Asthma Management: Medications and Considerations

• Estrogen

Estrogen Effects on Asthma

• Estrogen replacement during menopause can exacerbate asthma unless combined with progesterone
• Estrogen alone may worsen asthma during PMS

Non-Selective Beta Blockers (Propranolol)

• These drugs do not cause bronchospasm but prevent the reversal, thus reducing the effects of Albuterol if taken together

Aspirin Allergies

• ICS's are the primary preventative treatment

Acute Asthma Exacerbation

• Identify the correct steroid
• Key drugs to administer; SABA (Albuterol), Systemic Corticosteroids (Prednisone, Prednisolone, Methylprednisolone, Dexamethasone), Inhaled Ipratropium (anticholinergic), Intravenous Magnesium Sulfate, and O2
• For severe cases; IV option for steroids, optional IV Magnesium, optional ICS, and mild/moderate coverage
• For mild or moderate asthma; use the oral route
• Severe asthma requires the IV route due to airway closure
• Dosage is based on age
• ICS for chronic asthma

Mometasone Furoate DPI

• Low dose 110-220
• Medium dose 220-240
• High dose >440

Budesonide (Symbicort) 90-180 mcg/dose DPI

• Has the ability to use the same inhaler when stepping up or down
• Max Inhalations/day for Adults: 12
• Max Inhalations/day for 12-17 y/o: 11
• Max Inhalations/day for 4-11 y/o: 8

Advair (LABA/ICS) (Fluticasone and Salmeterol)

• Diskus - 1 inhalation BID (ages 4-11) and (12 and up)
• HFA - 2 puffs BID (ages 12 and up)
• Fluticasone and salmeterol
• Montelukast (Singulair)
• LTRA - Leukotriene receptor antagonist

Montelukast

• Reduces production or action of leukotrienes in inflammation and allergy
• Is approved for exercise induced asthma
• Treats chronic asthma
• LTRA in GINA guidelines
• Available in chewable, granules, and tablets
• Administer at night
• Dosage is 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 Patient

• Based on GINA guidelines, determine the appropriate step and therapy
• Symbicort (Budesonide)
• Mometasone
• Advair (Fluticasone and Salmeterol)

Counseling Points for Asthma and COPD

• Asthma products require priming with two pumps if new or unused for 7 days
• SABA puff intervals need 15-30 seconds; other puff intervals do not
• Inhale with inhaler slightly outside mouth, with a spacer, or the whole mouth
• Use a Spacer under 6 years

COPD Products

• To use, Turn, Open, Press (TOP) on the Spiriva Respimat and Combivent soft mist inhalers
• Spiriva Respimat and Combivent
• Expiration date: 3 months after opening
• Spiriva contains Tiotropium (antimuscarinic aka anticholinergic)
• Combivent contains Ipratropium and Albuterol
• Spiriva Handihaler
• Capsule device
• DPI - breath it in on your own
• Expiration date: 6 weeks after opening
• Tiotropium (antimuscarinic)
• Advair Diskus DPI
• Contains Fluticasone and salmeterol
• Should rinse mouth out with water
• Expiration date: 1 month after opening
• Trelegy contains Fluticasone furoate, umeclidinium, and vilanterol
• DPI
• Rinse mouth after use
• Expiration date: 6 weeks

ICS Therapy

• Review slides on asthma and COPD lecture
• Stepping down ICS doses 25–50% at 3-month intervals is considered feasible and safe
• Avoid stepping down therapy during gestation in pregnancy
• Drugs That Are an Option for an Acute Exacerbation of Asthma
• Albuterol and corticosteroids
• Corticosteroids
• Prednisone
• Methylprednisolone
• Prednisolone
• Dexamethasone

Anticholinergics

• Ipratropium bromide, nebulizer and MDI
• Usually combined with Albuterol (Duoneb)
• Albuterol and Levalbuterol
• Nebulizer and MDI

Nebulizer Albuterol

• Continuous nebulization is recommended if there is unsatisfactory response (FEV1 or PEF less than 50% normal) following the initial 3 doses (every 20 minutes) of aerosolized b-agonist
• Also use where PEF or FEV1 is less than 30% of predicted value
• Know all of the guidelines: CBC, IDSA, AAP, RSV, GOLD, GINA

