ASTHMA.docx

[ASTHMA ] - Diagnosing: - Hx of respiratory symp: variable in time and intensity, occur or are worse at night or walking, triggered by exercise/laughter/allergens/cold air, occur w/or worsen w/viral infections - Confirmed Variable Expiratory Airflow Limitatio...

[ASTHMA ] - Diagnosing: - Hx of respiratory symp: variable in time and intensity, occur or are worse at night or walking, triggered by exercise/laughter/allergens/cold air, occur w/or worsen w/viral infections - Confirmed Variable Expiratory Airflow Limitation: at a time when FEV1 is reduced, confirm that FEV1/FVC is reduced (usually \>0.75-.80 in adults) - documented Excessive Variability in Lung Function - Shared Decision Making - Inhaler skills, adherence, written asthma action plan, self-monitoring of symp and/or peak flow, regular medical review - Written asthma plan should include: pts usual asthma meds, when/how to increase med and start , how to access medical care if symp fail to respond - Non-pharm interventions: smoking cessation, physical activity, investigation for occupational asthma, identify aspirin-exacerbated respiratory disease MED STEPS \>12 years: refer to sheet! Track 1: Fomoterol is short acting and can act as a reliever and maintenance med. Track 2 already on track 2 and well controlled. Saba is reliever INITIAL CONTROLLER TX: refer to sheet! STEPPING UP ASTHMA TX - Sustained step-up (for at least 2-3 mo) - If symp and/or exacerbations persiste despite 2-3 months of controller tx, assess the following common issues before considering a step-up - Incorrect inhaler technique, poor adherence, modifiable RF, symp due to comorbidities - Short-term step-up (1-2 wks) - By clinician or by pt w/ written asthma action plan, e.g. during viral infection or allergen exposure - Day-to-day adjustment by pt - w/ as-needed low dose ICS-formoterol for mild asthma, or ICS-formoterol as maintenance and reliever therapy. This is effective in reducing severe exacerbations STEPPING DOWN ASTHMA TX - consider once good asthma control has been achieved and maintained for 3mo, to find the lowest tx that controls both symp and exacerbations, and minimizes s/e: - choose appropriate time, assess RF, document baseline status, provide asthma action plan, monitor closely, book f/u, reduce ICS dose by 20-50% at 2-3 mo intervals TX EXACERBATIONS - an acute or sub-acute worsening in symp and lung function from the pts usual status; occasionally it may be in the initial presentation of asthma - oral corticosteroids (preferably morning dose; review before ceasing) - for adults, prednisolone 40-50mg, usually 5-7 days - tapering not needed if OCS has been given for less than 2wk STEPWISE FOR 5 AND UNDER - step 1: as needed inhaled SABA - step 2: low dose ICS daily plus SABA as needed or daily LTRA + SABA as needed or intermittent short courses of ICS at onset of respiratory illness - step 3: double low dose ICS + SABA as needed or low dose ICS +LTRA and consider specialist referral - step 4: continue controller and refer to specialist for assessment or add LTRA or increase ICS frequency or add intermittent ICS [COPD] Group E (exacerbation): those who have \>/= 2 moderate exacerbations or \>/= 1 leading to hospitalization LABA + LAMA (consider LABA+LAMA+ICS if blood eosinophil \>/= 300) \*\*ICS increases risk for pneumonia in these pts For those that have 0 or 1 moderate exacerbations (not leading to hospital admission) Group A: bronchodilator (LABA) mMRC 0-1, CAT\/=2, CAT \>/=10 [COMMUNITY ACQUIRED PNEUMONIA ] - Adults - Viruses including influenza - Bacterial (most common): strept (most common, esp in elderly), haemophilus influenzae (common in smokers), staph aureus (pts recovering from flu), mycoplasma, chlamydia, legionella - \ - Outpatient treatment - For healthy adults W/OUT comorbidities or RF for antibiotic resistant pathogens - Amoxicillin 1g three times daily or - Doxycycline 100mg twice daily: best for \ - High risk individual\'s - Combination therapy - Amoxicillin/clavulante or Cephalosporin - AND Macrolide (azithromycin or clarithromycin) or Doxycycline - Or monotherapy: respiratory fluoroquinolone (floxacin) - How to know what agent to use? - Have they recently been on antibiotics? if they have you want to choose a different class - How long? minimum of 5 days. Pts should be afebrile and clinically stable for 48-72 hrs before stopping - Corticosteroids: not recommended for outpt use w/pneumonia - Chest imaging f/u not recommended [RSV] +-----------------------------------------------------------------------+ | Nirsevimab | | | | - A monoclonal antibody for infants under 8mo entering their first | | RSV season (oct-march) not vaccinated | | | | - Children up to 24mo who remain at risk of severe RSV disease | | through their second season | | | | - Be aware, vaccinating pregnant (32-36wks) people for RSV | | generally means the baby will NOT need nirsevimab | +=======================================================================+ | Palivizumab | | | | - Monoclonal antibody produced by recombinant DNA | | | | - Why is it used? | | | | - RSV prevention in infants/children at high risk for sev RSV | | | | - Noted reduced RSV disease hospitalization rate by up to 55% | | | | - Provides PASSIVE immunity, plays no role in tx of acute RSV, | | provides active immunity, is FDA approved for adults at high | | risk for sev RSV | +-----------------------------------------------------------------------+ | RSV Vaccination | | | | - Provide protection against RSV | | | | - Vaccine currently available | | | | - Models | | | | - Direct immunization of at-risk adults | | | | - Especially adults age \/= 60 | | | | - Immunize during pregnancy | | | | - Infant protect via passive immunity in 32-36 wk of | | pregnancy during RSV season | +-----------------------------------------------------------------------+ [FLU] Antiviral therapy do not tx the virus but helps prevent mortality and hospitalizations - Recommend that anybody exposed to flu or has flu take antiviral - Children \ - Management: - Antivirals +-----------------------------------------------------------------------+ | Oseltamivir- children 2wk and older; pill and suspension; given twice | | daily for 5 fays; s/e: nv | +=======================================================================+ | Zanamivir- children 7 and older; powder inhaler; should not be given | | to pts w/asthma or COPD; s/e: bronchospasm | +-----------------------------------------------------------------------+ | Peramivir- children 2 and older; IV only; s/e: diarrhea | +-----------------------------------------------------------------------+ | Baloxavir: children 5-12 who do not have any chronic medical | | conditions and for all people \12; given once PO; not rec for | | pregnant or lactating women | | | | Should be given w/in 48hours of onset | +-----------------------------------------------------------------------+ - For empiric tx most effective w/in 24hrs - Or \>48 hrs if person is at increased risk for serious morbidity and mortality - For outpts w/suspected or confirmed uncomplicated influenza - Oral oseltamivir or inhaled zanamivir or oral baloxavir - Any are acceptable depending on age COVID-19 - Preferred therapies - With + SARS test, eligible adults, peds pt w/risk for sev covid - Ritonavir-boosted nirmatrelvir PO - Start w/in 5days of symp onset for 5 days or - No antiviral activity - Co-packaged w/ritonavir to inhibit CYP metabolism of nirmatrelvir - Ritonavir is strongest known CYP inhibitor - RENAL IMPAIRMENT! GFR\>/=30 - 150mg nirmatrelvir w/100mg ritonavir, both tablets taken twice daily for 5 days - With sev renal impairment not rec - Remdesivir IV - Start w/in 7 days of symp onset for 3 days - Alternative therapies: bebtelovimab and molnupriravir [ALLERGIC RHINITIS] Three classes of drugs are utilized +-----------------------------------------------------------------------+ | 3. Glucocorticoids (intranasal) | | | | h. Best for both seasonal and perennial rhinitis | | | | i. Budesonide , fluticasone propionate (flonase), and | | triamcinolone | | | | j. AE: nasal mucosa drying, burning/itching, sore throat, | | epistaxis, ha | +=======================================================================+ | 1. Antihistamines (oral and intranasal) | | | | a. First line for mild-mod allergic rhinitis. Most effective | | when taken prophylactically | | | | b. First gen- sedation | | | | i. Ethanolamines (diphenhydramine) and phenothiazines | | (promethazine) | | | | ii. Alkylamines (chlorpheniramine) only modest reduction in | | alertness | | | | c. Second gen- less sedation but less effective | | | | iii. Less sedation bc crosses BBB poorly and low affinity for | | H1 receptors of the CNS | | | | iv. Fexofenadine | | | | 1. Reduce dose for renal impairment | | | | 2. Fruit juices can reduce absorption do not drink | | within 4hrs before dosing or 1-2 hrs after | | | | d. Intranasal: azelastine and olopatadine | | | | v. AE: nosebleed, ha, unpleasant taste | +-----------------------------------------------------------------------+ | 2. Sympathomimetics (oral and intranasal) | | | | e. Only relieves congestion. AE: rebound congestion when | | used \> a few days. More common in topical than oral | | | | f. Phenylephrine (oral and nasal) | | | | vi. More effective nasally due to first pass metabolism | | w/oral | | | | g. Pseudoephedrine (oral) | | | | vii. More effect than above orally | +-----------------------------------------------------------------------+