Asthma

Question 1

Clinical Presentation

Answer 1

• Episodes of SOB, chest tightness, coughing (mostly at night), wheezing
  -exercise, spontaneous, allergen

Question 2

Agents & Events Triggering Exacerbations

Answer 2

-Resp. infections
-Allergens
-Environment
-Emotions
-Exercise
-Job stimuli (dust, spice, mold, chemicals)
-Host factors (AA, hispanic, obesity)

Drugs
-Acet, Aspirin, NSAIDs
-NS BB = carvedilol/propranolol/labadolol
-Sulfites
-Benza chloride
BANANS

Question 3

In asthma, reversibility is shown by an increase in _____ after SABA

Answer 3

FEV1 >12%

Question 4

Asthma Sx Control

Answer 4

In the last 4 weeks:
-Daytime sx more than twice a week?
-Waking up at night?
-SABA used more than twice a week?
-Activity limitation?

1. Well controlled: none
2. Partly controlled: 1-2
3. Uncontrolled: 3-4

Question 5

Treatment GOALS

Answer 5

Goals
-few asthma sx, no sleep disturbance, no exercise limitation
-maintain normal lung function
-prevent flare ups / asthma deaths
-minimize side effects

Assess
-take every opportunity to assess, routine visit once a year but also when pts get refill or are having sx

Question 6

12+ Adults - Track 1: Preferred Controller and Reliever

Answer 6

1-2. As needed only Symbicort (12 puffs max)
3. Maintenance Symbicort 2 puffs twice a day of 80/4.5 AND as needed Symbicort
4. Maintenance 160/4.5 Symbicort AND as needed Symbicort
5. Symbicort 160/4.5 PLUS Spiriva PLUS as needed Symbicort reliever
-OR Trelegy, SABA or SABA ISC reliever
*Refer - type 2 phenotype: add biologic therapy

START AT IF
1-2. less than 4-5 days a wk
3. sx most days, waking with asthma
4. daily sx, waking with asthma, low lung function

Question 7

12+ Adults - Track 2: Alternative Controller and Reliever

Answer 7

2 inhlaers needed
-Controller
-Reliever: ProAir (albuterol) or AirSuptra

1. Take ICS whenever SABA taken
2. Low dose maintenance ICS (Flovent diskus, Flovent HFA, or QVAR)
3. Low dose ICS LABA (Dulera or Symbicort)
4. Medium/high dose ICS LABA (Dulera or Symbicort)
5. Add Spiriva or switch to Trelegy
   *refer - biologics therapy

Other Controller Options
-LTRA: Singular/Montelukast (ex)
-Can add azithromycin in step 5 for adults

Question 8

Track 1 Advice

Answer 8

-Emphasize that they should use ICS formoterol instead of previous SABA and additional inhaler with more sx
-1 at home, 1 to go
-Rinse and spit out after maintenance doses (not needed for reliever)

Difficult to Tx/Severe
-Refer to specialist
-Blood Eosinophils/FeNO
-Biologics if tx already optimized
-Maintenance OCS as last resort

Question 9

6-11 yo Children Track

Answer 9

1. low dose ICS taken whenever SABA taken (FQ + ALB)
2. daily low dose ICS (FQ)
3. low dose ICS LABA or medium dose ICS, or low dose ICS formoterol (FQ OR SYM/DU)
4. medium dose ICS LABA or low dose ICS formoterol (DU OR SYM)
5. Refer, phenotype assess, high dose ICS LABA, biologic therapy

Reliever
-As needed SABA (or ICS formoterol for MART only in step 3-4)

Question 10

Follow Ups

Answer 10

• Patients should be seen 1-3 months after starting treatment & every 3-12 months thereafter
• Every 4-6 weeks in pregnancy
• After an exacerbation, within 1 week

New med: 1-2 weeks, 1 month max

Question 11

Stepping Up

Answer 11

Short term step up
-for 1-2 weeks during viral infection or allergen exposure

Sustained step up
-for 2-3 months if sx persist
-assess technique, adherence, risk factors, conditions

