Asthma Treatment Guidelines and Medications
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Questions and Answers

Which organization is primarily responsible for the preferred guidelines for asthma care?

  • National Heart, Lung, and Blood Institute (NHLBI)
  • World Health Organization (WHO)
  • National Asthma Education and Prevention Program (NAEPP) (correct)
  • Global Initiative for Asthma (GINA)

What is the primary purpose of short-acting beta-2 agonists (SABAs) in asthma treatment?

  • To induce long-lasting effects
  • To provide as-needed relief from acute symptoms (correct)
  • To prevent airway inflammation
  • To control chronic asthma symptoms

Which technique is emphasized for asthma management according to the guidelines?

  • Use of oral medications only
  • Regular blood tests for airway inflammation
  • Proper use of inhalers and assessment of medications (correct)
  • Increasing physical activity levels

What is the purpose of inhaled corticosteroids in asthma treatment?

<p>To decrease airway inflammation (C)</p> Signup and view all the answers

Which class of asthma symptoms includes severe persistent asthma?

<p>Moderate persistent (C)</p> Signup and view all the answers

What is a potential benefit of Formoterol over traditional short-acting beta-agonists?

<p>It has a longer duration of action. (A)</p> Signup and view all the answers

Which medications are considered controllers in asthma management?

<p>Inhaled corticosteroids and long-acting beta-2 agonists (A)</p> Signup and view all the answers

What is the primary action of beta-2 agonists in asthma treatment?

<p>They promote smooth airway muscle relaxation. (A)</p> Signup and view all the answers

What are the main benefits of using oral corticosteroids in treating acute exacerbations?

<p>They reduce treatment failure and relapse rates. (B)</p> Signup and view all the answers

What is a significant risk of chronic oral steroid use during extreme physical stress?

<p>Risk of death from increased steroid demand. (B)</p> Signup and view all the answers

Which medication is a phosphodiesterase-4 (PDE4) inhibitor used for COPD, particularly in chronic bronchitis?

<p>Roflumilast. (B)</p> Signup and view all the answers

What is the primary action of Roflumilast in the management of COPD?

<p>To increase intracellular cyclic AMP. (D)</p> Signup and view all the answers

Which of the following is not a common adverse effect associated with Roflumilast?

<p>Weight gain. (A)</p> Signup and view all the answers

Which inhalation device delivers a measured dose of the drug with each use but requires hand-breath coordination?

<p>Metered-dose inhaler (MDI). (C)</p> Signup and view all the answers

Which inhalation device delivers more drug to the lungs, approximately 20%, and does not require hand-breath coordination?

<p>Dry Powdered Inhaler (DPI). (D)</p> Signup and view all the answers

What is an important consideration when using nebulizers compared to inhalers?

<p>They allow for less drug deposition on the oropharynx. (D)</p> Signup and view all the answers

What is a reported neuropsychiatric effect of Roflumilast use that healthcare providers should monitor?

<p>Anxiety and depression. (A)</p> Signup and view all the answers

Which therapeutic advantage is associated with inhalation as a delivery method for medications?

<p>More rapid onset of action. (B)</p> Signup and view all the answers

What is the primary disadvantage of using leukotriene receptor antagonists compared to inhaled corticosteroids?

<p>They are less effective for asthma control. (A)</p> Signup and view all the answers

Which type of medication is tiotropium bromide categorized as?

<p>Long-acting muscarinic antagonist (D)</p> Signup and view all the answers

What must be monitored when using theophylline due to its potential for toxicity?

<p>Serum theophylline concentrations (D)</p> Signup and view all the answers

What is the primary concern regarding the use of long-acting beta-2 agonists in asthma treatment?

<p>They lead to increased risk of asthma-related deaths when used alone. (D)</p> Signup and view all the answers

Which of the following side effects is commonly associated with theophylline therapy?

<p>Rapid heart rate (C)</p> Signup and view all the answers

Which monoclonal antibody works by inhibiting IgE binding to receptors on mast cells and basophils?

<p>Omalizumab (C)</p> Signup and view all the answers

What effect do long-acting muscarinic antagonists have when they block acetylcholine binding?

<p>Bronchodilation (D)</p> Signup and view all the answers

What is a potential risk associated with the use of monoclonal antibodies for asthmatic patients?

<p>Immune-type reactions (A)</p> Signup and view all the answers

What should be ensured when a patient with asthma is prescribed a long-acting beta-2 agonist?

<p>To combine it with an inhaled corticosteroid (D)</p> Signup and view all the answers

How does zileuton differ from leukotriene receptor antagonists?

