asthma

what is asthma? it’s a heterogenous disease, usually characterized by chronic airway inflammation, defined by the history of respiratory symptoms like wheezing, SOB, chest tightness, cough, & expiratory airflow limitation that varies, and is usually diagnosed in children

etiology: SES, family size, second-hand smoke, allergen exposure, urbanization, RSV infection, low birth weight, male, parental smoking

triggers: respiratory infection, allergens, environment, emotions, exercise, drugs (ASA, NSAIDS, nonselective beta-blockers), occupational stimuli

s/sx: expiratory wheezing, dry/hacking cough, atopy, reduced oxygen saturation, episodic dyspnea, chest tightness, nighttime coughing

diagnosing: patient history, physical exam, confirmation of airflow limitation –  FEV1/FVC < 75%ish

therapy! goals are to reduce impairment & reduce risk
(can also tell patient to get IM inactivated influenza vaccine, PPSV23 if they’re between 19-64)
Choose – Check – Correct – Confirm
Use an asthma action plan so the patient knows their therapy & how to adjust (need PEF – take BID xx,2-3W [15-20min post-SABA] & green > 80%, yellow 50-79% take SABA & repeat in 1 hour/can increase ICS or add OCS, red <50% take SABA & OCS & call MD – give it 15 minutes and then ER)

#1 SABA – every asthma patient!
MOA: stimulates beta-2 receptors in the lungs = relaxation of smooth muscle = bronchodilation
A/E: tremor, shakiness, lightheadedness, cough, palpitations, tachycardia, (can even see hypokalemia & hyperglycemia with multiple puffs)
Onset: 5-15 minutes, Duration: 2-6 hours
– Albuterol MDI: ProAir HFA, Ventolin HFA, Proventil HFA
– Albuterol DPI: ProAir Respiclick
– Albuterol Neb: Accuneb, Albuterol sulfate solution
Dosing: inhale 2 puffs 5-15 minutes prior to exercise & inhale 1-2 puffs Q4-6h prn for sob/wheezing
– Levalbuterol SMI: Xopenex HFA
– Levalbuterol Neb: Xopenex solution
Dosing: inhalte 2 puffs Q6-8h prn
*Biggest difference? Levalbuterol lasts 6-8H, Albuterol lasts 4-6H

#2 ICS – most effect anti-inflammatory medication for persistent asthma; starts in step 2
MOA: reduce chronic airway inflammation, reduce exacerbation risk, improve lung function, reduce symptoms, improve QOL
A/E: fear of growth suppression, hyperglycemia, increased fracture risk – those are all kind of dose-dependent; the more common one are oropharyngeal candidiasis & dysphonia – prevent? rinse & spit!
– Ciclesonide: Alvesco MDI [activated in the lung, BID]
– Fluticasone Propionate: Flovent Diskus or Flovent HFA, Arnuity Ellipta, ArmonAir Respiclick [see higher risk of sore throat & hoarseness compared to other ICS with all of these formulations]
– Beclomethasone: QVAR MDI [smaller inhaled particles = better lung penetration]
– Mometasone: Asmanex Twisthaler or Asmanex HFA [QD – BID but QD dosing better when given at night]
– Budesonide: Pulmicort Flexhaler or Pulmicort Neb
– Flunisolide: Aerospan [built-in spacer; never seen]

#3 LABA – same MOA & A/E as SABA; starts in step 3
**BBW: do NOT give as monotherapy for patients with asthma – see increased risk of death**
– Salmeterol: Serevent
– Foradil: Formoterol

#3/#4  ICS/LABA Combos –
– Fluticasone/Salmeterol: Advair MDI & Advair Diskus, AirDuo Respiclick
– Budesonide/Formoterol: Symbicort MDI
– Fluticasone/Vilanterol: Breo Ellipta
– Mometasone/Formoterol: Dulera

#4 LAMA –
MOA: inhibit action of Ach at M3 receptors in lungs = bronchodilation because no constriction
– Tiotropium: Spiriva

Alt LTRAs – Leukotriene Receptor Antagonists
MOA: block pro-inflammatory leukotrienes at receptor sites to reduce airway constriction & mucus secretion
– Montelukast: Singulair (10mg QD)
A/E: headache, URTI, NVD, can cause psychiatric changes
– Zafirlukast: Accolade
A/E: hepatic problems, HA, neuropsych.
*Take on an empty stomach
DDI: theophylline, warfarin, abilify
– Zileuton: Zyflo
A/E: NVD, HA, hepatotoxicity, neuropsych.
*CR tabs – DNC
DDI: theophylline, ramelteon

Alt Methylxanthines – Theophylline
MOA: blocks PDE-4 = increased cAMP = EPI release = bronchodilation
A/E: nausea, loose stools, HA, tachycardia, insomnia, tremor, nervousness
*Dose to target 5-15mcg/ml

Alt Cromolyn
MOA: mast cell stabilizer
*QID Neb

Alt Omalizumab = Xolair
MOA: anti-IgE antibody
*SQ injection at MD office Q2-4W

Alt: IL-5 Receptor Antagonists
MOA: decreased circulating number of eosinophils
– Mepolizumab (SQ), Resilizumab (IV), Benralizumab (SQ)

Alt: OCS
– Only used in severe asthma d/t A/E

**You do NOT want to give OTC EPI