Asthma

Asthma

Reversible inflammatory disorder of the airways

Bronchodilatory reversibility → lung function increase by at least >12%

Med triggers: NSAID (aspirin) and beta-blockers

FEV1

FVC

FEV1/FVC

FEV1: how much air can you get out in 1 second → lower in both asthma and COPD, good predictor of M/M in COPD

FVC: how much air can you get out in total

FEV1/FVC: ratio <0.7 required for diagnosis COPD (usually doesnt change that much in asthma)

PEF Readings and Asthma Exacerbation

Green, yellow, red zone

Red zone = go to emergency room

Red/yellow zone: be on rescue inhaler

• Preferred: Low dose ICS + formoterol (1 inhaler)

• Alt: low dose ICS taken with SABA (2 inhalers)

• Start oral steroids as needed (preferred in red zone, use if patient remains in yellow zone despite rescue)

GINA (asthma) guidelines stepwise approach

TRACK 1: ICS-formoterol as reliever and controller

Symptoms <4-5 days a week

• PRN low dose

Symptoms most days of the week

• Daily low dose

Symptoms every day or waking with asthma

• Daily medium dose

• Add LAMA or anti-IgE, anti IL5/5R, anti-IL4R

-

Note:

• only the dose of the ICS portion will increase (not formoterol portion)

• both Track 1 and 2 use daily low dose maintenance with ICS-LABA with symptoms most days

GINA (asthma) guidelines stepwise approach

TRACK 2: SABA + ICS as reliever

Symptoms < twice a month

• PRN SABA (with ICS each use)

Symptoms > twice a month but <4-5x a week

• Daily low dose ICS

Symptoms most days or waking with asthma

• Daily low dose ICS + LABA

Symptoms every day or waking up with asthma

• Daily med-high dose ICS + LABA

• Add LAMA or anti-IgE, anti IL5/5R, anti-IL4R

-

Note:

• only the dose of the ICS portion will increase (not formoterol portion)

• both Track 1 and 2 use daily low dose maintenance with ICS-LABA with symptoms most days

• Remember that ICS dose will always be higher than LABA in combination inhalers

COPD GOLD Grades based on FEV1

COPD GOLD Groups Initial Treatment

Vaccines recommended for COPD patients

SABA/LABA

Bronchodilators

LABA never use alone without ICS or never for acute asthma attack

ADE:

• Palpitations, tachycardia, tremor (think opposite of Beta-blockers used for HTN/HF)

• Hypokalemia (high doses)

• Hyperthyroidism, glaucoma, seizures, increased glucose

Albuterol Formulation

MDI - Ventolin HFA, Proventil HFA, ProAir HFA

DPI - ProAir RespiClick

-

Also comes as neb, syrup and tabs

MDI counseling points

Shake all except ciclesonide (Alvesco) and ipratropium (Atrovent HFA)

Prime before use.

Most reprimed after 3-7 days of non-use except for Albuterol (Ventolin HFA, Proventil HFA, ProAir HFA) → 14 days

Use a spacer

Breathe in slowly and deeply (vs DPI → quickly)

Clean mouthpiece weekly

-

**MDI Suffix: HFA, Respimat**

DPI Counseling Points

No shaking. No priming (except for Pumicort Flexhaler). No spacer use.

CI in milk protein allergy

Inhale quickly and deeply

-

DPI Suffix: Twisthaler, Diskus, Ellipta, Flixhaler, HandiHaler, RespiClick, Neohaler, Pressair

Xopenex

Levalbuterol (Xopenex): R-isomer of albuterol

-

Xopenex HFA: MDI

Xopenex Neb

• once the foil is open but kept IN the foil → good for 2 weeks

• kept OUT of the foil → good for 1 week

Terbutaline

Formulation, indication

Beta2-agonist

Oral: used for asthma, NEVER used for preterm labor

Injectable (SQ/IV): off label to stop preterm labor, no longer than 72 hrs

Side note: other agents for preterm labor → Magnesium sulfate, Indomethacin, Nifedipine

Corticosteroids Names and Side effects

Beclomethasone (Qvar RediHaler)

Budesonide (Pulmicort Flexhaler)

Mometasone (Asmanex Twisthaler/HFA)