Vaccines

• Flu – every year during fall
• Tdap – every 10 years
• RSV – one dose
• COVID- with flu

Pneumonia

• 19-50 with COPD!! Encouraged to get vaccine
• Shared decision making after 65
• After 50 you need an extra vaccine

Long-Acting Beta Agonist (LABA)

• Not recommended for monotherapy in asthma

MOA of Asthma Medication

• SABA - inhibition of immediate hypersensitivity mediators from mast cells

SABAs

• Albuterol (Short Acting Beta Agonist)
• Levalbuterol
• Epinephrine (OTC)
• Corticosteroids – reduce synthesis and release of pro-inflammatory cytokines, reduce inflammatory cell activation, possible effect on beta receptors:
• Beclomethasone (inhaled)
• Budesonide (inhaled)
• Ciclesonide (inhaled)
• Flunisolide (inhaled)
• Fluticasone (inhaled)
• Mometasone (inhaled)

Anticholinergic

• Competitive inhibitors of muscarinic receptors
• Blockade of m2 receptors allows further release of presynaptic acetylcholine and antagonize the bronchodilator effect

SAMAs

• Ipratropium
• DuoNeb (albuterol and ipratropium)

LAMAs

• Tiotropium (Spiriva Respimat)
• Do not use Spiriva handihaler 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 reduces 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
• Benralizumab - Il 5 antagonists
• Mepolizumab - Il 5 antagonists
• Reslizumab - Il 5 antagonists
• Additional for Asthma/COPD

Cromolyn

• Mast cell stabilizer

Methylxanthines

• Theophylline and aminophylline: phosphodiesterase inhibitor to reduce bronchodilation, inhibition of release of mediators from mast cells and leakocytes

COPD

• Can still use SABA, SAMA, and 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
• May be used 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 - Exprensive 50,000

Mucolytics- Guaifenesin

• Lack of evidence

Opioids

• Morphine - End stage dyspnea

Symbicort

• ICS/LABA is used for chronic asthma
• GINA guidelines recommends it for MART therapy (only one)
• One inhaler for acute and one for maintenance and emergency
• Budesonide (Symbicort + formoterol) 90-180 mcg/dose DPI
• Can use the same inhaler when stepping up and down
• 80 mcg for Low-medium dose
• 160 mcg for Med-high dose

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
• Recommended vaccines for someone with COPD
• 19-50 need pneumococcal
• 50 + get an addition vaccine
• Identify drug formulation (focus on combination PowerPoint or very specific ones from the last PowerPoints)
• Be aware of short- and long-term effects of using steroids and special points for geriatrics
• Cataracts, osteoporosis, skin thinning
• COPD patient with 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 can have adverse effects
• Beta agonist can have adverse effects
• Anticholinergics can have adverse effects
• Azithromycin may lead to increased risk of hearing loss especially for people with COPD
• Recommended antibiotics, steroid, or both for someone with acute COPD exacerbation:
• If 3 cardinal symptoms, dyspnea, cough, or sputum production
• If 1 cardinal symptom (mild), use only bronchodilator
• if 2 or 3 cardinal symptoms, use bronchodilator
• Prednisone 40 mg Qday x 5-7 days
• Uncomplicated means (less than 4 exacerbation in a year will need Azithromycin, cefdinir, or doxycycline)
• Complicated means (>4 exacerbations in a year or 65 and up with comorbidities, give Augmentin or Levaquin)

OCS Treatment Timeframes

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

Theophylline

• Theophylline drug has a narrow therapeutic index (5-15 mcg/mL)

Toxicities

• 20 mcg/mL drug serum levels presents with arrythmias and seizures must be medically addressed.

