Module 9 Data

Question 1

Long term goals for chronic asthma are to:

• Achieve good control of asthma symptoms
• Maintain normal or near-normal pulmonary function
• Maintain normal activity levels
• Meet patients’ and families’ expectations of satisfaction with asthma care
• Prevent exacerbations of asthma and the need for emergency department visits or hospitalizations
• Prevent progressive loss of lung function
• Provide optimal medications with minimal or no adverse effects
• Minimize risk of asthma-related death

Answer 1

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Question 2

Treatment goals for an acute asthmatic episode are to rapidly correct hypoxemia and reverse airflow obstruction.

Answer 2

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Question 3

Asthma is characterized by variable, but reversible, episodes of shortness of breath, coughing, wheezing and chest tightness caused by exposure to a “trigger” (inhaled antigen). The result is an early asthmatic response characterized by bronchoconstriction which may be followed by a late asthmatic response characterized by inflammation and bronchospasm.

Understanding the pathophysiology provides the basis of pharmacologic intervention.

Answer 3

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Question 4

Once a diagnosis of asthma has been established, it is important to:

• Identify precipitating factors or comorbidities that may aggravate the asthma.
• Assess the patient’s knowledge and skill for self management.
• Classify the severity (intermittent or persistent [mild, moderate or severe]) based on impairment and risk.
• Begin a stepwise treatment plan based on severity, stepping up or down depending on level of control.

Answer 4

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Question 5

Medications are divided into two (or three) categories; long-term controller (maintenance) medications, quick relief (rescue) medications, and other medications. Use is determined by disease severity at presentation and is modified (stepped up/stepped down) based on degree of control.

Answer 5

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Question 6

• Controllers
• • Anti-inflammatory
• • • Inhaled corticosteroids (ICS); oral corticosteroids may be used in short bursts when establishing control or during periods of gradual deterioration
• • • Cromolyn sodium
• • • Leukotriene modifiers
• • Bronchodilators
• • • Long acting beta-agonists (LABA)
• • • • A black box warning about increased risk of severe asthma attacks and death. This caution applies to patients with asthma, and is strongly recommended that LABAs should always be in combination with another controller (i.e. ICS). This concern applies ONLY to patients with asthma and is NOT relevant concerning the use of LABAs for COPD
• • • Long acting anticholinergics (LAMA)
• • • Methylxanthines

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Question 7

• Quick relief
• • Bronchodilators
• • • Short acting beta-agonists (SABA)
• • • Short acting anticholinergics (SAMA)
• • Systemic corticosteroids

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Question 8

• Other
• • Over the Counter
• • • Ephedrine , Racepinephrine
• • Monoclonal antibody
• • • Omalizumab
• • Immunotherapy

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Question 9

Things to remember:

• Non-pharmacological interventions (e.g., allergen avoidance, smoking cessation, environmental controls, vaccinations)
• Manage comorbidities (caution with medications that may worsen asthma. E.g., NSAIDs, beta-blockers)
• Step up therapy if not controlled and reevaluate
• • If alternative therapy used, discontinue and try preferred therapy for that step BEFORE stepping up
• Step down therapy if well controlled for 3 months
• Patient adherence (e.g., side effects)
• • ICE - inhaler technique, compliance, environment
• • • Evaluate at every step
• Monitoring (including peak flow)
• Written action plan

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Question 10

Guidance from EPR3 parallels GINA for the most part.

This guidance is dictated by asthma severity for initiating therapy & level of control for adjusting treatment.

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Question 11

• Impaired clearance means greater than anticipated plasma levels of theophylline (supra-therapeutic levels).
• Enhanced clearance means less than anticipated levels of theophylline (sub-therapeutic levels).

Answer 11

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Question 12

Impaired clearance means greater than anticipated plasma levels of theophylline (supra-therapeutic levels). Enhanced clearance means less than anticipated levels of theophylline (sub-therapeutic levels).

• Example:

Suppose that I am taking theophylline and experiencing some benefit with little ADRs. A blood level demonstrates that I am within the therapeutic range (10-20 mcg/ml). I develop CAP and correctly you put me on amox/ clav PLUS erythromycin (a macrolide).. Notice in the chart macrolides have a clearance factor of 0.75 .. so I am only able to eliminate / clear theophylline at 3/4 capacity. Theophilline accumulates and toxicity / ADRs develop.

• CNS stimulation
• Nervousness
• Insomnia
• Tachycardia
• Tremor
• Nausea/vomiting
• Dizziness
• Seizure
• Headache
• GI upset
• Do these ADRs look familiar? They should because theophilline and caffeine are both methylxanthines.

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Question 13

Inhalation of corticosteroids for chronic stable COPD:

• Does not modify the long-term decline of FEV1
• Current recommendation: group C or D not controlled by inhaled bronchodilators.