Fluticasone (Flovent HFA/Diskus, Arnuity Ellipta, Flonase)

Ciclesonide (Alvesco)

-

Always rinse mouth → decrease thrush

QVAR RediHaler

Generic

Counseling

What not to do

Beclomethasone: Breath-actuated aerosol inhaler approved in at least 4 yo

Pulmicort

Budesonide

-

Pulmicort Flexhaler: DPI

• Only DPI that needs to be prime → prime before first use ONLY

Pulmicort Respules: neb, at least 1 yo (very young)

• Only neb formulation in corticosteroids

Asmanex

Mometasone (Asmanex)

-

Asmanex HFA: MDI

Asmanex Twisthaler: DPI

• Discard 45 days after removal from pouch

Flovent

Arunity

ArmonAir

Flonase

Flovent HFA: MDI

-

DPI

Flovent Diskus → after removal of foil, good for 6 weeks (50 mcg) or 2 months (100 and 250 mcg)

Arunity Ellipta

ArmonAir Respiclick

-

Flonase nasal spray

Alvesco

Omnaris, Zetonna

Ciclesonide (Alvesco)

• MDI: shaking not necessary bc comes as solution

• Prodrug via hydroxylation

Also comes as nasal spray (Omnaris, Zetonna)

Systemic steroids

Oral Prednisone

Dexamethasone

Methylprednisolone

Rayos

Oral Prednisone: no need to taper if short term (only if high doses for extend period of timne)

Dexamethasone: more potent and longer half life than prednisone

Methylprednisolone: Taper 24 to 0 mg PO over 6 days. Start with 6, then 5, 4, 3, 2, then 1 tab. All tabs are 4 mg (total 21 tabs)

Rayos: delayed release prednisone for RA morning stiffness

Glucocorticoid Approximate Equivalent Dose

Steroid Systemic Side effects

TREATS nausea

Serevent Diskus

Salmeterol (Serevent Diskus)

After opening from foil pouch, good for 6 weeks

Prevention of exercise-induced bronchospasm → but just usual use albuterol (works faster)

Advair Diskus/HFA

AirDuo RespiClick

Fluticasone + Salmeterol

Symbicort

Formoterol + Budesonide (MDI)

Good for 90 days after opening from foil wrap

(remember: Budesonide (Pulmicort))

Dulera

Formoterol + Mometasone (MDI)

SABA and LABA Names

SABA: Albuterol, Levoalbuterol

LABA: Salmeterol, Formoterol

Anti-Leukotrienes Names

Leukotriene receptor antagonist

Zafirlukast (Accolate)

Montelukast (Singular)

-

5-lipoxygenase inhibitor

Zileuton (Zyflo, Zyflo CR)

Accolate

Zafirlukast (Accolate)

AccoLATE → eat later → empty stomach

Singular

Montelukast (Singular)

-

Comes as tabs, chewables and granules (good >6 months)

Packets mixed with solid foods (applesauce, carrots, rice, ice cream) OR baby formula/milk

Indication: asthma, allergic rhinitis, prevention of exercise induced asthma

Take 2 hrs before exercise for exercise-induced bronchospasm → still prefer albuterol (fast-acting)

Zyflo, Zyflo CR

Zileuton (Zyflo, Zyflo CR)

-

ziLeuton → check LFTs

Most CR taken QD but Zyflo CR taken twice daily with food

Xolair

Omalizumab (Xolair)

IgG monoclonal antibody bind to IgE → Only used for allergy related asthma

Also for chronic idiopathic urticaria (hives)

SubQ given once/twice a month

Cinqair

Nucala

Fasenra

Interleukin-5 receptor antagonist for eosinophilic asthma

Reslizumab (Cinqair) → IV q4 weeks

Mepolizumab (Nucala) → SQ q4 weeks

Benralizumab (Fasenra) → SQ q4 weeks x3 doses then q8 weeks

Theophyllines

MOA

Max dose

Therapeutic level

S/E at different levels

DDI

Can be used for apnea of prematurity (although IV caffeine citrate is preferred)

Theophylline ←→ Aminophylline

Cromolyn

Mast cell stabilizer

Comes only as nebulized solution

Usually used for allergies, can be used for asthma