From the Text. Clinical Indications. Clinical Indications. RSPT 2217 Non-steroidal Anti-asthma Agents. RSPT 2317 Non-steroidal Antiasthma Agents

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1 From the Text RSPT 2317 Non-steroidal Antiasthma Agents Gardenhire Chapter 12 Key Terms and Definitions Page 226 Nonsteroidal Antiasthma Meds Table 12-1; page 228 Comparative Features of Antileukotriene Agents Table 12-2; page 242 Advantages/Disadvantages of Antileukotriene Therapy Box 12-3; page 243 Self-Assessment Questions Page 246 Clinical Scenario Page 247 Clinical Indications General indication is for prophylaxis of mild persistent (step 2) asthma Cromolyn-like drugs and anti-lt agents are recommended as replacements for low-dose inhaled corticosteroids in step 2 asthma Cromolyn and nedocromil are particularly useful in infants and young children Anti-LT agents are useful in combination with inhaled corticosteroids to reduce the steroid dose All nonsteroidal antiasthma agents are controllers, not relievers Step 2 asthma: Symptoms more than 2 times/week, but less than 1 time/day, Nighttime symptoms more than 2 nights/month; FEV1 or PEF 80% or greater; PEF variability 20-30%. Clinical Indications General indication is for prophylaxis of mild persistent (step 2) asthma Cromolyn-like drugs and anti-lt agents are recommended as replacements for low-dose inhaled corticosteroids in step 2 asthma Cromolyn and nedocromil are particularly useful in infants and young children Anti-LT agents are useful in combination with inhaled corticosteroids to reduce the steroid dose All nonsteroidal antiasthma agents are controllers, not relievers Mechanisms of Inflammation in Asthma 1

2 Mechanisms of Inflammation in Asthma Asthma is a chronic inflammatory disorder of the airways It is divided into extrinsic and intrinsic on the basis of triggers extrinsic is dependent on allergy or atopy and is associated with younger subjects intrinsic shows no evidence of sensitization to common, inhaled allergens and is associated with adults and later onset in which childhood asthma may not have been present Asthma has been described as an evolving disease in early childhood, when viruses are an important trigger, whereas in school and teen years, allergens stimulate an immune response Mechanisms of Inflammation in Asthma As asthma progresses, and in adults, the disease becomes intrinsic and may be driven by T lymphocytes Asthma is chronic and persistent, with continual inflammation and episodes of acute obstruction. Three components of asthma are described as follows the acute asthma attack, which resolves spontaneously or with treatment a hyperresponsiveness of the airways to various stimuli persistent inflammation Mechanisms of Inflammation in Asthma In both forms, mediators and enzymes are released to act on target tissues Airway inflammation is manifested in the responses of bronchoconstriction, airway swelling, mucus secretion and obstruction The Immunological (Allergic) Response The majority of asthma is primarily an allergic response that involves mast cells and immunoglobin E (IgE), essentially a mistaken immune response. The response is initiated by the interaction of T lymphocytes and an antigen Activation of these T lymphocytes results in the production of antigen-specific IgE, which binds to effector cells such as mast cells When activated by subsequent exposure to an antigen or allergen, mast cells release physiologically active mediators of inflammation, such as prostaglandins, leukotrienes, proteases, histamine, platelet-activating factor (PAF), and certain cytokines The Immunological (Allergic) Response This cascade of mediators causes an inflammatory response manifested by vascular leakage, bronchoconstriction, mucus secretion and mucosal swelling T lymphocytes also release cytokines, causing accumulation and activation of eosinophils, which also release chemicals that damage the airway Once initiated by antigen exposure, the inflammatory process is amplified by chemoattraction of more lymphocytes, eosinophils, basophils and neutrophils and an increase in mast cells The Immunological (Allergic) Response Antigen stimulation of lymphocytes and mast cells cause an increase in adhesion molecules, which in turn causes recruitment of more eosinophils, neutrophils and lymphocytes from the microvascular circulation into the airways This further amplifies the inflammatory process The increase and activation of eosinophils is associated with increased inflammation and severity in asthma Nonspecific stimuli such as fog, sulfur dioxide, dust and cold air can stimulate sensory receptors and cause reflexive bronchoconstriction Asthmatic subjects are more sensitive to such stimuli due to either altered neural control or chronic inflammation sensitizing the airway, or both The release of neuropeptides and nitric oxide may also play a role in asthma 2

