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Asthmapresentation
- 1. Madison Block Doctor ofPharmacy Candidate 2016 WSU College of Pharmacy
- 2. Based offof the CDC 2012 results 9.3% children 8% of adults NHLBI 1.7 million ER visits 10.6 million physician office visits 12.8 million missed school days 10.1 million missed work days 444,000 hospitalizations 3,613 deaths $20.7 billion in direct and indirect costs Asthma Prevalence
- 3. “The exactcause of asthma isn’t known. Researchers think there is some genetic and environment factors that interact to cause asthma, most often early in life: These factors are: An inherited tendency to develop allergies, called atopy Parents who have asthma Certain respiratory infections during childhood Contact with some airborne allergens or exposure to some viral infections in infancy or in early childhood when the immune system is developing.” The Hygiene Hypothesis Asthma Causes
- 4. Coughing, wheezing,and SOB Whistling in the chest Difficulty or discomfort when breathing, tightness in chest, chest pain, breathing hard and/or fast. Nostril flaring (nostril opens wide to get in more air). Can only speak in short phrases or not able to speak Blueness around the lips or fingernails Best diagnostic tool is the Lung Function Test Asthma Exacerbation Symptoms
- 5. Reduce Impairment Prevent Symptoms Infrequent use of SABA (Short-acting Beta Agonist) Maintain (near) normal pulmonary function Maintain the QOL (Quality of Life) Meet Patient’s expectations (or know their goals) Reduce Risk Prevent recurrent exacerbations Prevent loss of lung function Provide optimal pharmacotherapy with minimal to no AE (adverse effects) Goals of Therapy: Asthma Control
- 6. Assessing andmonitoring asthma severity and control Education for a partnership in care (Between Patient, Doctor, and Pharmacist) Control of environmental factors and comorbid conditions that affect asthma Medications The Four Components
- 7. Partnership betweenpatient/family and healthcare providers Establish open communication Address patient’s concerns Develop treatment goals My Asthma Action Plan Select medications tailored for patient Educate the patient on the correct use Encourage self-monitoring (Peak Flow Meter) Education for Partnership of Care
- 10. Allergic Rhinitis Sinusitis Sleep Apnea Obesity GERD Sensitivity to sulfites in food (shrimp, dried fruit, beer, wine) Stress and depression All asthma patients should be encouraged to receive a flu shot. (an inactivated virus) Conditions that Impede Asthma Management
- 11. Controlling EnvironmentalFactors Animal Dander Dust Mites (found in mattresses, pillows, carpets, cloth furniture, and other cloth-covered items) Cockroaches Indoor mold Pollen and Outdoor Mold (during high allergy season) Irritants (tobacco smoke, smoke, strong perfumes etc.) Vacuuming Sulfites, cold air, other medicines, infections Non-Pharmacological Treatment
- 12. SABA (Short-ActingBeta Agonist) Low, Medium and High Dose ICS (Inhaled Corticosteroid) LABA (Long Acting Beta Agonist) Leukotriene Modifiers Immunomodulators Mast Cell Stabilizers Methylxanthines Oral Systemic Corticosteroids Pharmacological Treatment
- 13. Metered DoseInhaler (MDI) Produces a cloud of medication that reaches ~6in. (typical inhaler) Pros and Cons Dry Powder Inhalation (DPI) Micronized dry power inhaled directly into the lungs Pearl: Don’t breathe out into the inhaler (lose dose) Pros and Cons Nebulizer Produces an aerosol from a liquid solution in a cup. Pearl: hold cup upright or medicine will spill, tubing must be boiled after use. Pro’s and Con’s Other Equipment Spacer, valved holding chamber, face mask Devices