<p>It causes more adverse effects. (D)</p> Signup and view all the answers

What is a significant concern when using salmeterol in pediatric patients?

<p>Risk of prolonged QT interval (A)</p> Signup and view all the answers

What is the recommended dosing practice for omalizumab used in asthma treatment?

<p>Based on body weight and total IgE levels (B)</p> Signup and view all the answers

Which of the following best describes a common use for the methylxanthine theophylline?

<p>Treatment for severe asthma not controlled with standard therapies (D)</p> Signup and view all the answers

What is the role of acetylcholine in the pathophysiology of asthma?

<p>It triggers increased mucus secretion and inflammation (B)</p> Signup and view all the answers

What is generally not recommended for patients with chronic obstructive pulmonary disease who experience occasional dyspnea?

<p>Short-acting bronchodilators used regularly (D)</p> Signup and view all the answers

What is the primary role of pulmonary rehabilitation in chronic obstructive pulmonary disease treatment?

<p>To improve symptoms and quality of life (B)</p> Signup and view all the answers

Which medication is used as a last resort for patients with chronic obstructive pulmonary disease due to its side effects?

<p>Methylxanthine - theophylline (D)</p> Signup and view all the answers

What is a common side effect of long-acting beta-agonists in COPD treatment?

<p>Tachycardia (A)</p> Signup and view all the answers

What is a significant concern associated with long-term use of inhaled corticosteroids in patients with COPD?

<p>Increased risk of pneumonia (D)</p> Signup and view all the answers

Which bronchodilator combination is typically prescribed to relieve acute symptoms in COPD patients?

<p>Short-acting beta-2 agonist plus short-acting muscarinic antagonist (D)</p> Signup and view all the answers

What major cardiovascular concern is associated with long-acting muscarinic antagonists in COPD treatment?

<p>Cardiovascular events (C)</p> Signup and view all the answers

Which condition is not considered a component of chronic obstructive pulmonary disease?

<p>Acute bronchiolitis (C)</p> Signup and view all the answers

For which scenario is a combination of inhaled corticosteroids and long-acting bronchodilators appropriate?

<p>For patients experiencing exacerbations (C)</p> Signup and view all the answers

What is the primary action of anticholinergic medications in COPD management?

<p>Bronchodilation and decrease secretions (C)</p> Signup and view all the answers

Which is a common side effect of theophylline at therapeutic serum concentrations?

<p>Vomiting (D)</p> Signup and view all the answers

What should be emphasized to patients using ipratropium bromide?

<p>Increased fluid intake (D)</p> Signup and view all the answers

Chronic obstructive pulmonary disease encompasses which two primary conditions?

<p>Chronic bronchitis and emphysema (D)</p> Signup and view all the answers

Which of the following vaccines is recommended for patients with COPD to reduce exacerbations?

<p>Flu vaccine (A)</p> Signup and view all the answers

Combining which two types of bronchodilators can be beneficial for patients with persistent symptoms?

<p>LABAs and LAMAs (B)</p> Signup and view all the answers

What is the primary reason inhaled glucocorticoids should not be used alone during an acute asthma attack?

<p>They do not provide immediate relief of bronchoconstriction. (C)</p> Signup and view all the answers

What is a significant concern regarding the use of inhaled corticosteroids in children?

<p>They can negatively affect growth velocity. (C)</p> Signup and view all the answers

Which of the following is a potential side effect of using mast cell stabilizers?

<p>Headaches (D)</p> Signup and view all the answers

What does Zafirlukast (Accolate) primarily act on?

<p>Leukotriene receptors (B)</p> Signup and view all the answers

Which medication class is used as a prophylactic treatment for asthma and allergies?

<p>Mast cell stabilizers (A)</p> Signup and view all the answers

In which condition should Zileuton (Zyflo) be used with caution?

<p>Active liver disease (A)</p> Signup and view all the answers

What is a common recommendation for patients using inhaled corticosteroids to prevent oral thrush?

<p>Rinse the mouth after each use. (B)</p> Signup and view all the answers

Why must inhaled corticosteroids be tapered gradually before discontinuation?

<p>To avoid systemic withdrawal symptoms. (D)</p> Signup and view all the answers

What is the main purpose of long-acting beta-agonists (LABAs) in asthma treatment?

<p>To achieve sustained bronchodilation. (B)</p> Signup and view all the answers

Which side effect can be exacerbated by the use of beta-agonists in patients with cardiovascular disease?

<p>Arrhythmias (C)</p> Signup and view all the answers

What can prolonged use of inhaled corticosteroids potentially lead to?

<p>Bone loss (D)</p> Signup and view all the answers

Which of the following side effects is a boxed warning for montelukast (Singulair)?

