Asthma

Which of the following medications is available as a dry powder inhaler?

A) *Pulmicort Flexhaler* - budesonide DPI

Madison Sullivan is a four year old girl with asthma. She will receive montelukast. Select the correct dose for a four year old child.

A) A 4 mg chewable tablet taken once daily in the evening The montelukast dosage for pediatric patients 1-5 years of age is one 4 mg chewable tablet or one packet of 4 mg oral granules taken in the evening.

Carla Morales is an eleven year-old girl with asthma. The physician wants to give her montelukast, but is not sure of the correct dose. Choose the correct dose of montelukast for an eleven year-old child:

A) A 5 mg chewable tablet taken once daily in the evening. *Montelukast comes in an oral tablet, chewable tablet and oral granules.* The different formulations make it easy to use in children. Age 6-14 y.o: 5 mg daily in the evening Age 1-5 y.o: 4 mg daily in the evening: can mix in with baby formula or breast milk, or mixed with a spoonful of cold or room temperature applesauce, carrots, rice, and ice cream.

A patient with moderate asthma enters the pharmacy and asks for a pharmacist's recommendation for headache pain. Choose the safest option:

A) Acetaminophen NSAIDs (aspirin, ibuprofen, naproxen, diclofenac) and non-selective beta blockers and selective beta blockers at high (non-selective) doses may worsen asthma symptoms.

Which of the following medications can increase theophylline levels and possibly result in theophylline toxicity? (Select ALL that apply.)

A) Ciprofloxacin C) Zafirlukast E) Clarithromycin Ciprofloxacin, clarithromycin and zafirlukast can all increase levels of theophylline.

Heather Lazusky has had asthma for a number of years and has been in denial about her disease. At the age of 22 years, she wants to better manage her condition. Her doctor tells her that she is a Step 4 asthmatic and explains to her how to use a peak flow meter. Ms. Lazusky's personal best is 300 mL. Now she is in the pharmacy and she has selected a peak flow meter to purchase but admits to forgetting the steps for using it. Which of the following statements are correct in counseling Heather Lazusky on the appropriate use of a peak flow meter? (Select ALL that apply.)

A) Do the peak flow meter assessment in the morning, before she takes her medications. B) Record the highest number of each day in a log book. D) Coughing during the assessment invalidates the reading. E) If the value recorded is < 150 mL, she should go to the hospital immediately, regardless of symptoms. Using a peak flow meter requires the patient to be in standing (or at least in an upright) position for the best measurement. Do it 3 times and record the highest value (peak expiratory flow rate (PEFR)

A patient is starting on Singulair. Which of the following are side effects of Singulair?

A) Headache and upper respiratory tract infections The *most common* side effects of Singulair® (monetelukast) include headache, dizziness, upper respiratory infection, pharyngitis, stomach pain, sinusitis and others.

What is the generic name of Xopenex?

A) Levalbuterol

Which of the following medication classes has a boxed warning regarding an increased risk of asthma-related deaths when used as monotherapy?

A) Long-acting beta-2 agonists (*LABA*) Long-acting beta-2 agonists have a boxed warning regarding the increased risk of asthma-related deaths when used as monotherapy.

Which of the following are possible side effects from the use of an albuterol HFA inhaler? (Select ALL that apply.)

A) Nervousness, tremor, and palpitations E) Cough The major side effects include nervousness, tremor, shakiness, cough, tachycardia, *hyperglycemia* and *hypokalemia.* BG↑ and K↓

Which of the following asthma medications works by blocking interleukin-5 receptors?

A) Nucala - mepolizumab

Which of the following statements are correct regarding Pulmicort respules? (Select ALL that apply.)

A) Pulmicort respules are given via nebulization. B) The generic name is budesonide. D) Pulmicort respules can be used as first-line therapy. Pulmicort respules are stored at room temperature. Shake well before using. They do NOT leave a metallic taste in the mouth. Rinse mouth.

A patient has developed oral thrush. Which medication is most likely to have contributed to this condition?

A) QVAR

A patient with severe, persistent asthma has been using prednisone 20 mg daily for at least three years. Which side effects are likely to be due to long-term prednisione use? (Select ALL that apply.)

A) Reduced bone density and osteoporosis B) Elevated blood glucose and diabetes C) Poor wound healing No Alopecia, instead it is hirsutism No Hearing loss

A patient is started on the Advair Diskus. Which of the following statements are correct regarding Advair Diskus? (Select ALL that apply.)

A) This medication comes with a dose counter. D) This medication should not be used with a spacer device. E) Always use the Diskus in a level, flat position. Advair Diskus is *dosed 1 inhalation BID*. Since it is a dry powder inhaler, it cannot be used with a spacer device.