- 14. Albuterol (Proventil,Ventolin, Pro-Air, Accu-neb)- $55-$65 Levalbuterol (Xopenex) Metaproterenol (Alupent) Pirbuterol (Maxair)-$175 Terbutaline (mainly IV or SubQ)-$17,000 MOA: Rapidly relaxes the muscle lining of the airways that carry air to the lungs, by selectively stimulating beta-2 adrenergic receptors. They are Bronchodilators, not anti- inflammatory. If patient has exercise induced bronchospasm (encourage SABA use 15-20 min before physical activity. SABA (Short Acting Beta-2 Agonists)
- 15. SE: HA,dizziness, N&V&D, anxiety, tremor, racing heart, dry mouth, cough. Counseling: Overuse of quick-relief SABA’s can reduce the effectiveness of them, so should not be considered for maintenance therapy but as a rescue during exacerbation. This is their rescue inhaler. If the patient is having an asthma attack they should use this medication. Proper inhaler use. Wait 1 full minute between inhalations Try and hold breath for 10 seconds. Can rinse mouth with water and spit out for dry mouth and throat. (Shouldn’t swallow because then can cause more systemic effects) SABA Continued
- 16. Beclomethasone MDI(QVAR) (40mcg, 80mcg per puff) -$140 Budesonide (Pulmicort) DPI (90mcg, 180mcg per inhalation) $130-$180 Budesonide Nebules (Pulmicort Respules) (only FDA- approved labeling for children < 4 years of age) (0.25 mg, 0.5 mg, and 1 mg per nebule) Price for 1 carton: $280-$650 Ciclesonide (Alvesco) MDI (80mcg, 160 mcg/puff)-$195-$200 Flunisolide (AeroBid, Aerospan) MDI (80mcg/puff) Fluticasone (Flovent HFA) MDI (44mcg, 110mcg, 220mcg per puff)- $140-$290 Fluticasone (Flovent Diskus) DPI (50mcg, 100mcg, 250mcg per inhalation)- $160-$213 Mometasone (Asmanax Twisthaler) DPI (110 mcg, 220 mcg per inhalation)-$170-$290 Inhaled Corticosteroids
- 17. Not foruse if you are having an asthma attack, that is your SABA only. This is your maintenance medication. MOA: Reduce inflammation, swelling and mucus production in airways. Inhibits multiple inflammatory cytokines; produces glucocorticoid and mineralocorticoid effects. SE: thrush, hoarseness, throat irritation, HA Counseling: Not the same as anabolic steroids , these are for inflammation not for building muscle. (important for some parents to know if concerned to give to children). Rinse mouth after each use, can cause thrush Fungal infection on the lining of the mouth, tongue, gums, tonsils (candida albicans). The white lesions may bleed and become painful. Correct Inhaler Technique Use SABA first to open up lungs if having more of a flair up. ICS Continued
- 18. Salmeterol (SereventDiskus) DPI (50mcg blister)-$238 Formoterol (Foradil) DPI (12mcg/capsule)-$210-$285 Should not be used as monotherapy but rather in combination with ICS such as: Fluticasone/Salmeterol (Advair Diskus, or HFA) (MDI, or DPI) 1 inh. BID DPI: 100mcg/50mcg, 250mcg/50mcg, 500mcg/50mcg-$268-$394 MDI: 45mcg/21mcg, 115mcg/21mcg, 230mcg/21mcg-$270-$424 Budesonide/Formoterol (Symbicort) (MDI) 2 inh. BID 80mcg/4.5mcg, 160mcg/4.5mcg-$240-$273 Mometasone/Formoterol (Dulera) (MDI) 2 inh. BID 100mcg/5mcg, 200mcg/5mcg-$250-$272 MOA: Selectively stimulates beta-2 adrenergic receptors which relaxes bronchial smooth muscle like SABA’s, but onset of action is delayed and the action is prolonged. SE: shakiness, fast heartbeat, HA, muscle cramps, nervousness, irritation of mouth and throat. Counseling Points Not for the use of an acute asthma attack Proper use of the inhaler LABA (Long Acting Beta Agonists
- 19. LTRA (LeukotrieneReceptor Antagonists) Montelukast (Singular)-(take at bedtime) Adult: 10mg qHS Zafirlukast (Accolate) (take 1 hr. before or 2 hr. after a meal) -$50-$60 Monitor liver function Adult: 40 mg daily 5-lipoxygenase Inhibitor Zileuton (Zyflo) (60mg. Tab) 2,400 mg. daily $450 Monitor liver function Less desirable because of limited studies as adjunctive therapy and the need to monitor liver function. Pt. should report any stomach pain, nausea, fatigue or jaundice (liver dysfunction) Shouldn’t be used in children under the age of 12. Leukotriene Modifiers