<p>Psychiatric disturbances (A)</p> Signup and view all the answers

What is the recommended duration for using high-dose oral corticosteroids before a taper may be necessary?

<p>More than 10-14 days (C)</p> Signup and view all the answers

What potential side effect is associated with corticosteroid use, especially with high doses?

<p>Fluid retention (B)</p> Signup and view all the answers

What is one of the recommendations for preventing bone loss in patients taking inhaled corticosteroids?

<p>Calcium and vitamin D supplementation (B)</p> Signup and view all the answers

What is an effect of leukotrienes in asthma management?

<p>They are inflammatory mediators. (A)</p> Signup and view all the answers

How should corticosteroid therapy be managed when transitioning from systemic corticosteroids to inhaled products?

<p>Gradually reduce systemic corticosteroids to avoid adrenal insufficiency. (B)</p> Signup and view all the answers

What condition should caution be exercised with when prescribing beta-agonists due to potential serum glucose level increases?

<p>Diabetes Mellitus (B)</p> Signup and view all the answers

Which combination in the medication Advair makes it effective for asthma treatment?

<p>Long-acting B2-agonist and steroid (D)</p> Signup and view all the answers

What characteristic is required for effective use of the Advair Diskus system?

<p>Deep inhalation technique. (D)</p> Signup and view all the answers

Which of the following side effects can result from corticosteroid therapy?

<p>Euphoria (B), Decreased bone density (D)</p> Signup and view all the answers

Which condition should corticosteroids be avoided in due to the potential for severe consequences?

<p>Active tuberculosis (A)</p> Signup and view all the answers

What is a known risk associated with prolonged corticosteroid therapy?

<p>Kaposi sarcoma (A)</p> Signup and view all the answers

What type of corticosteroid therapy is generally given to asthma patients during exacerbations?

<p>Short-term oral corticosteroids in bursts (A)</p> Signup and view all the answers

Which of the following are potential psychiatric side effects of corticosteroid use?

<p>All of the above (D)</p> Signup and view all the answers

What effect do beta-agonists typically have on the QT interval?

<p>Prolong it (A)</p> Signup and view all the answers

What is a common side effect of short-acting beta-agonists?

<p>Tremors (B)</p> Signup and view all the answers

In what scenario is high-dose oral steroid therapy particularly risky without a proper taper?

<p>When taken for longer than 14 days (C)</p> Signup and view all the answers

Which of the following medications should not be used as monotherapy for asthma?

<p>Salmeterol (C), Formoterol (D)</p> Signup and view all the answers

What is the observation period required after the first three injections of omalizumab?

<p>2 hours (C)</p> Signup and view all the answers

What potential effect does the class of Interleukin-5 receptor antagonists have relating to eosinophils?

<p>Decrease the production of eosinophils (A)</p> Signup and view all the answers

Which side effect is most commonly associated with Interleukin-5 receptor antagonists?

<p>Headaches (D)</p> Signup and view all the answers

What is the preferred rescue therapy for asthma during pregnancy?

<p>Inhaled short-acting β2-agonists (A)</p> Signup and view all the answers

What is not a contraindication for dupilumab use in asthma treatment?

<p>Pregnancy (B)</p> Signup and view all the answers

What serious reaction can occur with both Reslizumab and Dupilumab?

<p>Anaphylaxis (D)</p> Signup and view all the answers

What is the primary concern for untreated asthma during pregnancy?

<p>Preeclampsia (A)</p> Signup and view all the answers

Which inhaled corticosteroid is preferred for asthma management during pregnancy?

<p>Budesonide (C)</p> Signup and view all the answers

What common side effect should patients be cautious about with dupilumab?

<p>Injection site reactions (C)</p> Signup and view all the answers

What recommendation should be made to patients regarding symptoms of anaphylaxis after omalizumab administration?

<p>Seek immediate medical care if symptoms occur (D)</p> Signup and view all the answers

Which medication has known neonatal side effects, particularly affecting sleep?

<p>Theophylline (D)</p> Signup and view all the answers

What kind of asthma is treated with Interleukin-5 receptor antagonists?

<p>Eosinophilia asthma (D)</p> Signup and view all the answers

What should be done if signs of serious hypersensitivity reaction occur with dupilumab?

<p>Discontinue the medication immediately (D)</p> Signup and view all the answers

How long after drug administration can symptoms of anaphylaxis occur?

<p>Up to 24 hours or longer (C)</p> Signup and view all the answers

Flashcards

Asthma Treatment Guidelines

Recommendations for asthma management provided by organizations like GINA and NHLBI (EPR-4).