Natalie Tsai is a 12 year-old with asthma. She uses Flovent. She has no other medications and has not had any asthma symptoms since she started Flovent two years ago. Natalie is wondering if she still needs an albuterol inhaler for her asthma. The pharmacist should respond:

A) Yes; all patients with asthma should have a short-acting beta-2 agonist. No matter what stage/step of asthma is present, all patients must have a short-acting beta-2 agonist like albuterol for acute relief ("rescue") of symptoms.

Sophia Fernando is a 3 year old girl who weighs 33 pounds. She is prescribed 0.1 mg/kg albuterol in 2.5 mL of normal saline. How many milliliters of the 0.5% albuterol solution is needed to fill this prescription?

B) 0.3 mL The patient's dose is 1.5 mg (0.1 mg/kg x 15 kg). When using the 0.5% solution, 0.3 mL would be needed (500 mg/100 mL = 1.5 mg/x mL, where x = 0.3 mL).

Samuel, a 35 y/o male, is in the hospital for an acute exacerbation of his asthma. *Medications* Albuterol nebulized treatments PRN Ipratropium nebulized treatments PRN Protonix 40 mg IV daily *Aminophylline IV 1,000 mg in 1L of NS at 30 mL/hr* How much theophylline will Samuel receive per day?

B) 576 mg Samuel will receive 576 mg of theophylline (1 mg/mL x 30 mL/hr x 24 hrs = 720 mg of aminophylline; 720 mg x 0.8 = 576 mg of theophylline). Aminophylline converts to theophylline as: 80% to 100% 0.8- 1

What is the mechanism of action of Theo-24?

B) Blocks phosphodiesterase, increasing cAMP and releasing epinephrine from the adrenal cells Wiki: 1) competitive nonselective phosphodiesterase inhibitor,[9] which raises intracellular cAMP, activates PKA, inhibits TNF-alpha, and inhibits leukotriene synthesis, and reduces inflammation and innate immunity 2) nonselective adenosine receptor antagonist, antagonizing A1, A2, and A3 receptors almost equally, which *explains many of its cardiac effects*

Alexa Grist is a 17 year-old patient with moderate persistent asthma. The physician is considering adding zileuton. Unlike the other agents in its class, zileuton has a risk for which of the following toxicities?

B) Hepatotoxicity Zileuton (Zyflo®)can cause liver toxicity; LFTs, liver enzymes, must be monitored each month for the first 3 months, then every 2-3 months for the rest of the year, and periodically thereafter. It is NOT recommended for pts less than 12 y.o. It is 5-lipoxygenase inhibitor and inhibits leukotriene formation.

The asthma guidelines recommend that patients with persistent asthma use maintenance medication in order to achieve and maintain control symptoms. Which class of agents is considered first line for maintenance of persistent asthma?

B) Inhaled corticosteroids Inhaled corticosteroids are the drugs of choice for maintenance of persistent asthma.

Albuterol comes in all of the following formulations EXCEPT:

B) Injection It comes as: Tablet, Nebulizer solution, Metered dose inhaler, Syrup

Counseling points on the use of Foradil should include the following:

B) Leave the capsule sealed in the blister foil until just before use. Foradil is used in the aerolizer and not swallowed whole. It is used for maintenance therapy; not an acute asthma attack. In the pharmacy it is stored in a refrigerator, patients can keep it at room T for p to 4 months.

Jason Wallach is well-controlled on his asthma medications which include Flovent HFA 220 mcg BID, Foradil 1 capsule BID, and Proventil HFA PRN symptoms. He is picking up his refills and asks if anything can help with his sore throat. When inspected, the pharmacist recognizes the throat is sore due to thrush. What are some counseling points the pharmacist can provide that will help reduce Mr. Wallach's risk of thrush in the future? (Select ALL that apply.)

B) Mr. Wallach should gargle with warm warm and spit out the rinse after using his medications. D) Mr. Wallach should purchase a spacer device and use with his Flovent HFA. Flovent HFA - fluticasone (Hydro-Fluoro-Alkane), not a powder but MDI Foradil in the form of a capsule is LABA - formoterol Proventil is albuterol

Which of the following are correct statements regarding Asthmanefrin? (Select ALL that apply.)

B) This medication is available OTC. C) This medication is not preferred in patients with asthma. Asthmanefrin is a racemic mixture of epinephrine that is available OTC. Since it is not beta-2 selective, it is not preferred as a SABA in asthma.

What is the therapeutic range for theophylline?