3 Mast Cell Stabilizing Agents s Intal (MDI; nebulizer solution), Nasalcrom (intranasal metered pump spray), Opticrom (eye drop solution), Gastrocrom (capsule with powder contents to be dissolved in hot water) inhibits the degranulation of mast cells by directly blocking the influx of calcium ions entering the mast cell, preventing the release of chemical mediators of inflammation action is prophylactic and pretreatment is required effective in blocking the late-phase reaction in asthma A more severe airway obstruction 6-8 hours after initial bronchoconstriction does not have an antagonistic effect on any of the chemical mediators does not operate through the camp system; does not affect α or β receptors does not prevent antibody formation, IgE attachment to mast cells or the ag-ab union Indications to decrease the frequency and intensity of asthma attacks in both allergic and nonallergic asthma prevention of exercise induced asthma treatment and prevention of allergic rhinitis and allergic conjunctivitis hypersensitivity to cromolyn, acute asthmatic attacks, status asthmaticus Precautions not indicated in the treatment of acute asthmatic attacks or status asthmaticus; indicated only as a prophylactic agent excreted in urine and bile (feces); therefore use with caution in pts. with impaired renal or hepatic function safety and efficacy in children under age 5 and in pregnancy have not been established if cough or bronchospasm occurs, pt. may not be able to continue tx; monitor pt. for symptoms and notify physician if coughing or wheezing occurs; prior use of a b2 adrenergic agonist should be used if a pt. develops bronchospasm and wheezing with the administration of cromolyn CNS: dizziness, headache pulmonary: bronchospasm, wheezing, cough, laryngeal edema miscellaneous: dermatitis, joint swelling, abdominal pain, sneezing, nasal congestion, epistaxis, urinary frequency, throat irritation or dryness allergic: urticaria, rash, angioedema, anaphylaxis Clinical application complete prophylactic activity may require 4-6 weeks forms nebulizer solution: 20 mg/2 ml liquid ampule MDI: 800 µg/actuation nasal spray: 40 mg/ml optical solution: 40 mg/ml oral solution: 100 mg/capsule nebulizer solution: adults and children 2 yrs.: 1 liquid ampule by SVN qid at regular intervals MDI: adults and children 5 yrs.: 2 inhalations qid at regular intervals nasal spray: adults and children 6 yrs.: 1 spray in each nostril q 4-6h optical solution: as directed oral solution: 200 mg qid (powder contents of capsule are dissolved in hot water) 3

4 Nedocromil sodium Tilade inhibits mediator release from mast cells inhibits eosinophil chemotaxis does not have bronchodilator properties optimum control of asthma symptoms depends on regular use, even if symptoms are not present Indications to decrease the frequency and intensity of asthma attacks in both allergic and nonallergic asthma Nedocromil sodium hypersensitivity to nedocromil, acute asthmatic attacks, status asthmaticus CNS: headache, dizziness GI: unpleasant taste, nausea, vomiting Cardiopulmonary: chest pain, cough, pharyngitis, rhinitis, bronchospasm, dyspnea, upper resp. tract infections form MDI: 1.75 mg/actuation MDI: 2 inhalations qid Leukotrienes and Inflammation Leukotrienes are members of a group of biologically active fatty acids known as eicosanoids Leukotrienes and Inflammation These molecules are synthesized from arachidonic acid and are lipid mediators of inflammation that mediate directly or indirectly some of the inflammation seen in asthma Leukotrienes are potent bronchoconstrictors and stimulate other cells to cause airway edema, mucus secretion, ciliary beat inhibition and recruitment of other inflammatory cells into the airway Leukotrienes and Inflammation Leukotrienes are not preformed; they are synthesized following a mechanical, chemical or physical stimulus, such as an antigen or allergen challenge Cells that have the necessary enzymes to synthesize leukotrienes include mast cells, eosinophils, basophils, neutrophils, monocytes, macrophages and B lymphocytes Leukotrienes bind to leukotrienes receptors to exert their inflammatory effects and several receptor types have been identified to date Leukotrienes and Inflammation These receptors are involved in cellular recruitment (chemotaxis), probably of neutrophils, and may be involved in ARDS Stimulation of these receptors not only cause bronchoconstriction, but also an increase in bronchial hyperresponsiveness, increased mucus secretion and viscosity, increased vascular permeability causing airway edema and plasma exudation into the airway lumen 4