Quick-Relief Asthma Meds

Medications used to rapidly relieve asthma symptoms or exacerbations.

Bronchodilators

Medications that relax the airways for quicker breathing.

Inhaled Corticosteroids

Medications that reduce airway inflammation in asthma.

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Asthma Classification

Categorizing asthma severity based on symptom frequency and severity.

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Maintenance Asthma Meds

Medications that prevent and control asthma, reducing future risks.

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Beta-2 Agonists

Medications that help relax airways and improve breathing.

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Two-pronged Asthma Approach

Treating asthma by quickly opening airways (bronchodilation) and decreasing inflammation.

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Short-Acting Beta-Agonists (SABAs)

Medications like albuterol that quickly open airways, relieving asthma symptoms. Used for immediate relief.

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Long-Acting Beta-Agonists (LABAs)

Medications like salmeterol or formoterol that provide sustained bronchodilation. Used for maintenance, preventing exacerbations.

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Combined Therapy for Asthma

Using both an inhaled corticosteroid and a long-acting beta-agonist (LABA) for asthma management. This is recommended over LABA alone.

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Side Effects of Beta-2 Agonists

Nervousness, shakiness, tremors, palpitations, and possible heart rhythm problems. Can worsen cardiovascular disease.

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Oral Corticosteroids for Asthma

Short-term use of prednisone (a steroid) to manage asthma exacerbations. Typically given as "bursts" for symptom control.

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Tapering Corticosteroids

Gradually reducing the dose of oral corticosteroids over time to avoid withdrawal symptoms and adrenal suppression.

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Corticosteroid Withdrawal Effects

Increased allergic symptoms, adrenal insufficiency, and potential for adrenal crisis. These are risks when transitioning from oral to inhaled corticosteroids.

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Corticosteroids and Infections

Prolonged use can weaken the immune system, increasing risk of infections, masking existing infections, and reducing vaccine effectiveness.

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Corticosteroids and Mental Health

May cause mood changes, including euphoria, insomnia, and even psychosis. Preexisting conditions can be worsened.

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Corticosteroids and Heart Health

Use with caution in heart failure and hypertension. Long-term use can cause electrolyte changes, fluid retention, and blood pressure issues.

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Corticosteroids and Diabetes

May disrupt blood sugar control, leading to hyperglycemia. Use with caution in diabetic patients.

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Corticosteroids and Digestive System

Use with caution in patients with digestive issues. Can increase the risk of ulcers and perforations.

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Inhaled Corticosteroids (ICS)

Medications like fluticasone or budesonide that directly deliver corticosteroids to the airways. Minimize systemic side effects.

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Oral Corticosteroids vs. ICS

Oral corticosteroids have more systemic side effects compared to inhaled corticosteroids.

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Dosing Corticosteroids

Oral corticosteroids are typically given in short bursts for quick relief. Dosing may require tapering if needed.

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What are inhaled glucocorticoids' role in asthma?

Inhaled glucocorticoids (ICS) control inflammation in the airways, preventing asthma exacerbations. They're not for immediate symptom relief.

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Why are inhaled corticosteroids not used alone during acute asthma?

Inhaled corticosteroids don't offer rapid bronchodilation. They require time to reduce inflammation, while acute episodes need immediate relief.

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Explain Advair's mechanism in asthma.

Advair combines a long-acting beta-2 agonist (Salmeterol) with the steroid fluticasone. It opens airways and reduces inflammation for longer durations.

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Concerns of inhaled corticosteroids in children

Inhaled corticosteroids can impact growth velocity in children, but this effect is temporary. Long-term use may also pose a risk of bone loss.

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What is the importance of monitoring eye exams in patients using inhaled steroids?

Prolonged use of inhaled steroids may increase intraocular pressure, potentially worsening or increasing the risk of cataracts and glaucoma.

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What is the proper approach to discontinuing inhaled steroid therapy?

A gradual tapering of the inhaled steroid dose is recommended before discontinuing, especially in patients on high doses.

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How do mast cell stabilizers work in asthma?

Mast cell stabilizers like cromolyn are anti-inflammatory agents. They prevent the release of histamine and other substances that trigger bronchoconstriction.

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Explain the use of mast cell stabilizers in asthma.

Mast cell stabilizers, while not for acute symptoms, are used for prophylaxis, preventing future asthma attacks.

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Why are antileukotrienes used as controller medications?

Antileukotrienes block the action of leukotrienes, chemicals that contribute to inflammation and bronchoconstriction.

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Explain the mechanism of leukotriene receptor antagonists (LTRAs) in asthma.

LTRAs like montelukast bind to leukotriene receptors in the airways, preventing the inflammatory cascade.

