Clin Pharm Asthma Drugs

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inhaled
corticosteroids direct
MOA

inhibit (cytokine-induced)
production of inflammatory proteins

2.

pharm agents causing

ASA, Beta blockers

3.

physical triggers

cold air, exercise

4.

physiologic triggers
(4)

stress, GERD, URI, rhinitis

factors influencing
dev/exp - host

genetic, gender, obesity

6.

inflam cells in asthma

mast, eosino/baso/neutrophils,
platelets, TH2

7.

mediators

histamine
LTE
Kinins, endothelin, prosanoids

8.

diagnosis

>12% reversibility or increase in

FEV1 of 200c

9.

obstructive pattern

reduced FEV1/FVC ratio w/ albuterol

10.

restrictive pattern

reduced FVC (normal ratio) w/

albuterol

11.

methacholine
challenge

bronchoprovocative test;
20% or more decrease in FEV1

12.

Severe asthmatic
episode - ABG

pH down
paCo2 down
pa02down
HCO3 way down

1.

5.

13.

sputum

eosinophils, charcot-leyden crystals,

inc IgE

14.

chest xray

inc AP diam, dark (translucent)

fields, depressed/flat diaphragm

15.

Step 1 - 4; symptom
freq

1; <2x per week

2; > 2x per week
3; daily
4; continual

21.

mast cells

filled w/ basophil granules

22.

short acting beta agonists

relax smooth muscle,

inc airflow in 30 sec; DOC for
attacks

23.

indicates inadequate
control

> 1 canister/mth SABA

24.

dosing positive response is

200 ml increase or 12%

increase in FEV1

25.

Beta2 agonists SE

tremor
heart palps
hypokal
O2 sat reduction

26.

SABAs - ALPMT
(short goats on alp
mountains)

Albuterol
Levalbuterol
Pirbuterol
Metaproterenol
Terbutaline

27.

dosing levalbuterol
(Xopenex) - only R
isomer/active

half of racemic albuterol - 0.63

mg, 1.25 mg (3X cost)

28.

LABAs - AFAS

Albuterol ER
Formoterol
Aformoterol,
Salmeterol,

29.

LABA's considerations

not monotherapy;
only if cannot be controlled
otherwise
shortest duration & taper off

30.

LABAs - COPD only

Formoterol
Aformoterol

31.

combo LABA &

corticosteroids (3)

Symbicort, Dulera, Advair

32.

Symbicort

Formoterol & Budesonide

33.

Advair

Salmeterol & Fluticasone

16.

Zone mgmnt
green/yellow/red

patient self monitoring system

34.

Dulera

Formoterol & Mometasone

(asthma only)

17.

asthma classifications

allergic, exercise induced, nocturnal

35.

Dulera

18.

non drug treatment,

avoid triggers & treat
aggravating

allergies, GERD, rhinitis, viral RI

combo LABA & steroid for

asthma only

36.

inhaled corticosteroids
direct MOA

inhibit cytokine (induced

prod of pro-inflamm proteins)

19.

drug types for asthma

(6)

beta agonists, corticosteroids, mast

cell stabilizers, LTE modifiers,
theophylline, anti IgE ab's

37.

inhaled corticosteroids
indirect MOA (4)

20.

Beta 2 agonists MOA

G-protein receptors activates

adenylyl cyclase/cAMP - >
intercellular Ca ->
bronchodiliation & mast cell
stabilization

alter m-RNA prod

suppress inflam
produce anti-inflam mediator
increase B2 receptors,
decrease mucous

38.

mild asthma - once a day

inhaled steroid options

budesonide
ciclesonide
mometasone furoate

39.

corticosteroids
SEs

thrush; hypergly
adrenal suppress
osteoporosis
elev WBC

52.

cromolyn (intal) - class

nedocromil (tilade)

mast cell stabilizer

(no inherent bronchodilation)

53.

cromolyn MOA

blocks Cl channels
blocks histamine release from
mast cells

54.

cromolyn SE

bad taste; GI

55.

Montelukast (Singulair) class

Zafirlukast (Accolate)

LTE receptor antagonists

56.

Zileuton (zyflo) - class

LTE receptor antagonists

5-lipoxygenase inhibitor reduces synthesis

57.