Interactions

• Drug interactions occur with CYP 1A2, CYP 3A4 - be cautious
• Fluoroquinolones may decrease drug clearance,
• Smoking and CYP 3A4 inducers can increase drug clearance
• Oral beta agonist (theophylline and albuterol syrup) not preferred for use in Asthma per GINA guidelines

Smoking Cessation

• When recommending smoking cessation product for someone with COPD – must identify products and contraindications
• NRT contraindicated with recent (in past two weeks) stroke or MI
• Bupropion SR should be avoided w/ PMH of seizures or eating disorders
• Nicotine gum, Nicotine patches and Varenicline are ok to use w/ patients with COPD if not contraindicated.
• Varenicline MoA: partial agonist on nicotinic receptors
• Other options to treat nicotine addiction are: tricyclic antidepressents, behavioral therapy, hypnosis

Bacterial Abx Overview

• Know bacterial Abx slides with diagnosis, treatment, second line options, allergic reactions and the dosage and duration of each
• Someone with CAP with pneumococcal resistance rates, patient allergy info, here is past medical history – what do you recommend? Review curb score and appropriate drugs and dosages

Bacterial Tx

• If severe: Treat empirically for MRSA or Pneumonia
• Severe CAP = 3+ minor or 1 major

Major Bacterial CAP Traits

• Septic shock with need for vasopressors
• Respiratory failure requiring mechanical ventilation

Minor Bacterial CAP Traits

• Hypotension
• Uremia 20+
• Confusion
• Resp rate 30+
• PaO2/flo2 <250
• Multilobar infiltrates
• Leukopenia <4000
• Thrombocytopenia <100,000
• Hypothermia

Outpatient CAP Treatments

• Amoxicillin recommended, can use doxycycline
• Azithromycin or clarithromycin if pneumococcal resistance to macrolides is <25% If they have chronic heart, lung, liver, DM, alcoholism, asplenia, malignancy Augmentin + azithromycin Or cefuroxime + doxycycline

CAP Monotherapy Agents

• Fluoroquinolone

Inpatient CAP Treatment

• Ampicillin/sulbactam + azithromycin
• No doxycycline and use IV instead of PO

Inpatient Monotherapy

• Respiratory fluoroquinolone

Bacterial Interactions

• Contraindication to marcolide or fluoroquinolone
• Ceftriaxone + doxycycline

Inpatient Severe CAP Tx

• no monotherapy, use IV beta lactam w/ beta lactamase inhibitor or ceph +macrolide
• Can also add respiratory fluoroquinolone

Antitussive Chart

• Know everything on the antitussive chart with opioids
• Opioids suppress the cough reflex in the medullary center
• Opioid Side effects are: nausea, itching, constipation, and respiratory depression
• Additive and synergistic cns depression with cns depressants so be cautious.
• Must be 18 y or older to take so check ID.
• Hydrocodone/chlorpheniramine is given 5ml Q 12 hours max at 10 ml/day.
• Hydrocodone/homatropine (5 ml every 4-6 hours at 30 ml max/day).
• Codeine/ guifenesin (15ml every 4-6 hours max 90 ml/ day)

Tamiflu (Oseltamivir)

• Know everything about oseltamivir (Tamiflu) except for pediatric dosing
• Adult dosage for treatment and prevention based on CrCl
• Adult: 75 mg BID x 5 days
• CrCl 30-60 -> 30 mg BID x 5 days
• CrCl: 10-30 ->30 mg QDay x 5 days
• Exception: If you have flu and pneumonia and have been sick for more than 48 hours, they will treat you with oseltamivir and not Tamiflu.

Tamiflu Facts

• Nursing homes- on Tamiflu for a long time
• Prophylaxis is 48 hours from exposure
• 75 mg Qday x 10 days
• CrCl 30-60 -> 30 mg BID x 10 days
• CrCl: 10-30 ->30 mg QID x 10 days
• Recommended treatment of patients with acute otitis media - what patient age, fever, ear pain is needed for acute ottis media?
• Ages 6 moths-12 years old), fever (102.2), ear pain greater than 48 hours
• If positive treat with 1st line.
• Amoxicillin line amount: 80-90 mg/kg/day BID
• Augmentin dosage: 90 mg/kg/day BID

Bacterial Allergies

• Only if patient has taken Abx in past 90 days, purulent conjunctivitis, history of recurrent infection, unresponsive to amoxicillin
• Cefdinir is beneficial if the patient has Type ii PCN allergy
• Or clindamycin is beneficial is patient is: type i
• If there is therapy failure after 48-72 hours, consider prescribing: Augmentin or Clindamycin + or – cefdinir.