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What is the purpose of the boxed warning for montelukast?

Montelukast carries a boxed warning due to reports of psychiatric disturbances, including agitation, aggression, depression, and suicidal thoughts in some patients.

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How does zileuton work as an antileukotriene?

Zileuton inhibits the enzyme responsible for producing leukotrienes, preventing their formation and reducing inflammation.

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Compare and contrast LTRAs and leukotriene synthesis inhibitors.

LTRAs like montelukast block leukotriene receptors, while zileuton blocks their production. Both reduce airway inflammation and bronchoconstriction.

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What are Zafirlukast and Montelukast used for?

Both Zafirlukast and Montelukast are medications that are used as controllers in asthma management. Unlike quick-relief meds, they help prevent exacerbations.

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LTRAs

Leukotriene receptor antagonists like montelukast and zafirlukast are used as alternatives to inhaled corticosteroids (ICS) for patients struggling to use ICS.

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LTRAs vs. ICSs

Leukotriene modifiers are generally less effective than inhaled corticosteroids (ICSs) for asthma control.

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LTRAs vs. LABAs

LTRAs are usually less effective than inhaled long-acting beta-agonists (LABAs) when added to ICSs for poorly controlled asthma.

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Zileuton

A 5-lipoxygenase inhibitor used as an add-on therapy for severe asthma, but tends to cause more side effects compared to LTRAs.

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SAMAs and LAMAs

Short-acting (SAMAs) and long-acting (LAMAs) muscarinic antagonists are used to treat asthma and COPD, by blocking acetylcholine receptors.

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Tiotropium Bromide

An inhaled LAMA (long-acting muscarinic antagonist) approved for asthma maintenance in patients 6 years and older.

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Tiotropium Benefits for Asthma

Adding tiotropium to ICSs for moderate-to-severe asthma can improve lung function, reduce symptoms, and lower exacerbation risk.

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Theophylline (Theodur)

A methylxanthine previously used for asthma, but is less common now due to better alternatives and many side effects.

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Theophylline Toxicity

Theophylline can be toxic, often reaching toxic levels before it becomes effective. Monitoring blood levels is crucial.

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Theophylline Drug Interactions

Theophylline interacts with various medications, including macrolides, quinolones, cimetidine, and anticonvulsants.

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Theophylline and COPD

The use of theophylline for chronic obstructive pulmonary disease is controversial, lacking sufficient evidence of its effectiveness.

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Salmeterol (Serevent)

A long-acting beta-2 agonist often combined with fluticasone (inhaled corticosteroid) in the medication Advair.

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Salmeterol Black Box Warning

Salmeterol is contraindicated as monotherapy (alone) for asthma, as it increases the risk of asthma-related deaths.

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Monoclonal Antibodies and Asthma

Monoclonal antibodies, like omalizumab (Xolair), target specific immune system components to treat severe asthma.

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Omalizumab (Xolair)

An anti-IgE antibody that reduces allergic reactions by limiting histamine and leukotriene release in severe asthma.

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Omalizumab Side Effects

Omalizumab carries a black box warning for anaphylaxis and bronchospasm, which can occur even after the first dose.

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Oral Corticosteroids in COPD

Used for acute exacerbations in hospitalized patients or emergencies to reduce treatment failure, relapse, and improve lung function and breathlessness. However, they have no role in chronic daily treatment due to numerous side effects like muscle weakness, decreased functionality, and risk of respiratory failure.

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Omalizumab Administration

Omalizumab requires careful monitoring after administration due to the risk of anaphylaxis. The first 3 injections need 2 hours of observation, while subsequent injections need 30 minutes.

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Roflumilast (Daliresp)

A phosphodiesterase-4 (PDE4) enzyme inhibitor used for chronic bronchitis patients on maximal inhaled therapy. It reduces inflammation by inhibiting cyclic AMP breakdown, decreasing lung inflammation and potentially slowing COPD progression.

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Antibiotics in COPD

Although older studies showed no effect on exacerbation frequency, recent research suggests regular use, especially of azithromycin in non-smokers, might reduce exacerbations due to their anti-inflammatory properties.

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Anaphylaxis Symptoms

Severe allergic reaction characterized by symptoms like hives, swelling, difficulty breathing, and low blood pressure. It can occur within 24 hours of drug administration.

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Reslizumab (Cinqair)

An IL-5 receptor antagonist used for severe asthma with eosinophilia, decreasing eosinophil production and inflammation.

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N-Acetyl-Cysteine (NAC)

An antioxidant agent and mucolytic used in patients not receiving inhaled corticosteroids. Regular treatment can reduce exacerbations and improve health status.

