Asthma Chapter 35
ProAir HFA 2 inhalations Q6H PRN (last two refill dates: 7/29, 6/3) Protonix 40 mg daily How often, on average, is LY using her ProAir HFA inhaler based on the refill history?
3-4 inh/day Most albuterol inhalers, including ProAir HFA, contain 200 inhalations per canister. Based on the refill history, LY used one inhaler in 56 days (number of days between June 3rd and July 29th). 200 inhalations/56 days = 3.6 inhalations/day (which falls in the range of 3-4).
Which of the following side effects may LY be experiencing from excessive use of ProAir HFA inhaler?
A Nervousness and anxiety B Hyokalemia C Hyperglycemia
A patient is started on the ProAir RespiClick. Which of the following statements are correct regarding ProAir RespiClick? (Select ALL that apply.)
A This medication contains a rescue drug, albuterol. D This medication should not be used with a spacer device. E The dose should be administered with a quick and forceful inhalation. RespiClick inhalers are DPIs. They have a similar shape to an MDI but they should not be shaken and the dose should be administered with a quick, forceful inhalation
HL 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. HL'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 HL on the appropriate use of a peak flow meter? (Select ALL that apply.)
A Use the peak flow meter in the morning, before taking any asthma medications. B Record the highest number of each day in a log book. E If the value recorded is < 150 mL, go to the hospital immediately, regardless of symptoms. Using a peak flow meter requires the patient to be in a standing (or at least in an upright) position for the best measurement. Patients should blow out as hard and as fast as possible.
MS is a four year old girl with asthma. She will receive montelukast. Select the correct dose for a four year old child.
A 4 mg chewable tablet taken once daily in the evening
HL 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. HL'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 HL on the appropriate use of a peak flow meter
A.Use the peak flow meter in the morning, before taking any asthma medications. B. Record the highest number of each day in a log book. E. If the value recorded is < 150 mL, go to the hospital immediately, regardless of symptoms. Using a peak flow meter requires the patient to be in a standing (or at least in an upright) position for the best measurement. Patients should blow out as hard and as fast as possible.
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)
ABCDE Shake for 5 secs, breathe out, place in mouth, press top and breathe in, hold breath 10 secs
CD is a 17 year-old with asthma. She likes to play basketball. Before heading to the court, CD needs to use her albuterol inhaler to help prevent exercise-induced symptoms. Choose the correct statement
Albuterol inhalers are preferred for exercise-induced bronchospasm. LABAs can be used as an alternative 30-minutes prior to exercise, as long as they are not taken daily.
Based on her patient profile, all of the following are possible asthma triggers for LY except:
Answer A A Obesity B Ibuprofen C Stress D Allergic rhinitis E GERD Based on her body weight, LY is not obese. NSAIDs (aspirin, ibuprofen, naproxen, diclofenac) and non-selective beta-blockers are medications that may trigger asthma symptoms. The use of Protonix suggests LY suffers from reflux disease. Other triggers to watch for include cold air, exercise, dust mites, pet dander and airborne pollens (grass, tree, weeds, etc.).
Which of the following medications is available as a dry powder inhaler?
Breo Ellipta
Which of the following vaccination recommendations is appropriate for LY?
C Annual influenza vaccine, Pneumovax 23 now, and a second dose of Pneumovax 23 after age 65.
LY is prescribed Advair Diskus for her asthma. Which of the following counseling points should be reviewed with LY
C This is not a rescue medication for acute asthma attacks. D Rinse the mouth with water and spit after each dose of medication. E Never breathe into the Diskus.
Which of the following medications can decrease theophylline levels?
Carbamazepine and primidone can increase the metabolism of theophylline, therefore, decreasing levels of theophylline.
Pulmicort Respules are used primarily in this population group:
Children
Which of the following medications can increase theophylline levels and possibly result in theophylline toxicity? (Select ALL that apply.)
Ciprofloxacin, clarithromycin and zafirlukast can all increase levels of theophylline.
CH is a 16 year-old teenager who has asthma. His only medication is Ventolin HFA which he uses 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.)
Continue to take the Ventolin PRN for acute symptoms. Start Pulmicort Flexhaler 2 inhalations BID for better symptom control. CH's asthma is not controlled as evidenced by his Ventolin usage. Ventolin should not be taken on a scheduled basis; he needs to be on maintenance therapy (a controller).
Which of the following medication classes has a boxed warning regarding an increased risk of asthma-related deaths when used as monotherapy?
Correct Long-acting beta-2 agonists have a boxed warning regarding the increased risk of asthma-related deaths when used as monotherapy.
Based on her recent asthma exacerbation and use of her ProAir HFA, LY needs a step up in her asthma treatment. Which of the following would be appropriate?