- 20. MOA: Selectivelybinds to leukotriene receptors blocking them. (which are thought to play a role in airway edema, smooth-muscle contraction and the inflammation process). SE: HA, N&V, insomnia, irritability Counseling Points: Not for acute asthma attacks. Maintenance therapy. Can mix in applesauce, carrots, rice or ice cream (for those with a hard time swallowing) If taking an antihistamine as well, make sure to take these at opposite times of the day. Leukotriene Modifiers Continued
- 21. Omalizumab (Xolair)(Anti IgE) 150-375 mg SubQ q3-4 weeks (body weight dosing, and pre treatment IgE serum level) Must be reconstituted Be prepared to treat anaphylaxis (can happen even > 1year after getting it) Should be injected in doctors office or clinic Only considered for patients who have persistent allergic asthma Based on evidence for dust mites, animal dander, and pollen. Evidence is weak or lacking for molds and cockroaches. Evidence is strongest for immunotherapy with single allergens. Allergy in asthma is greater in children than adults. MOA: Inhibits IgE protein from binding to mast cells and basophils, decreasing mediator release; decreases free IgE levels. SE: redness, pain, swelling, itching, joint pain, fatigue, anaphylaxis. Counseling Points: Tell patients about the signs and symptoms of anaphylaxis and to get to an ER immediately if experiencing them. Immunomodulators
- 22. Cromolyn Sodium(Intal)-$115-$400, or nedocromil Can be used safely for patients >2 years of age. A nebulized treatment of 20 mg/ampule 1 ampule nebulized Four Times Daily MOA: work by preventing the release of inflammatory cytokines and histamines from mast cells (degranulation). SE: unpleasant taste, HA, hoarsness, coughing, N&V Counseling Points: Take 3-4 weeks to start working. Not for acute asthma attacks Mast Cell Stabilizer
- 23. Theophylline (Theo-24,Theo-Dur, Elixophyllin, Uniphyl)-$6-$70 Liquid, SR tablets, and capsules Monitor serum concentration levels Starting dose is 10 mg/kg/day Adult max: 800mg/day Less desirable alternative because of the need to monitor serum concentration levels. MOA: Increases cAMP; antagonizes adenosine receptors, causes bronchodilation. Contraindicated use with mifepristone. SE: N&V&D, insomnia, HA, tremor, restlessness, diuresis Counseling Points Take with a full glass of water on an empty stomach (if SR) Don’t eat or drink large quantities of caffeine. Make sure they are getting their levels drawn Methylxanthines
- 24. Methylprednisolone (Medrol,A-methopred, Solu-Medrol, Depo- medrol) : 2, 4, 8, 16, 32 mg tablets-$40-$63 Prednisolone(Millipred, Orapred, Flo-pred, Pediapred, Prelone, Veripred): 5mg tabs, 5mg/5mL, 15mg/5mL inj.-$8-$12 Prednisone (Rayos, Sterapred): 1, 2.5, 5, 10, 20, 50 mg tabs, 5mg/5mL, and 5mg/mL inj.-$4-$100 MOA: inhibits multiple inflammatory cytokines; produces multiple glucocorticoid and mineralocorticoid effects. Drug Interactions: Increased effect: warfarin, NSAIDS, Loop Diuretics, thiazide diuretics, ACh inhibitors Decreased effect: Anti-diabetic agents, Salicylates, inactive vaccines. Oral Systemic Corticosteroids
- 25. How theyare used: Short course BURST: (rescue treatment) Adults: 40-60mg/day as single or 2 divided doses for 3-10 days. Continued Treatment: 7.5-60 mg daily in single dose in a.m. or every other day prn for control. SE: weakness, acne, weight gain, mood or behavior changes, upset stomach, bone loss, eye changes, slowing of growth, increased blood sugar, insomnia, edema. Counseling Points: Make sure the patient understands the taper if there is one. If a diabetic patient make sure they are checking their blood sugars. Take in the morning with food as it can cause insomnia, and stomach upset. May feel a little restless, may feel really hungry or really thirsty, and can sometimes cause mood swings Systemic Corticosteroids