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Dupilumab (Dupixent)

An IL-4 receptor alpha antagonist used for moderate to severe asthma, reducing inflammatory responses triggered by IL-4 and IL-13.

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Advantages of Inhalation

Delivers drugs directly to their site of action in the lungs, minimizing systemic side effects, and provides rapid relief of acute attacks.

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Metered-Dose Inhalers (MDIs)

Small, hand-held devices delivering a measured dose with each actuation, requiring hand-breath coordination. Only ~10% of the drug reaches the lungs, so spacers are recommended to increase delivery and minimize oral thrush.

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Asthma & Pregnancy

Uncontrolled asthma during pregnancy increases risks of preeclampsia, preterm birth, fetal growth restriction, and perinatal mortality.

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Appropriate Asthma Rescue Therapy During Pregnancy

Inhaled short-acting β2-agonists are the preferred rescue therapy during pregnancy. Albuterol is the first-choice agent.

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Dry Powdered Inhalers (DPIs)

Deliver drugs in dry micronized powder directly to the lungs. No hand-breath coordination required, and they deliver ~20% more drug to the lungs. Spacers aren't needed.

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Controller Therapy for Asthma During Pregnancy

For mild, intermittent asthma, no controller therapy is needed. Budesonide is the preferred inhaled corticosteroid for those needing one.

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Nebulizers

Convert drug solution into a finer mist than inhalers, reducing oropharyngeal deposition and increasing lung delivery. Delivered through a face mask or mouthpiece.

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Roflumilast Side Effects

Common side effects include diarrhea, nausea, reduced appetite, weight loss, abdominal pain, sleep disturbances, and headaches. These can lessen over time. Monitor liver enzymes as hepatotoxicity is possible.

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Asthma Medications and Lactation

Most asthma medications are considered safe during lactation. Albuterol and budesonide are typically safe due to low bioavailability.

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Roflumilast and Psychiatric Effects

Neuropsychiatric effects like anxiety, depression, and insomnia have been reported. Rarely, suicidal behavior/ideation and completed suicide were reported. Assess risk versus benefits in patients with a history of depression.

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Theophylline and Breastfeeding

Theophylline, an asthma medication, can cause hyperstimulation and sleep disruption in infants. However, breastfeeding remains recommended due to its benefits.

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IL-5 Receptor Antagonists

Drugs like Reslizumab that target the IL-5 receptor, reducing the production of eosinophils, a type of white blood cell involved in asthma inflammation.

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Eosinophilia Asthma

Asthma characterized by an elevated number of eosinophils in the airways, suggesting a specific type of inflammation.

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Interleukin-5 (IL-5)

A cytokine responsible for the differentiation and maturation of eosinophils in the bone marrow. By inhibiting IL-5, drugs can reduce eosinophil production.

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Interleukin-4 (IL-4)

A cytokine involved in inflammatory responses, particularly in allergic conditions like asthma. Inhibiting IL-4 reduces inflammation.

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Dupilumab

A monoclonal antibody that targets the IL-4 receptor, effectively blocking IL-4 and IL-13 signaling, thus reducing inflammation in asthma.

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Pregnancy and Asthma Control

Maintaining adequate asthma control during pregnancy is crucial for the well-being of both mother and fetus. Uncontrolled asthma poses significant risks.

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COPD and airway obstruction

Chronic Obstructive Pulmonary Disease (COPD) involves two conditions: chronic bronchitis and emphysema, both causing airway obstruction.

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COPD goals of treatment

Treatment aims to reduce symptoms, lessen exacerbations, improve exercise tolerance, and enhance overall health.

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Does medication slow lung decline?

Current medications cannot conclusively halt the long-term decline in lung function associated with COPD.

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Vaccines for COPD patients

Influenza and pneumococcal vaccinations are crucial for COPD patients to decrease lower respiratory infections.

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Bronchodilators for COPD

Bronchodilators, commonly prescribed regularly, help relax constricted airways, easing breathing and reducing symptoms.

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Long-acting vs. Short-acting Bronchodilators

Short-acting bronchodilators (SABAs & SAMAs) are for immediate relief, while long-acting bronchodilators (LABAs & LAMAs) provide sustained opening of airways.

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Combining SABA & SAMA

Combining a short-acting beta-agonist (SABA) and a short-acting muscarinic antagonist (SAMA) is more effective than using either alone.

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Ipratropium bromide (Atrovent)

The only available SAMA agent, ipratropium bromide, comes as an inhaler or nebulizer solution.

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Ipratropium bromide: Side Effects

The main side effect of ipratropium bromide is dryness of the mouth. It's essential to emphasize increased fluid intake.