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Question 14

• Antibiotics for COPD
• Used during acute infectious exacerbations when Increased dyspnea/cough + increased sputum volume and purulence
• Common pathogens : Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis and possibly pseudomonas aeruginosa in complicated exacerbations

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Question 15

Chronic low dose antimicrobial therapy as prophylaxis in patients with recurrent COPD exacerbations is NOT recommended.

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Question 16

Immunotherapy (for COPD?)

• Influenza vaccine Q year
• Pneumococcal vaccine (13-valent) - All patients > 65 y/o
• Pneumococcal vaccine (23-valent)
• • All Patients > 2 years of age with asthma
• • Revaccination recommended if >65yo if got 1st vaccine >5y earlier and patient was <65yo
• • • 6-12months after Pneumococcal vaccine (13-valent)

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Question 17

Therapeutics for COPD

• Stepwise approach including active reduction of risk factors

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Question 18

Therapeutics for COPD

• Bronchodilators are central to COPD on an as needed basis or scheduled to prevent or reduce symptoms and exacerbations
• • long-acting formulations are preferred over short-acting formulations
• • The combined use of short- or long-acting beta2-agonists and anticholinergics may be considered if symptoms are not improved with single agents

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Question 19

Therapeutics for COPD

• Theophylline is not recommended unless other bronchodilators are not available or unaffordable for long-term treatment.

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Question 20

Therapeutics for COPD

• Addition of inhaled glucocorticosteroids (ICS) to bronchodilators for symptomatic COPD with FEV1 < 50% predicted and repeated exacerbations
• • Long-term monotherapy with oral or inhaled corticosteroids is not recommended

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Question 21

Therapeutics for COPD

The phospodiesterase-4 inhibitor roflumilast may be useful to reduce exacerbations for patients with FEV1 < 50% of predicted, chronic bronchitis, and frequent exacerbations.

Answer 21

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Question 22

Regarding COPD:

• Therapies in category B are in addition to PRN use of SAMA and/or SABA for as-needed relief of intermittent increases in dyspnea
• For patients taking a LAMA, we prescribe a short-acting beta agonist (SABA) for rescue use; for those taking a LABA, we prescribe a short-acting muscarinic agent (SAMA) or a combination SAMA-SABA for rescue use.

Answer 22

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Question 23

Regarding COPD

Step-Down from ICS: Withdrawal of ICS was not associated with an increase in exacerbations, suggesting that many patients may safely have their ICS withdrawn. However, there was a drop in FEV1 and patient quality of life (WISDOM trial)

Answer 23

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Question 24

Pulmonary rehabilitation:

Includes exercise training, smoking cessation, breathing exercises, optimal medical treatment, psychosocial support, health education.

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Question 25

COPD Exacerbation Classified as: - Mild (treated with short acting bronchodilators only, SABDs) - Moderate (treated with SABDs plus antibiotics and/or oral corticosteroids) or - Severe (patient requires hospitalization or visits the emergency room) - - Inhaled bronchodilator - - - short-acting, ß2-agonists are preferred with or without short acting anticholinergic - - - maximize dose/frequency - - - combine ß2-agonist and anticholinergic - - - use spacers or nebulizers (may provide subjective benefit) - - - Methylxanthines not recommended - - Glucocorticosteroids (PO or IV) (30-40mg po prednisone x 5-7d) - - - Systemic corticosteroids and antibiotics can shorten recovery time, improve lung function (FEV1) and arterial hypoxemia (PaO2), and reduce the risk of early relapse, treatment failure, and length of hospital stay. - - Antibiotic therapy with clinical signs of airway infection (increased volume and change of color or sputum and/or fever) - - Oxygen: titrate to improve the patient’s hypoxemia with a target saturation of 88-92%. - - Consider Noninvasive mechanical ventilation (form of ventilation without insertion of endotrachael tube)

Answer 25

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Question 26

Medications for Allergic Rhinitis Antihistamine - Oral and intranasal used in all severities of intermittent and persistent AR - Oral: sneezing, itching, rhinorrhea, ocular - - 1st generation agents structurally resemble muscarinic and α blockers, thus exhibit antagonistic effects at these receptors to varying degrees - - - Cross the BBB making them useful for motion sickness, insomnia, anxiety, EPRs, etc - - - notorious from causing drowsiness and significant anticholinergic effects (dry mouth /eyes, urinary retention, constipation, falls, etc) - - - - When are these ADRs problematic ? - - - eg diphenhydramine

Answer 26

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Question 27

Medications for Allergic Rhinitis - Second generation (aka non-sedating antihistamines (NSAs)) recommended due to less sedation and anticholinergic effects - - (Do not cross BBB). NOT true with 1st generation agents - - eg loratadine

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