- 27. When shouldyou step up a patient to the next higher level of therapy? When the patient is using their SABA> 2 times per week for symptom relief. First should check medication adherence, inhaler technique, environmental control and co-morbities. When should you step down a patient to the next lower level of therapy? When a patient has been controlled on their therapy regimen for 3 months or longer, should consider stepping down therapy. Our goal is to have control at the lowest strength of medications. FEV (Forced Expiratory Volume) Normal Values 8-19 years: 85%, 20-39 years: 80%, 40-59 years: 75%, 60-80 years: 70% Assessing (Stepwise Approach)
- 29. Peak FlowMeter Green Zone 80-100% of personal best Yellow Zone 50-79% of personal best (asthma is getting worse add a quick relief medication) Red Zone (signals a medical alert) Call Doctor now Follow-up with patients 2-6 weeks while gaining control 1-6 months to monitor control Every 3 months if step down therapy is anticipated Lung Functions tests at least every 1-2 years; more frequent if asthma is uncontrolled Asthma control, proper technique, written asthma action plan, patient adherence, patient concerns. Monitoring
- 32. M.J. isa 26 year old male presents to your pharmacy to pick up his normal maintenance medications and you see that he has labored breathing and is wheezing. He pulls out his inhaler and uses it. You get to talking with M.J. and figure out that he really hasn’t been doing anything different, but it just seems that his asthma is getting worse. He says that he has symptoms throughout the day, is waking up almost every night from sleep, and has been having to use his rescue inhaler way more than usual, but when he uses it, he does get relief. When pressed further he states that he uses his albuterol at least three times a day. Is there anything else you want to ask M.J. or want to know? What would you tell M.J? What would you tell the doctor? Based on our follow up chart what would you recommend to the doctor?
- 33. Asthma COPD Problem Bronchoconstriction reversible SmallAirway Narrowing Alveolar Destruction. irreversible Effects All Airways (with little fibrosis or epithelial shedding) Peripheral Airways, lung destruction, Fibrosis and squamous cell metaplasia First Line Therapy Short-Acting Beta Agonist as needed then ICS Anticholinergic (Spiriva, or ipratropium) then LABA Goal Reduce exacerbations, control symptoms Slow disease progression, improve QOL Symptoms Dry cough, wheezing, SOB, noisy breathing SOB, chronic cough, increase in sputum production can cause an increase in bacterial infections. Differences in Asthma vs. COPD
- 34. www.goodrx.com (Prices) APhA Lexicomp Drug Information Handbook. 23rd edition. 2014-2015 www.cdc.gov/asthma/asthmadata.htm www.nhlbi.nih.gov/health/health- topics/topics/asthma.htm. June 15, 2012 www.nhlbi.nih.gov/health/public/lung/asthma_ac tplan.pdf References
Editor's Notes
- #2 Store 66
- #3 9% of children and 8% of adults in the U.S. have asthma, and that is a significant portion of our population, which is why asthma is such a large issue.
- #4 The Hygiene Hypothesis. We are too clean. Children aren’t exposed the same to the environment and infections as they once were.
- #5 The main symptoms are coughing, wheezing, and SOB. There can also be noisy breathing such as whistling in the chest and nasal flaring …. The important thing to realize is a patient doesn’t have to have all of these symptoms to be diagnosed with asthma.
- #7 The four components of asthma treatment.
- #8 We really want to get the patient as adherent to their maintenance therapy as possible so that they have less dangerous exacerbations. If a patient is being controlled on their maintenance medication they shouldn’t even have to touch their rescue inhaler unless preventing activity induced symptoms.
