Review Question - QID 100844

Ipratropium, an anti-muscarinic, is indicated for the treatment of asthma. It antagonizes the effects of acetylcholine, which normally causes bronchoconstriction.

This patient's diagnostic workup indicates hypersensitivity to an allergen that causes bronchoconstriction when inhaled due to activation of the Type I hypersensitivity pathway. Ipratropium would counteract the constrictive effects of released acetylcholine in airway smooth muscle. Ipratropium, however, is clinically used more in elderly patients with a clinical picture of COPD plus asthma. Other pharmacologic antagonists used in the treatment of asthma include zafirlukast and montelukast, both of which are LTD-4 and LTE-4 leukotriene receptor antagonists.

Elward and Pollart discuss medical management of asthma, which may include inhaled corticosteroids alone, or additionally long-acting beta-2 agonists, and leukotriene receptor agonists as an alternate, second-line therapy. Patients should also have short-acting beta-2 agonists for exacerbation of symptoms; although if they are using them more than two nights per month or two days per week control is inadequate and clinicians should work with the family to modify the treatment regimen.

Gross reviews use of anticholinergic agents in asthma and COPD management. These include ipratropium and tiotropium. They are often used in conjunction with short-acting beta-2 agonists such as albuterol. Ipratropium has a duration of action of 4-8 hours. By contrast, tiotropium lasts 1-2 days meaning it can be taken as a once-a-day controller medication.

Illustration A shows the various effects of cholinergic signaling in the airway, including stimulation of mucus production and constriction of smooth muscles.

Incorrect Answers:
Answer 1: Beta-2 agonists, not antagonists, are used in asthma management.
Answer 2: Theophylline, also used in the treatment of asthma, is a histone deacetylase (HDAC) stimulator, so a HDAC inhibitor would not be effective in asthma treatment.
Answer 3: VEGF inhibitors are used to prevent angiogenesis in cancer cells.
Answer 5: Anticoagulants do not play a role in asthma management.