5 Clinical Use of Antileukotriene Agents Clinical Use of Antileukotriene Agents Antileukotrienes are prophylactic controller drugs used in persistent asthma, including mild, moderate and severe states; they are not indicated for acute relief or rescue therapy Antileukotrienes are particularly useful in controlling asthma resulting from certain triggers, including exercise-induced asthma, aspirin-induced asthma, and to a lesser extent, allergen-induced asthma Clinical Use of Antileukotriene Agents Antileukotrienes can be tried as an alternative to inhaled corticosteroids or cromolyn-like agents in mild persistent asthma requiring more than as-needed β 2 agonists Antileukotrienes may not be optimal as monotherapy in persistent asthma Antileukotriene Agents Antileukotrienes may allow reduction of high-dose inhaled corticosteroids or prevent an increase in the dose of inhaled corticosteroids and reduce or prevent the need for oral corticosteroids Zafirlukast Accolate antagonizes leukotrienes receptors; blocks inflammatory effects of leukotrienes action is prophylactic and regular use is required hypersensitivity to zafirlukast, or components of the formulation Administration 1 hr. before or 2 hrs. after meal Zafirlukast Drug interactions theophylline, warfarin and aspirin headache, infection, nausea, possible liver enzyme changes forms tablets: 20 mg tablets: adults and children 12 yrs.: 1 tablet bid 5

6 Montelukast Singulair inhibits the 5-LO enzyme, which is a catalyst for the formation of leukotrienes action is prophylactic and regular use is required hypersensitivity to monteluskast, or components of the formulation, active liver disease or elevated liver enzymes Administration can be taken with food Montelukast Drug interactions theophylline, warfarin and propranolol headache, dyspepsia, unspecified pain, liver enzyme elevations forms tablets: 10 mg, 4 mg and 5 mg cherry-flavored chewable tablets: adults and children 15 yrs.: one 10 mg tablet each evening children 6-14 yrs.: one 5 mg chewable tablet each evening children 2-5 yrs.: one 4mg chewable tablet each evening Zileuton Zyflo inhibits the 5-LO enzyme, which is a catalyst for the formation of leukotrienes action is prophylactic and regular use is required hypersensitivity to zileuton, or components of the formulation, active liver disease or elevated liver enzymes Administration can be taken with food Zileuton Drug interactions theophylline, warfarin and propranolol headache, dyspepsia, unspecified pain, liver enzyme elevations forms tablets: 600 mg tablets: adults and children 12 yrs.: 1 tablet qid Zileuton Zyflo inhibits the 5-LO enzyme, which is a catalyst for the formation of leukotrienes action is prophylactic and regular use is required hypersensitivity to zileuton, or components of the formulation, active liver disease or elevated liver enzymes Administration can be taken with food Zileuton Drug interactions theophylline, warfarin and propranolol headache, dyspepsia, unspecified pain, liver enzyme elevations forms tablets: 600 mg tablets: adults and children 12 yrs.: 1 tablet qid 6

7 Omalizumab Xolair a subcutaneously injected monoclonal antibody (mab) Monoclonal Antibodies Indications evidence supports the use of omalizumab in uncontrolled moderate to severe asthma also used to treat moderate to severe asthma in adults and adolescents 12 years who have a positive skin test or in vitro reactivity to a perennial aeroallergen may also be useful in treating seasonal allergic rhinitis Omalizumab Mode of Action omalizumab is a recombinant DNA-derived humanized IgG(x) binds selectively to human IgE blocks the binding of IgE to the IgE receptor on the surface of mast cells and basophils allows the reduction of mediators released in an allergic response and Administration available as a powder that must be reconstituted after reconstitution the concentration is 150 mg/1.2 ml administration is by subcutaneous injection dosing is every 2 or 4 weeks and depends on the patient s weight and serum IgE Omalizumab Pharmacokinetics bioavailability is 62% absorbed slowly - peak concentration is 7-8 days half-life averages 26 days Hazards and side effects rare: anaphylaxis and malignancies more common: injection site reactions, viral infections, URIs and pharyngitis Precautions not for acute asthmatic episodes will not replace regular corticosteroid use RC Assessment of Nonsteroidal Antiasthma Agents Evaluate pt. for optimal aerosol delivery formulation for inhaled meds, if more than one method is available Instruct pt. on use of aerosol delivery system then: Assess breathing rate and pattern Assess breath sounds and pulse pre and post treatment Assess pt s subjective reaction to treatmenrt Verify that pt. understands that nonsteroidal antiasthma agents are controller drugs, not reliever drugs Instruct pt. in use of peak flow meter - verify that there is an action plan based on symptoms and peak flows RC Assessment of Nonsteroidal Antiasthma Agents Long term: Assess severity of symptoms, use of rescue drugs, number of exacerbations, number of missed school/work days and pulmonary function results Modify therapy as described in the NAEPP EPR-2 guidelines for step therapy Assess pt. for medication side effects 7

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