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Long-acting Bronchodilators: LABAs & LAMAs

Regular long-acting bronchodilator treatment (LABA or LAMA) is recommended for moderate to severe COPD symptoms.

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LAMAs: Effects and Uses

LAMAs like tiotropium bromide (Spiriva) are taken daily to keep airways open, providing better symptom control than LABAs.

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Methylxanthines: Theophylline (Theodur)

Theophylline is a daily pill with bronchodilator and anti-inflammatory properties, but it's typically a last resort due to side effects.

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Theophylline: Side Effects

Theophylline can cause nausea, nervousness, headache, insomnia, and at higher doses, vomiting, hypokalemia, tremors, and seizures.

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Combination Inhalers: Convenience and Cost Reduction

Combination inhalers offer different drug combinations for COPD treatment, providing convenience and potentially lower costs.

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Anti-inflammatory Therapy: Inhaled Corticosteroids (ICS)

Inhaled corticosteroids (ICS) are used in COPD patients with high eosinophilia or asthma component to decrease inflammation.

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Study Notes

Asthma Treatment Guidelines

  • Two main bodies provide asthma treatment recommendations: GINA (Global Initiative for Asthma) and EPR-4 (National Heart, Lung, and Blood Institute).
  • GINA's approach is integrated evidence-based strategies for clinical practice.
  • EPR-4 is the preferred guideline for asthma management.
  • Inhaler technique assessment is crucial.

Asthma Treatment Approach

  • Two-pronged approach: bronchodilation (rapid onset) and inflammation reduction.
  • Bronchodilation achieved with short-acting beta-agonists (e.g., albuterol) or long-acting beta-agonists (LABAs, e.g., formoterol) and, to a lesser extent, short-acting muscarinic agents.
  • Inflammation reduction done primarily with inhaled corticosteroids.
  • Asthma classified into mild intermittent, mild persistent, moderate persistent, and severe persistent.

Asthma Medications

Relievers

  • Used for "as-needed" relief of acute asthma symptoms.
  • Include short-acting beta-2 agonists (SABAs), short-acting muscarinic agents (SAMAs), and oral corticosteroids.

Controllers/Maintenance

  • Prevent and control symptoms by reducing inflammation.
  • Include inhaled corticosteroids, leukotriene modifiers, or inhaled corticosteroids combined with long-acting beta-2 agonists.

Beta-2 Agonists

  • Promote airway smooth muscle relaxation.
  • Include SABAs (e.g., albuterol) and LABAs (e.g., salmeterol, formoterol).
  • LABAs used in combination with inhaled corticosteroids, not as monotherapy.
  • Side effects of SABAs include nervousness, shakiness, tremors, palpitations.
  • Increased risk of arrhythmias in patients with cardiovascular disease. -Albuterol has the potential for direct myocardial toxicity or exacerbation of underlying myocardial dysfunction.
  • May prolong QT interval.
  • Use cautiously in patients with diabetes mellitus (increase serum glucose levels).
  • Use cautiously in patients with glaucoma (elevate intraocular pressure).

Oral Corticosteroids

  • Short-term use (bursts), especially during exacerbations.
  • Used as initial burst along with an inhaled glucocorticoid to cover until the inhaled corticosteroid acts.
  • High doses (>40mg) require tapering if for over 10-14 days.
  • Potential side effects: headaches, dizziness, sleep disturbance, mood swings, hyperglycemia, bone loss.
  • Adrenal suppression, especially in children. Careful withdrawal is crucial.
  • Potential fatalities with adrenal insufficiency following steroid cessation transfer.
  • Use of stress doses during surgical periods
  • Immunosuppression: increased susceptibility to infection, masking infections.

Inhaled Corticosteroids (ICS)

  • Mainstay of maintenance therapy.
  • Do not provide immediate bronchodilation.
  • Do not use alone for acute asthma.
  • Side effects similar to oral steroids, but at lower rates.
  • Examples: Fluticasone, Budesonide, Advair (fluticasone/salmeterol).
  • Advair's Diskus easier for correct inhalation (deep inhalation needed).
  • Concerns in pediatric patients: possible impact on growth velocity, bone loss; need for calcium and vitamin D, exercise, and smoking cessation.
  • Use cautiously in those with cataracts or glaucoma.

Mast Cell Stabilizers

  • Anti-inflammatory agents preventing bronchoconstriction.
  • Block histamine and SRS-A release from mast cells.
  • Example: Cromolyn sodium.
  • Requires several weeks for full effect.
  • Not for acute symptoms, but for prophylaxis.
  • Side effects include headaches, nasal irritation, and cough.