Question 12

Consider stepping down when:

Answer 12

• Good asthma control has been achieved and maintained for 2–3 months
• If asthma is well controlled on low-dose ICS or LTRA, as- needed low-dose ICS-formoterol is a step-down option
• Do not completely withdraw ICS, except if needed temporarily while confirming the diagnosis of asthma

Question 13

Management of Exacerbation in Primary Care

Answer 13

Mild or Mod
-SABA 4-10 puffs every 20 min for 1 hr
-Prednisolone: 40-50 mg for adults (5-7 days), 1-2 mg/kg for children (40 max, 3-5 days)
-Oxygen

Severe or Life Threat
-Transfer to acute care
-SABA, ipratropium bromide (Atrovent), oxygen, systemic CS

Question 14

Management of Exacerbation in Acute Care (Emergency Department)

Answer 14

Mild or Mod
-SABA
-Ipro bromide (Atrovent)
-Oxygen
-Oral CS

Severe
-SABA
-Ipra bromide (Atrovent)
-Oxygen
-Oral or IV CS
*oral is as effective/preferred (quicker, less invasive, cheaper)
*BUT give IV if pt is too SOB to swallow or unconscious

Dose: prednisolone 50 mg as single dose or hydrocortisone 200 mg/day in divided doses

Question 15

Short Acting Beta-2 Agonists (SABA)

Answer 15

-Albuterol (ProAir, Ventolin)
-Levalbuterol (Xopenex®)

Adverse Effects:
-Nervousness
-Tremor
-Tachycardia
-HA
-N/V
-Hypokalemia

NN TT HH

Question 16

Short Acting Muscarinic Antagonists – SAMA Anticholinergics

Answer 16

-Ipratropium (Atrovent HFA)
*flare up only

Adverse Effects:
-Dry mouth
-Dizzy
-HA
-N/V
-Tremors

Question 17

Long Anti-Muscarinic Antagonist (LAMA)

Answer 17

-Tiopropium (SPIRIVA RESPIMAT®)

add on option for step 4-5

Adverse Effects:
-Dry mouth, urinary retention (uncommon)

Question 18

Inhaled Corticosteroids (ICS):

Answer 18

-Flovent (fluticasone)
-QVAR (beclomethasone)
-budesonide, ciclesonide, mometasone, triamcinolone

-most effective, primary
-most benefit at low doses

Adverse Effects:
-Hoarseness, cough, sore throat
-Risk of systemic AE

Question 19

Inhaled Long-Acting Beta-2 Agonists (LABA)

Answer 19

Serevent (salmeterol)

-NOT to be used as monotherapy
-Increase risk of respiratory failure death BBW
-Combined with ICS

Question 20

ICS-LABA

Answer 20

-Symbicort (budesonide-formoterol)

AE:
-LABA: tachy, HA, cramp, tremor
-ICS: same as ICS slide (H,C,ST)
CCHH STTT

Question 21

Leukotriene Modifiers

Answer 21

-montelukast (Singulair®)
-zafirlukast (Accolate®)
-zileuton (Zyflo CR®)

AE:
-elevated LFTs with ZZ
-airway infection, fever, rash, diarrhea with ZZ
-BBW for montelukast: behavior and mood changes in children

zileuton NEED LFT monitoring

DDI: warfarin, theo, erythromycin (E only for ZA)

Question 22

ICS-SABA

Answer 22

-Albuterol/budesonide inhalation aerosol 90mg/80mcg (Airsupra®)

18+ only
-2 puffs prn, max 12 puffs in 24 hours

same AE for ICS/SABA
-NN TT HH, (H,C,ST)

Question 23

Biologics

Answer 23

Anti-IgE
-Omalizumab, Zolair

subQ, IV

severe asthma only

AE
-Injection site rxns
-Anaphylaxis is rare
-Headaches

Question 24

Non Pharm Strategies

Answer 24

-Smoking cessation
-Physical activity, regular exercise
-Avoid meds/allergens
-Weight reduction (obese)
-Dealing with emotion/stress