Discontinue Pulmicort Flexhaler and start Advair Diskus Advair Diskus contains a long-acting beta-2 agonist (which opens the airways) and an inhaled corticosteroid (which reduces inflammation). It is a combination inhaler that treates the two primary lung processes occurring in asthma. Serevent Diskus contains salmeterol (a LABA) and Flovent HFA contains fluticasone; neither would provide an appropriate step up in treatment. Use of monoclonal antibodies such as reslizumab should be reserved for patients with severe forms of eosinophilic asthma who have failed first line inhaled treatments.
SF is an 18 month old boy who has been prescribed montelukast granules. Counsel the parents on how to administer the granules to their son:
Instruct 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 it 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).
NT 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. NT is wondering if she still needs an albuterol inhaler for her asthma. The pharmacist should respond:
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.
Which of the following asthma medications works by blocking interleukin-5 receptors?
Nucala
Which of the following statements concerning omalizumab is correct?
Omalizumab can cause anaphylaxis; each dose must be administerd in a healthcare setting.
Choose the correct statement regarding the use of a prednisone taper in LY.
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. In asthma, oral steroids are used for exacerbations and for severe, persistent asthma (step 6); they should always be used for the shortest duration and at the lowest dose possible.
Which medication is most likely contributing to the HEENT finding on the physical exam? (thrush)
Pulmicort
Most metered-dose inhalers need to be shaken well immediately before use. Which metered-dose inhaler does not have to be shaken before use?
QVAR and Alvesco are MDIs that do not need to be shaken before use.
ST, 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? (Answer must be numeric; no units or commas; round final answer to the nearest WHOLE number.)
ST will receive 576 mg of theophylline (1 mg/mL x 30 mL/hr x 24 hrs = 720 mg of aminophylline; aminophylline contains 80% theophylline; 720 mg x 0.8 = 576 mg of theophylline)
Symbicort
Symbicort contains formoterol + budesonide.
AirDuo RespiClick for asthma. What does this product contain?
The AirDuo RespiClick is a new formulation of fluticasone/salmeterol.
TJ use Spiriva Respimat 2.5 mcg/inhalation. He inhales 5 mcg once daily. If each cartridge contains 60 metered actuations, how long will each cartridge last?
The patient takes 2 inhalations once daily, therefore each cartridge will last 30 days.
When assessing theophylline treatment in LY, which of the following statements is true? level is peak of 7
The therapeutic range for theophylline is 5-15 mcg/mL (peak levels at steady state are appropriate). In most patients it should be dosed using ideal body weight (IBW); in this case, LY is less than her IBW so total body weight should be used.
A patient is starting on Singulair. Which of the following is a warning associated with the use of Singulair?
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.
Based on an assessment of SM's asthma control, his healthcare provider asks the pharmacist if he should start QVAR. Which of the following statements is correc
This is appropriate; QVAR is considered a first line agent for persistent asthma.
SC 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 SC's regimen. Which agent can be recommended?
Three leukotriene modifiers are indicated for use in children with asthma. Montelukast is indicated for patients at least one year old, zafirlukast is indicated for patients 5 years and older and zileuton is indicated for patients 12 years and older.
JW is well-controlled on his asthma medications which include Flovent HFA 220 mcg 2 inhalations BID, Serevent Diskus 1 inhalations BID, and Proventil HFA 1-2 inhalations Q4-6H 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 JW's risk of thrush in the future? (Select ALL that apply.)
Thrush is a side effect of his Flovent that can be decreased by using a spacer. Common brand names for OTC spacer devices include OptiChamber and AeroChamber.
History of Present Illness: SM is a 36 y/o male who presents to the HIV Clinic today for a routine appointment. He is doing well and has no major complaints at this time. During the medication history portion of the visit, he states that he uses his albuterol inhaler 4 days per week (about 6 puffs on each of those days) and has been trying some over-the-counter medications to manage occasional heartburn. While completing a medication reconciliation at the clinic for SM, the pharmacist notices that his albuterol inhaler is the Ventolin HFA brand that contains 60 inhalations per canister. Based on his current usage, how many weeks will his inhaler last? (Round answer to the nearest TENTH)
Ventolin HFA comes in two sizes, 200 inhalations and 60 inhalations per canister. SM is using 24 inhalations per week (6 inhalations on 4 days of the week). 60 inhalations/24 inhalations per week = 2.5 weeks
A 70 year old patient has been prescribed Xopenex. Choose the correct statement concerning Xopenex:
Xopenex is levalbuterol, the R-isomer of 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.
Which medication on LY's profile works by blocking phosphodiesterase and increasing cAMP?
theoph Theophylline works by blocking phosphodiesterase, causing an increase in cyclic adenosine monophosphate which promotes release of epinephrine from adrenal cells. This causes bronchodilation.