Zileuton (zyflo) interaction

inhibits metabolism of
theophylline & warfarin
(increases levels)

58.

LTE antagonists - not

indicated for

acute attacks

blockade adenosine receptors

59.

Montelukast vs Zafirlukast

Montelukast more favorable;

can be used in kids 2-5 yrs

Ca+ released from sarcoplasm

60.

Ipratropium - class

antimuscarinic (atropine - like)

61.

Ipratroprium - indication

quick relief; additive to beta

agonists

62.

Omalizumab (xolair) - class

IgE antibody inhibitor

63.

Omalizumab MOA

binds IgE on mast

cells/basophils; prevents
release

64.

Omalizumab - indication

persistent, mod-severe
allergic asthma not controlled
on oral steroids

65.

Omalizumab dosage

every 2-4 weeks; half-life 26

days

66.

Omalizumab concern

very expensive

67.

Omalizumab dosage based

on

IgE serum levels -but 1+ yr

post treat

68.

Omalizumab SE

HA
injection site rxn
URI arthralgia

69.

MOA of Omalizumab
(Xolair)?

Inhibits binding of IgE to the

high affinity IgE receptor on
surface of mast cells and
basophils

70.

Which type of patient

should use Omalizumab
(Xolair)?

Patient with moderate-severe

persistant allergic asthma not
controlled by inhaled steroids

71.

When prescribing Inhibitors

of IgE antibodies, what
should the dosing be based
on?

IgE serum levels and body

weight

40.

corticosteroids dosing therapy

oral or IV "burst" therapy

41.

corticosteroids
dosing strategy
long term

step down: after controlled

dec 25% every 2 wks (8wks min)

42.

methylxanthines
include

caffeine, theophylline, theobromine

43.

methylxanthine indication

adjuvant to inhaled steroids

alt to LABA to control nocturnal
symptoms

methylxanthines
MOA (3)

phosphodiesterase inhib, inc CAMP->

inhibits LTE broncho/vasodilate, cardiac
stim, vasodilate

44.

45.

theophylline SE's 7 NITSCHA

N/V
insomnia
tremors
seizures
confusion
HA
arrhyth

46.

theophylline concern

narrow therapeutic window; monitor

conc

47.

theophylline interaction

is a Cyp 450 substrate; many interactions

theophylline CYP450
interaction
causes

inhibitors inhibit liver metabolism;

increase Theo levels
inducers enhance ......cause decreased
Theo

theophylline avoid CY450

INHIBITORS
(inhibited hide
FACE Very well)

Fluvoxamine
Amiodarone
Cipro
Erythromycin
Verapamil

theophylline avoid CY450

INDUCERS
(PCPR - induce
halluc)

Phenytoin
Phenobarbital
CBZ
Rifampin

theophylline disease state

interactions

smoking, hyperthy - dec Theo

CHF, liver disease - inc Theo

48.

49.

50.

51.

72.

T/F: Inhibitors of IgE antibodies are cost

effective for the patient

False: They are about $600 per 1 150mg. vial

73.

Intermittent Asthma - Step 1 Tx

SABA as PRN

74.

Intermittent Asthma - Step 1, w/ mod/sev viral

inf Tx

SABA PRN
short course systemic steroids

75.

mild persistent asthma - Step 2 Tx

daily long term control

inhaled steroids or (cromolyn or nedocromil)
Zafirlukast or zileuton in adults (12+YOA)

76.

mod persistant asthma - Step 3 Tx

increased inhaled steroids or

add LABA or
add nedocromil

77.

mod persistant asthma - Step 3 not controlled

Tx

increase to high dose inhaled steroids

add LABA (servent or theophylline)

78.

severe persistent asthma - Step 4 Tx

Add oral systemic steroids

monitor closely

79.

LABA black box warning

inc risk for asthma-related deaths; only for uncontrolled (w/ inhaled corticosteroid
or 2+ maintenance meds)

80.

Acute asthma exacerbation; FEV1 or PEF < 50% Tx

O2 90-95% sat
inhaled SABA or cont albuterol
oral systemic steroids (prednisone)
anti-cholinergics (never alone)

81.

which drugs specifically not recommended for

acute asthma

methylxanthine/theophylline
mucolytic
sedation
abx

82.

aggressive hydration in acute asthma

not reco'd adults; maybe infants/children