Antileukotrienes

  • Controller medications (do not treat acute symptoms).
  • Prevent airway edema, smooth muscle contraction, and inflammation.
  • Examples: Zafirlukast (Accolate), Montelukast (Singulair), Zileuton (Zyflo).
  • Monitor liver function with zileuton.
  • Singulair has a boxed warning for psychiatric disturbances.
  • Less effective than inhaled corticosteroids.

Short and Long-Acting Muscarinic Antagonists (SAMAs and LAMAs)

  • Block acetylcholines effect on muscarinic receptors
  • Result in bronchodilation, decreased mucus, and less inflammation.
  • Tiotropium bromide (LAMA) is FDA-approved for asthma (≥6 years old).
  • Adding tiotropium to ICS can improve lung function in moderate to severe asthma.
  • Combination inhaler (Trelegy Ellipta) containing fluticasone furoate, umeclidinium, and vilanterol.

Methylxanthines (Theophylline)

  • Less commonly used.
  • Monitor blood levels closely (10-15 mcg/mL).
  • Multiple drug interactions.
  • Side effects include stomach upset, sleep disturbance, headache, nervousness, rapid heart rate.
  • Not a preferred agent in COPD exacerbations.

Long-Acting Beta-2 Agonists (LABAs)

  • Not for monotherapy in asthma (increased risk of asthma-related deaths/hospitalization)
  • Use only in combination with inhaled corticosteroids.

Monoclonal Antibodies

  • Risk of immune reactions (vasculitis, eosinophilia, hypersensitivity).
  • Anti-IgE antibodies (omalizumab/Xolair): reduce allergen-triggered release of inflammatory mediators.
    • FDA-approved for severe asthma
    • Anaphylaxis risk, observe for 2 hours after first injection, 30minutes after subsequent injections.
  • IL-5 Receptor Antagonists (e.g., reslizumab): decrease eosinophil production. Used in severe eosinophilia-related asthma.
  • IL-4 Receptor Alpha Antagonists (e.g., dupilumab): inhibit IL-4 and IL-13-induced inflammatory responses.

Asthma and Pregnancy/Lactation

  • Asthma treatment essential, safer than untreated asthma.
  • Uncontrolled asthma increases preeclampsia, preterm birth risk.
  • Albuterol preferred SABA in pregnancy.
  • Budesonide preferred ICS for pregnancy.
  • Most asthma medications considered safe during lactation; consult current data. Minimise exposure via breastfeeding timing.

Chronic Obstructive Pulmonary Disease (COPD)

  • Includes chronic bronchitis and emphysema.
  • Goal of pharmacologic therapy is symptom reduction, exacerbation prevention, improved exercise tolerance.
  • No medication conclusively changes long-term lung function decline.

Bronchodilators for COPD

  • Regular use for symptom prevention.
  • Long-acting bronchodilators often preferred over SABAs.

Inhaled Medications

  • Advantages: direct effect on lungs, minimized systemic effects, rapid relief for acute attacks.
  • Types: Metered-Dose Inhalers (MDIs), Dry Powdered Inhalers (DPIs), Nebulizers.
  • MDIs: hand-breath coordination is needed, limited delivery.
  • DPIs: no hand-breath coordination, higher lung delivery.
  • Nebulizers: provide fine mist, useful for acute attacks.

Other COPD Treatments

  • Influenza and pneumococcal vaccines.
  • Pulmonary rehabilitation.
  • Antibiotics (e.g., azithromycin) may reduce exacerbations rates in some cases.
  • Mucolytics/N-acetylcysteine may be helpful in reducing exacerbations.
  • Combination inhalers available.

Anti-inflammatory Therapy in COPD

  • Inhaled corticosteroids (ICS) can reduce inflammation, especially in patients with high eosinophilia or asthma components.
  • ICS not approved as monotherapy for COPD worldwide. Long term use may pose issues.
  • Combination agents with ICS and LABAs are appropriate for COPD exacerbations on long acting bronchodilators.
  • Oral corticosteroids primarily for acute exacerbations.

Phosphodiesterase-4 (PDE4) Inhibitor

  • Roflumilast (Daliresp) reduces inflammation, slowing COPD progression.
  • Not a bronchodilator, not for acute symptoms.
  • Side effects include diarrhea, nausea, weight loss, sleep disturbances.
  • Monitor liver enzymes. Assess risks and benefits in patients with depression.

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Description

This quiz covers essential asthma treatment guidelines provided by GINA and EPR-4, highlighting the importance of proper inhaler techniques. It also discusses the dual approach to asthma management focusing on bronchodilation and inflammation reduction, along with an overview of medications used for asthma relief.

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