- #9 My Asthma Action Plan
- #12 Animal dander: what are some things you think you could do to reduce pet dander? -keep pets with fur or hair out of the home -keep pet out of the bedroom and other sleeping areas and keep the door closed -remove carpets and cloth furniture from your home. (or keep pet away from these surfaces as much as possible). Dust Mites: -many people with asthmas are also allergic to dust mites (small bugs, too small to see) -put mattress and pillow in special dust proof covers -wash sheets and blankets on your bed each week in HOT water (hotter than 130 deg)… or you can use bleach with warm water which will also do the trick -reduce indoor humidity to below 60%, dehumidifiers or central air conditioners can do this. -try not to sleep or lie on cloth cushions -remove carpets from your bedroom and those laid on concrete (tend to hold more moisture) -keep stuffed tows off of the bed or sleeping area, wash stuffed toys weekly same as bedding. (can also be killed by putting stuffed animals in a plastic bag and stored in the freezer overnight. Cockroaches: dried droppings and remains -keep food and garbage in closed containers -Never leave food, dirty dishes, or standing water out -Use poison baits, powder, gels or paste -if spray is used to kill roaches, stay out of the room until the odor goes away. Indoor Mold -Fix leaky faucets, pipes or other sources of water that have mold around them -Scrub mold off hard surfaces with soap and water and dry completely. Wear gloves to avoid touching mold with your bare hands. Always ventilate the area with strong smelling chemical cleaners. Pollen and outdoor Mold: -try to keep windows closed -stay indoors with windows closed from late morning to afternoon. Pollen and some mold spore counts are highest at that time -If you go outside, change your clothes as on as you get inside and put dirty clothes in a covered hamper or container to avoid spreading allergens inside your home -ask your doctor whether you need to take or increase anti-inflammatory medicine before your allergy season starts. Irritants: -if the person smokes, have them ask their doctor for way to help quit, or have a sit down with them on ways to stop smoking and the benefits of doing so. -do not allow smoking in the car, ask parents to not smoke around children, at least only smoke outside and change clothes when coming back inside -do not use a wood burning stove, kerosene heater or fireplace, vent gas stoves to outside -Try to stay away from strong odor and spray such as perfume, talc powder, hair spray and paints. Vacuuming: -try to get someone else to vacuum for you once or twice a week, stay out of the room while being vacuumed and a short time afterward -You a dust mask, a double-layered or microfilter vacuum cleaner bag, or a vacuum cleaner with a HEPA filter. Sulfties are in wine, drited fruts, intant potatoes and shrimp as a preservative Cold air: cover you nose and mouth with a scarf on cold or windy days Infections: certain lung infections like a cold or the flu may also make asthma worse.
- #13 Special populations include: 2 different child stages, children ages 0-4, and children ages < or = to 12 years old, the elderly and pregnant women. My talk will be mostly about Adult dosing. However you would be surprised, that there usually isn’t a large difference in strength or how to use the medication between adults and children. Elderly: coordination of taking the medication (spacer) In Pregnancy the benefits greatly surpass any risks. ICS are the preferred long-term control medication.
- #14 MDI PROs: small, portable, doesn’t require deep or fast breathing MDI Con’s: requires coordination of actuation and inhalation. (Spacer for children, elderly) (Prime inhaler before first use or if haven’t used in 7 days) shake before each use. DPI Pro’s: Breath-actuated, doesn’t require coordination of depressing device while inhaling DPI Cons: Not approved for < 4 years old dose lost if pt. exhales through device before inhaling, requires deep, and rapid inhalation, mouth rinsing and spitting needed to reduce systemic absorption of medication and side effects. Nebulizer Pro’s: appropriate for any age, less dependent on coordination and cooperation Nebulizer Con’s: bulky, time-consuming, requires electricity (usually), potential for bacterial infection if not cleaned. Other equipment: spacer, valved holding chamber and face mask can help the administration of the medication to all populations and should be mandatory in the special populations such as young children, and the elderly. This is something you can recommend to the doctor and or patient. I have attached sheets just for your reference on the different devices and how to use them/ counsel on them. I would find all of the demo inhalers in your pharmacy and play with them. You can use them to your advantage when practicing your counseling and when really counseling your patients. If your pharmacy doesn’t have any demo inhalers, you can contact the companies drug reps and they are usually more than happy to send one to you.
- #17 They are all expensive. Check to see which formulation is the preferred on their insurance plan. -Also if the patient is on multiple medications, in which there is a combo unit that can be used. It can be beneficial to switch them to a combo unit, for not only increased adherence to the drug regimen but also to decrease the total cost of their medications.
- #20 These medications are not first line usually and are mainly used in a patients who also have allergies. Singular is the preferred agent because there is no liver fxn monitoring needed.
- #22 Skip
- #23 Still used but not a frequently
- #24 Mifepristone: used to terminate pregnancy. (increases theophylline level risk of toxicity) Caffeine will increase risk of cardiovascular and CNS stimulatory effects, and toxicity. (theophylline metabolized to caffeine in neonates, additive effects) Only SR (because of dose dumping)
- #27 In assessing and monitoring, we use a STEPWISE APPROACH TO MANAGING ASTHMA Now, to talk about the steps. The steps go from 1-6, 1 referring to intermittent asthma, 6 being the most severe persistent asthma. Step 1, which, once diagnosed with asthma is what every patient will be put on immediately is a SABA or short acting beta agonist. (albuterol, levobuterol), if the patient is controlled at this step, then you leave them on that therapy. If not then we will need to step up. Step 2: is adding on a low-dose inhaled corticosteroid. If patient is still uncontrolled (using their SABA >2 days/week for symptom relief) you should step up treatment. Step 3: is where you start getting more options based on what the patient and provider are wanting to do. You can either bump up the inhaled corticosteroid to a medium dose, or you can keep the low dose ICS and add a LABA or long acting beta agonist (such as salmeterol or fomoterol) good thing with these is they have a combined dose of these medications giving the patient the opportunity to not have to use as many inhalers. Besides Step 1, each of these steps have alternative treatments which you can see on the chart as well. The best medication for the patient is unique to each patient and each option should be discussed with the doctors.