C) 5-15 mcg/mL Measure peak level after 3 days of oral dosing - @ STEADY STATE

Cassandra Day is a 17 year-old with asthma. She likes to play basketball. Before heading to the court, Ms. Day needs to use her albuterol inhaler to help prevent exercise-induced symptoms. Choose the correct statement regarding albuterol:

C) A brand name for albuterol is Ventolin. Albuterol inhalers are short-acting beta-2 adrenergic agonists taken as needed for rapid, short-term relief of asthma symptoms OR *to prevent an asthma attack*. HFA inhalers have replaced CFC inhalers because HFA inhalers do not damage the ozone. Albuterol comes as Aerosol Powder Breath Activated, Aerosol Solution, Inhalation, Nebulization Solution, Inhalation; Syrup, Oral; Tablet, Oral; Tablet Extended Release 12 Hour, Oral (VoSpire®)

Which of the following medications can decrease theophylline levels? (Select ALL that apply.)

C) Carbamazepine D) Primidone (Anticonvulsant)

Pulmicort respules are used primarily in this population group:

C) Children Pulmicort respules are indicated for children. Because it is Suspension, for nebulization

Caleb Hayhoe is a 16 year-old teenager who has asthma and his only medication is Ventolin. He has been using his Ventolin inhaler for acute symptoms. When asked how many times he has used his Ventolin, he states he used it twice on Sunday, one time on Tuesday and one time on Wednesday. It is now Thursday. What would be an appropriate recommendation to make at this time? (Select ALL that apply.)

C) Continue to take the Ventolin PRN for acute symptoms. D) Start Pulmicort Flexhaler 2 inhalations BID for better symptom control. Severent DIscus is salmeterol and it is not appropriate for this patient, because LABAs are not 1st line for chronic maintenance.

Boris Higgins is taking QVAR (beclomethasone) 80 mcg 1 inhalation twice daily. Which of the following would be a therapeutic substitute for this medication?

C) Flovent HFA (fluticasone)

Which of the following statements concerning omalizumab is correct?

C) Omalizumab can cause *anaphylaxis*. *Omalizumab (Xolair®)* is a monoclonal antibody that prevents binding of IgE to the high-affinity receptors on basophils and mast cells. Omalizumab is used as adjunctive therapy for patients 12 years and older who have allergies and severe, persistent asthma. Clinicians who administer omalizumab should be prepared and equipped to identify and treat anaphylaxis. Dose and frequency is based on pre-treatment *IgE* serum levels and *body weight*. It is SC inj given Q 2 or 4 weeks. NOT a home therapy, always given in healthcare setting

A patient with severe, persistent asthma has had an acute exacerbation. The physician has prescribed a short course of oral prednisone. Choose the correct statement:

C) Short-term use of prednisone is not associated with decreased bone mineral density. Oral steroids, used chronically, have many adverse effects. The risk depends on the dose and duration (higher dose and longer duration will cause more problems). Oral steroids can *increase blood pressure* and increase appetite causing *weight gain*.

Brian McGough is prescribed Advair Diskus for his asthma. Which of the following counseling points should be reviewed with Mr. McGough about his Advair Diskus medication? (Select ALL that apply.)

C) This is not a rescue medication for acute asthma attacks. D) Rinse his mouth with water after his dose of medication. E) Never breathe into the Diskus. Never take an extra dose, even if the patient did not taste or feel the medicine. Keep the Diskus dry at all times.

What is the correct dose of Advair HFA?

D) *2 inhalations BID.* REMEMBER: Advair HFA is dosed at 2 inhalations twice daily. *HOWEVER: Advair Discus is 1 inhalation BID*

A patient with asthma has been prescribed the Advair Diskus. Which of the following statements is correct?

D) Advair Diskus treats both airway constriction and inflammation. Advair Diskus contains salmeterol, a long-acting beta-2 agonist (which opens the airways) and fluticasone, an inhaled corticosteroid (which reduces inflammation). The mechanisms of action were reversed in the question. The correct dose for Advair Diskus is 1 inhalation twice daily.

A patient has been prescribed fluticasone for asthma. What is the brand name of fluticasone when used for asthma?

D) Flovent Be very careful with the steroids used for asthma and those used for allergic rhinitis as they are same generic drug name but different brand names and delivery devices.

What are the ingredients in *Symbicort*?

D) Formoterol + budesonide

A patient has been prescribed beclomethasone for asthma. What is the brand name of beclomethasone when used for asthma?

