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What are the 3 main components of asthma?
What do Eosinophils do?
esInophIls cause Inflammation and epIthelial Injury
What do TH2 lymphocytes do?
supercharge leukotrienes; increase adherence, locomotion and activation
What do macrophages do?
Release inflammatory mediators called Leukotrienes?
Describe a Mast Cell.
IgE mediated release of leukotrienes and histamine
What are the 3 chemical mediators involved in asthma?
What 3 functions do all the chemical mediators have in common?
- ↑ mucus secretions
- ↑ edema
- ↑ bronchoconstriction
What do leukotrienes do that the other mediators do not?
attract and activate inflammatory cells in the airways
How is asthma classified?
frequency and severity of symptoms and attacks
List the 4 asthma categories in order (from lowest).
- Mild intermittent
- Mild persistent
- Moderate persistent
- Severe persistent
Describe Mild Intermittent asthma.
- symptoms 2 or fewer times a week
- acute symptoms are usually brief
- normal peak flow >80% of predicted value
Describe Mile Persistent asthma
- symptoms over 2x week WITH more than 2 nocturnal attacks a month
- Acute attacks interfere with ADLs
- PF (peak flow) >80% predicted value
Describe Moderate Persistent asthma.
- daily symptoms
- need rescue meds
- nocturnal >1x week
- acute attacks over 2x week and can last days
- PF 60-80% predicted values
Describe Severe Persistent Asthma.
- severely limits ADLs
- frequent nocturnal attacks
- PF <60% predicted values
What are the daily/acute meds for mild intermediate asthma?
What are the daily/acute meds for mild persistent asthma?
- low-dose inhaled corticosteroid
What are the daily/acute meds for moderate persistent asthma?
- low/med dose inhaled CS + Beta 2 agonist
What are the daily/acute meds for severe persistent asthma?
- High-dose Inhaled CS + Inhaled long-acting Beta 2 agonist + Prednisone
- inhaled short-acting B2 agonist
What does MDI stand for? How much drug reaches lungs?
How long does a pt wait btw puffs of a MDI?
What does DPI stand for? How much drug reaches lungs?
Are glucocorticoids anti-inflammatory or bronchodilators?
What are the three classes of anti-inflammatory asthma meds?
- Mast Cell Stabilizers
- Leukotriene Modifiers
What is the inhaled glucocorticoid? What is the oral?
- Inhaled: Fluticasone Propionate
- Oral: Prednisone
What is the mast cell stabilizer prototype? Is it inhaled or oral?
Cromolyn sodium (intal) - inhaled
What is the leukotriene modifier prototype?
What are the 6 goals of pharmacotherapy for asthma?
- Prevent chronic/troublesome symptoms
- Prevent recurring acute attacks and ER visits
- Provide optimal pharmacotherapy w/ little/no side effects
- Maintain near "normal" pulmonary function
- Maintain normal activity levels
- Meet patients expectations of and satisfaction with asthma care
How do anti-inflammatory meds help with B.C.?
Increase B2-receptors and their response to B2-agonist. This increases CAMP = increased bronchodilation
Describe how anti-inflm drugs affect inflammation/edema in asthma.
- 1. Decrease activity of inflm cells which 2. decreases numbers/activity of TH2 lymphocytes and Eosinophils that damage the epithelial lining so it can now repair
- 3. Decrease synthesis/release of mediators which 4. stops the increased perm they cause so there is a reduction in airway edema
What is the effect of glucocorticoids on mucus?
What should a pt do before they use a glucocorticoid inhaler?
Use a B2-agonist to open up the bronchi
What are the benefits of using an inhaler vs. oral?
Target the drug right to the site of the problem and less systemic side effects.
What is the first line therapy for moderate-severe asthma that is taken daily?
Inhaled fluticasone propionate
What are two side effects of fluticasone propionate? What pt education can help?
Oropharyngeal candidiasis and Dysphonia. Teach them to wash out mouth and proper administration.
