthma.
  • GINA guidelines recommend it for MART therapy (only one).
  • One inhaler for acute and maintenance.
  • Total daily dose calculation for maintenance and emergency use cases.
  • Budesonide (Symbicort + formoterol) 90-180 mcg/dose DPI.
• It can be used when stepping up and down.
  • Low-medium = 80 mcg.
  • Med-high= 160 mcg.
• Maintenance treatments:
• 1-2 inhalations once or twice daily. -Adults: max 12 inhalations/day.
  • 12-17 y/o: 11 inhalations/day. -4-11 y/o: 8 inhalations/day.

COPD Vaccines

• Vaccines recommended for someone with COPD:
  • 19-50 pneumococcal vaccine.
  • 50 + get an additional vaccine.

Other

• Focus on combination PowerPoint and specific items from the last PowerPoints to identify drug formulations.
• Identify long and short-term effects of using steroids and special points for geriatrics (cataracts, osteoporosis, skin thinning).
• Identify the group and selective therapy for a COPD patient with community-acquired pneumonia (CAP) or Mycoplasma pneumoniae pneumonia.
• If therapy fails, identify options.
• Drug side effects are commonly tested.
  • Examples: Monoclonal antibodies, Beta agonist, Anticholinergics, Azithromycin increases the risk of hearing loss for people with COPD, Et

Acute COPD Exacerbations

• Someone with acute COPD exacerbations for which antibiotics, steroid, or both are recommended.
  • 3 cardinal symptoms- dyspnea, sputum production, or cough.
  • 1 cardinal symptom (mild)- bronchodilator alone.
  • 2 or 3 cardinal symptoms
    • Prednisone 40 mg Qday x 5-7 days + bronchodilator.
    • If uncomplicated (less than 4 exacerbations a year) Azithromycin, cefdinir, doxycycline can be added to the treatment listed above.
    • Complicated (>4 exacerbations in a year or those 65 and up with comorbidities) Augmentin or Levaquin, or a patient with >14 days of steroids, hospitalization, or IV Abx in the prior 90 days or are in long-term care; Levaquin or IV Piperacillin / tazobactam or cefepime can be added to the bronchodilator.
• Theophylline has a narrow therapeutic index (5-15 mcg/mL).
  • Toxicities (>20 mcg/mL).
  • Drug interactions – CYP 1A2, CYP 3A -Fluroquinolones decrease clearance
  • 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

• Recommend a smoking cessation product for someone with COPD while identifying contraindications.
  • NRT is contraindicated with recent (in the past two weeks) stroke or MI.
  • Use Bupropion SR if all is clear from the patient's medical hx - Avoid with PMH of seizures or eating disorders.
  • Nicotine gum and patches as well as varenicline (partial agonist on nicotinic receptors) are possible options.
  • Others: tricyclic antidepressants, behavioral therapy, hypnosis.
• Bacterial Abx overview slides with diagnosis, side dose treatment durations and for each type.
  • Know the dosage and duration of each.
• Someone with CAP with pneumococcal resistance rates, patient medical history – give the proper recommendation. Review curb scores and proper dosages:
  • Treat empirically for MRSA or Pneumonia if the patient is severe.
  • The Patient is diagnosed as 3+ minor or 1 major is severe CAP.
• Major (minor) Criteria: Septic shock, respiratory failure, Hypotension Uremia 20+, Confusion Resp rate 30+, PaO2/flo2 Multilobar infiltrates Leukopenia Thrombocytopenia Hypothermia
• Out-patient criteria: if a patient needs assistance to be treated through amoxicillin along with doxycycline along with azithromycin, and clarithromycin if patients are pneumococcal and resistant is <25%.
• In-patient treatment: Chronic Heart Issues: ( Augmentin+ Azithromycin Or Cefuroxime + Doxycycline). The treatment should be (Fluoroquinolone) monotherapy.
• Inpatient CAP: Patients can take Ampicillin / sulbactam + azithromycin, can use iV instead of PO, and their contraindication against Macrolide or fluoroquinolone treatment must be considered. A patient with acute inpatient severe CAP is going through a non-monotherapy state needs to be treated with, iV beta lactam,w/ beta lactamase inhibitor ceph + macrolide and needs respiratory Fluoroquinolone to cure it.

Coudh Medications

• Antitussive chart with opioids. Should be Known by students. Opioids: suppresses the cough in the medullary area.

Medical Properties

• The medication’s side effects and the synergistic effect on cns are additive.
• Need 18+ To take that treatment.
• Need medical attention more than a couple of times.
• Hydrocodone and chlorpheniramine are one of the strongest medications when it comes to opioids
• Know everything about oseltamivir (Tamiflu) except for pediatric dosing properly.
• The recommended adult dosage for prevention and other forms of treatments.
• If there is any exception patient needs to be reported.
• If a patient is in need of a nursing home and the flu is ongoing a long treatment is required to cure the disease properly

Acute Otitis Media.

• If we have a patient for a ( 6 mths – 12 years) old patient- treat a patient accordingly to provide a 1st line Amoxicillin 80-90 mg/kg/day And Augmentin 90 mg/kg/day.
• The patient requires a 2nd type of recommendation to be only given a certain Type II or Cefdinir

Bacterial Infections

• The information of Bacteria With the infection can be used in practice properly
• Neuraminidase inhibitor slide- patients can compare a new drug or a previous drug in their history to find better ways to cure the disease. (Oseltamivir) for example can improve influenza by stopping the release of new viral particles.
• Patients with neuropsychiatric disorders have difficulties and their treatments require different forms of procedures for better treatments and effects.

Other Bacterial Information

• CUREs - are the type of infections you should calculate and take in consideration with medical advice .
• You should consider the criteria of (Respiratory, Confusion).
• RSV medication for Patients are AAP- related and what is not normally and commonly recommended.
• For nebulized is a much better option in recommendation.
• The recommended bronchitis treatment for a patient ( cough, fever,2 years olds) require Antiseptic in treatment.
• It is more likely safe that the cough is a type of production.

LAMA/LABA

• Umeclidinium or vilanterol : Used For Group B/E . With just One Inhalation per Day
• Antibacterials: if symptoms continue to be present healthy with respiratory problems patients will start to come together to get a solution fast,

Explore potential impacts of hormone replacement therapy, systemic corticosteroids, and inhaled corticosteroids on asthma. Learn about dosage classifications, medication interactions, and treatments for specific conditions like AERD. Understand appropriate montelukast dosage for children.