- #28 FEV is usually something done in the doctors office to show how controlled a patients’ asthma is, however I just heard that they are making a unit for at home use for patients. So be on the look out for this cool device that we can direct patients toward.
- #29 Initial Visit: Classification of Asthma Severity This chart is the basis of how we the doctor would first initiate therapy. Asthma has strict guidelines that have been developed by the nhlbi (or National institutes of Health, national Heart, lung and blood institute).. The publication number 08-4051. Assess the impairment (symptoms, nighttime awakenings, interference with normal activity) by the recall of events during the previous 2-4 week period. Assess risk (such as asthma exacerbations requiring oral systemic corticosteroids) over the last year. If you have a spirometer, you can also measure the patients FEV (this is normally done at the doctor’s and not in a retail pharmacy) After you get all of this information you can see what category the patient fits into best (intermittent, or persistent either mild, moderate, or severe). For example, You have a 32 year old female with daily asthma symptoms, wakes up from sleep about 2-3 times per week, and feels that she is unable to do normal stuff that a regular person should be able to do without issue. We are able to get an FEV (forced expiratory volume) of 75% . What step would you classify this patient at solely based on the information above? Step 3.
- #31 Peak Flow Meter Chart
- #32 FOLLOW-UP VISITS The follow up visit chart is the one that I believe would be the most helpful to us when talking with the patient. On the next slide is a patient case we will go through together, but refer back to this chart for the questions.
- #33 M.J. who is a 26 year old male presents to your pharmacy to pick up his normal maintenance medications and you see that he has labored breathing with a slight wheeze. He pulls out his inhaler and uses it. You get to talking with M.J. (aka oldcart) and figure out that he really hasn’t been doing anything different, but it just seems that his asthma is getting worse. He says that he has symptoms throughout the day, is waking up almost every night from sleep, has been having to use his rescue inhaler way more than usual, but when he uses it, he does get relief. When pressed further he states at least three times a day he is using his SABA. What other things would you ask M.J. ? -has he been admitted to the hospital with any exacerbations? -Does he have any new allergies? -Is his doctor aware? -Any new medications? -How is he using his maintenance medications? Turns out he doesn’t have any new allergies. No new medications, using his Advair 1 puff BID What do you want to know? -His medications: He is currently on Advair diskus 100mcg/50mcg (fluticasone/salmeterol) and ProAir 90mcg rescue inhaler 1-2 puffs po q4-6 h PRN symptoms What would you tell M.J. ? -It seems that maybe your asthma isn’t as controlled anymore, I think you would do a lot better if we possibly stepped up your therapy. -Refer him to his doctor, and make an appointment as soon as possible, make sure to tell him that if his asthma gets any worse or if his SABA isn’t working anymore make sure he gets to the ER to get treatment (steroid oral) -Stress to the patient that they should be self monitoring with their peak flow meter. If they drop to at or below 50% of their best (RED ZONE) need to get medical attention, so no permanent damage happens. -Let the patient know that you are going to call the doctor to let them know as well. What would you tell the doctor? -I would call and let the doctor know that M.J. doesn’t seem to be doing well on his current therapy regimen. It would be helpful if you gave the doctor a brief SOAP note over the phone, or via fax, that includes all of the information you discussed with M.J. along with his current medications. -State that you believe his therapy should be stepped up. What would you recommend? -What step is he currently on? Step 3 -Recommend Stepping up to either step 4 or 5 (increase M.J.’s ICS dose to either medium or high) -Recommend a short course of oral systemic corticosteroids -Re-evaluate in 2 weeks.
- #34 What questions do you have for me?
- #35 What questions do you have for me?