How do you remember the side effects of fluticasone propionate?
People who take FluPro can't talk because of their oro candidiasis.
How do you remember the side effects of prednisone?
Prednisone Really (renal suppression) Pisses (peptic ulcer disease) Off (osteoporosis) My (mood swings) Grandma's (growth suppression in kids) Cousin (candidiasis) Hank (hyperglycemia).
What is the MOA of a mast cell stabilizer? What is the prototype?
Cromolyn Sodium (Intal): stabilizes the cytolasmic membrane of mast cells preventing release of histamine, eosinophils and other inflm cells; NOT a bronchodilator!
When is a mast cell stabilizer administered?
15 minutes before exercise or a forseen exposure to an allergen
How many puffs per day can be taken with cromolyn?
What is the prototype anti-cholinergic asthma drug?
What is the MOA of Ipratropium?
Muscarinic Antagonist: it blocks the ACh in bronchial smooth muscle which results in a decrease in GMP, a B.Constrictor.
Ipratropium: when do effects start, when do they reach 50% and how long do they last?
- Start: 30 seconds
- 50%: 3 minutes
- Last: 6 hours
What type of drug is taken with Ipratropium?
What is the indication for Ipratropium?
Allergy and Exercise induced asthma
Ipratropium is contraindicated for who?
People with glaucoma, it can make it worse or they could go blind.
Why can someone with glaucoma not take Ipratropium? What other drug is contraindicated for glaucoma?
Iprotropium is a derivitive of atropine which is an M-antagonist Anti-cholinergic drug. So it dilates the pupils. When the pupils are dilated, the irises are crowded into the angle of the anterior chamber which stops drainage of aquaeous solution from the champer increasing the pressure. Benadryl also has M-antagonist and anti-cholinergic effects.
What are some side effects of Ipratropium? What is the most severe?
- Anti-cholinergic effects: dry mouth, constipation, urinary retention
- most serious: people with glaucoma can go blind!!
Why is atropine given pre-sx?
To dry up secretions
What is the generic name for Benadryl?
What is the MOA of diphenhyrdamine?
Histamine H1-receptor antagonist; competative antagonist so it binds to receptor therefore histamine can not cause inflm, edema, and B.C. Also, M-receptor antagonist so it blocks ACh in bronchial smooth muscle = ↓GMP = ↓B.C.
What are side effects of 1st gen Diphenhydramine?
crosses the BBB so there is drowsiness, dizziness, confustion. Also has anit-cholinergic effects, dry mouth, constipation, urinary renention
What do you not take when you are taking dihydramine?
Other drugs that have effects on CNS, like alcohol, anti-anxiety, anti-depressives
What is the absolute contraindication for diphenhydramine?
What is different about 2nd gen diphenhydramines? Name some.
Do not cross BBB so no drowsiness or anti-cholinergic effects. Allegra, Clarinex, Zyrtec
What is the most effective drug for seasonal rhinitis, histamine and inflammatory mediator activity?
- Intransasal Glucocorticoid
- Ex: Flonase
What are side effects of nasal fluticasone proprionate?
burning, itching, sores, perforation of nasal mucosa, headache, nose bleeds
Why use a intranasal cromolyn sodium spray instead of an intranasal fluticasone propionate nasal spray?
Although less effective, the comolyn sodium spay has only irritation of the nasal mucosa as its side effect so the pt can take it for a long time.
Why are nasal glucocorticoids absorbed so quickly from the nasal mucosa? What is the prototype of the nasal glucocorticoid?
Fluticasone propionate (Flonase) nasal spray: high potency and high lipophilic properties
What is the MOA for Intranasal cromolyn sodium spray?
OTC: provides a protective layer that shields mast cells lining the nasal passage and prevents them from breakin gdown and releasing histamines and inflammatory agents.
When does a pt take intranasal cromolyn sodium?
One full week before contact with allergy trigger and then tid