D) QVAR The brand name of beclomethasone for asthma is QVAR. But Beconase® is Beclomethasone Nasal spray indicated to treat nasal allergy symptoms Asmanex - is momentasone Pulmicort - is budesonide Alvesco - is ciclesonide

A 55 year-old male patient has continuous asthma symptoms, even with high dose inhaled corticosteroid therapy. He also has NYHA Class III heart failure. The physician will initiate theophylline. Choose the correct statement:

D) Signs of theophylline toxicity include *vomiting, ventricular tachycardias, and seizures.* Heart failure can increase theophylline levels; therefore, the patient may require a lower dose of theophylline. Although high-protein diets can decrease levels, patients should not limit the amount of protein consumed. It is usually does @ 300-600 mg daily (NOT weight based)

Raffi Luce is a pharmacist in a busy store. Cheryl Klein is a mother who came in with her eight year old daughter. The child had a new prescription for an albuterol inhaler. Mr. Luce quickly instructed Ms. Klein how to use the MDI. When Ms. Klein got home, she had no idea how to instruct her daughter properly. The child, like many patients, had poor technique and did not obtain proper relief from the medicine. What is the most important thing that Mr. Luce should have done to ensure that the parent and child understood how to use the inhaler?

D) The pharmacist should have demonstrated how to use the inhaler and then watched the patient demonstrate proper technique. Delivery device instructions should be provided by demonstration. The only way to know for sure if the patient absorbed the information is to have them demonstrate proper use.

Dawn Harrison has been using prednisone 10 mg PO daily for the past month post discharge from her recent asthma exacerbation. Her physician wants to taper her off the medication. What is the reason corticosteroids must be tapered?

D) They can cause hypothalamic pituitary adrenal axis suppression. Corticosteroids need to be tapered due to hypothalamic pituitary adrenal axis suppression.

A 70 year old patient has been prescribed Xopenex. Choose the correct statement concerning Xopenex:

D) Xopenex is the R-isomer of albuterol. Xopenex (levabluterol) is the R-isomer of the beta-2 adrenergic agonist albuterol. Like albuterol, it is available in a metered-dose inhaler (Xopenex HFA) and for use in a nebulizer. The frequency of systemic effects (tachycardia, headache, nervousness) is reported to be *SIMILAR* to albuterol.

Sammy Finkelstein is an 18 month old boy who has been prescribed montelukast granules. Counsel the parents on how to administer the granules to their son:

D)Mix with a spoonful of cool, mashed carrots and administer within minutes. nstruct parents using the granules not to open the granule packet until they are ready to use it since granules mixed with foods or liquids cannot be stored. The granules can be mixed with 1 teaspoonful (5 mL) of baby formula or breast milk, or a spoonful of applesauce, mashed carrots, rice, or ice cream. Whatever the medicine is mixed with must be cold or at room temperature. Instruct the parents NOT to mix the granules with extra amounts of milk or food; they need to make sure the entire dose has been consumed. Administer the mixutre immediately (within 15 minutes).

A patient has been prescribed mometasone for asthma. What is the brand name of mometasone when used for asthma?

E) Asmanex

A 42 year-old female patient has been diagnosed with asthma. She only likes taking medication that comes in a pill for easy administration. Which of the following routes is preferred for drug therapy when treating asthma?

E) Inhaled The inhaled route is preferred in asthma since the medication is delivered directly to the airways of the lungs.

Sammy Chang is a 4 year-old patient with moderate persistent asthma. He has been poorly controlled on an albuterol inhaler and a low-dose inhaled corticosteroid. The physician wants to add a leukotriene modifier to Sammy Chang's regimen. Which agent can be recommended?

E) Montelukast Two leukotriene receptor blockers are indicated for use in children with asthma. Montelukast is indicated for patients at least 1 year old and zafirlukast is indicated for patients 5 years and older.

A patient is starting on Singulair. Which of the following is a warning associated with the use of Singulair?

E) Neuropsychiatric events The warning involves neuropsychiatric events; behavior and mood-related changes have been reported. This warning was added in 2009 and applies to *ALL the leukotriene modifiers.*

A 12 year-old male patient has a new prescription for QVAR HFA. Previously, the patient had been using only an albuterol inhaler. He has been using the albuterol inhaler 3-4 times per week. Choose the correct statement:

E) This is appropriate; QVAR HFA is considered a first line agent per the asthma guidelines. Inhaled corticosteroids, like QVAR HFA, are first line therapy for anyone with persistent asthma as demonstrated in this case.

A patient with mild, intermittent asthma has been prescribed an albuterol MDI. Counsel the patient on the correct use of the device. Place the instructions for proper MDI technique below in the correct order (left-click the mouse to highlight, drag, and order the answer options; ALL options must be used).

Remove the dust cap from the inhaler. Inspect the mouthpiece for any debris. Place the mouthpiece on lips and close lips around it. Press the top of the canister while breathing in deeply and slowly. Hold breath as long as possible, up to 10 seconds.