Treat Duration Ranges

• <2 years old 10 day treatment
• 2-6 years old 7 days mild, 10 if severe

• 6 years old 5-7 days mild-mod, 10 if severe

Bacterial Associations

• Bacteria associated with each infection
• S. Pneumonia is assoc with the follwoing: acute bacterial rhinosinusitis and pneumonia
• H. influenza is assoc with the follwoing: acute bacterial rhinosinusitis and pneumonia
• M. catarrhalis is assoc with the follwoing: acute bacterial rhinosinusitis
• Klebsiella is seen with Alcoholics patients
• E. Coli is associated with pneumonia patients.
• P. Aeruginosa is assoc with pneumonia.
• S. Pyrogens (group A) are assoc with Strep throat (pharyngitis)

Neuraminidase Inhibitor Slide

• Slide - compare oseltamivir to the others:
• Inhibits the release of new viral particles from host cells by stopping catalyzing the cleavage of linkages to sialic acid and may cause Neuropsychiatric complications
• Oseltamivir is a Capsule and a solution and should be taken at the 5 day treatment mark. This is the Preferred drug for influenza and Can take 2 weeks old and and even if Pregnant and lactating. Remember, it is Renally dosed.
• Zanamivir is a Diskhaler given with at the 5 days treatment mark and is Not renally dosed and only approved for 7 years and up

Antivirals

• Peramivir is an IV antiviral medication for patients that are 2 years and up, given at the 1 day treatmark and it is Renally dosed

Curb Score

• To Calculate a Curb-65 score, must include minor and all other criteria, for this, Curb-65 is made up of Confusion, high Uremia, High Respiratory rate and low Blood pressure and will need to know patient current medical history and age.
• The scoring for Curb comes out to the follwoing:
• If <2, patient is determined to be outpatient
  • If =2, the patient is determined to be an inpatient need to be treated for such.
  • If a persons score comes out to 3+, determined that the patient needs ICU as the matter is more severe.
• If a patient has a 3+ minor traits or a singular major trait, that is considered SEVERE.

Major Bacterial Infection Traits

• This includes: Septic shock with need for vasopressors or Respiratory failure requiring mechanical ventilation- if these are present or is severe

Minor Bacterial Infection Traits

• This includes: Hypotension or an Uremia of 20+ or they are presenting with confusion or a Respiratory rate of 30+ or if there reading for PaO2/flo2 is <250 or if patient had Multilobar infiltrates or if the patient presents to be Leukopenia <4000 or if they Thrombocytopenia is <100,000or lastly, If patient in Hypothermia from the bacterial infection.

RSV

• Should AAP recommend and what is not routinely recommended:
• In the instance of someone coming in with RSV – and being Nebulized that Nebulized hypertonic saline should be prescribed vs aerosolized b2-agonist or other treatments to consider being prescribed or considered to be prescribed includes: Systemic corticosteroids or Ribavirin or other synthetic nucleoside.
• Should be given Antipyretics and/or analgesics.

Bronchitis Tx

• Shouldnt be considered: No benefit from aerosolized b-agonist or aerosolized corticosteroids and use Antitussives with caution when cough is productive:
• Possible perscriptions and Antitussives includes: Dextromethorphan with Codeine andor guaifenesin and even Guaifenesin by itself

Bronchitis Medications and Solutions

• H2o by itself or should considered the need of the patient or the infection possibly treat with Antibiotics for: Healthy with respiratory symptoms for more than 5-7 days or for predisposed patients (elderly, COPD, immune compromised)
• Group BE perscriptions inclue: Anoro Ellipta for patients who a LAMA/LABA and who only need One inhalation one in a daily fashion with the medication in the combination called: Umeclidinium/vilanterol.

This content covers key considerations and treatments for asthma management, including estrogen replacement therapy, use of beta-blockers, corticosteroid administration, and appropriate dosing of medications like montelukast and inhaled corticosteroids. It addresses specific scenarios related to asthma exacerbations and chronic management.