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bnf 2021 > 3. Asthma > Flashcards

3. Asthma Flashcards

1
Q

Medical emergency in Community

Respiratory

A

Acute asthma

Anaphylaxis

Severe Croup

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2
Q

What is asthma

A

Asthma is caused by swelling (inflammation) of the breathing tubes that carry air in and out of the lungs. This makes the tubes highly sensitive, so they temporarily narrow. It may occur randomly or after exposure to a trigger.

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3
Q

Asthma

Symptoms

A

wheezing (a whistling sound when breathing)

breathlessness

a tight chest – it may feel like a band is tightening around it

coughing at night & early morning

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4
Q

Asthma

Step 1

A

REGULAR PREVENTERS

Low dose ICS
Start at BD then OD if good control

Memetasone
Fluticasone
Beclomethasone 
Budesonide 
Ciclesonide

ALTERNATIVELY

🟢 leukotriene receptor antagonist 
(Montelukast) 
🟢theophylline 
🟢inhaled sodium cromoglicate
🟢inhaled nedocromil
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5
Q

Give a drug name

leukotriene receptor antagonist

A

Montelukast

To be taken ON

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6
Q

Montelukast

MHRA warning on SE

A

Can cause:

neuropsychiatric reactions

sleep disturbances,
depression and agitation (1 in 100)

disturbances of attention /memory (up to 1 in 1,000)

very rarely, hallucinations and suicidal behaviour (up to 1 in 10,000 people).

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7
Q

ICS

SE

A

Headache;
oral candidiasis;
pneumonia (in patients with COPD); taste altered;
voice alteration

Uncommon
Anxiety; 
bronchospasm paradoxical; 
cataract; 
vision blurredpp
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8
Q

Asthma

Step 2

A

ADD to initial Tx (low dose ICS)

LABA:
Formoterol
Salmeterol

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9
Q

LABA

SE

A

Arrhythmias; cardiovascular disease; diabetes (risk of hyperglycaemia and ketoacidosis, especially with intravenous use); hypertension; hyperthyroidism; hypokalaemia; susceptibility to QT-interval prolongation

Cautions, further information

Hypokalaemia

Potentially serious hypokalaemia may result from beta2 agonist therapy. Particular caution is required in severe asthma, because this effect may be potentiated by concomitant treatment with theophylline and its derivatives, corticosteroids, diuretics, and by hypoxia.

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10
Q

Asthma

Step 3

A

A) LABA not effective: STOP and increase dose ICS

B) LABA effective but asthma not adequately controlled : continue LABA & increase ICS to medium

C) LABA effective but asthma not controlled adequately: continue LABA and trial:

Montelukast (LTRA)
Or 
Toitropium (LAMA) 
Or 
SR theophylline
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11
Q

Asthma

Step 4

A

Persistent poor control

ADD:

A) Oral drug:

Montelukast
SR theophylline
MR beta2 agonist (bambuterol)
Tiotropium bromide

B) ⬆️ dose ICS + spacer
2000mcg beclomethasone or equivalent

Still no control?
Specialist

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12
Q

Asthma

Step 5

A

ADD

Regular oral
Corticosteroids: prednisolone OM
Continue taking ⬆️dose ICS

Specialist referral if still poor control

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13
Q

What do

beta 2 agonists do

List a few

A

Bronchodilators of the bronchi

salbutamol
salmeterol
formoterol
vilanterol

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14
Q

Difference between

salmeterol

And

salbutamol

A

duration of action.

Salmeterol lasts 12 hours LABA

salbutamol lasts about 4–6 hours SABA

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15
Q

Salbutamol
(blue inhaler)

A SA bronchodilator, reliever

Usual dosage ?

A

Up to QDS prn

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16
Q

SABA

Short Acting beta2 agonist

Name 2

A

Salbutamol

Or

Terbutaline

Onset 5mints
Duration:4-6hrs

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17
Q

When to refer pt to Gp if no relief on a SABA

How many hours?

A

If SABA fails to relief for atleast 3 hours

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18
Q

LABA

Long Acting Beta-2 agonists

List

ASTHMA

A

Salmeterol
Formoterol

Most common used in asthma

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19
Q

LABA

Long Acting Beta-2 agonists

List

COPD

A

Formoterol

Indacaterol

Olodaterol

Vilanterol

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20
Q

SABA
&
LABA

SE

A

Arrhythmias; headache; hypokalaemia (with high doses); muscle spasms; nasopharyngitis; nausea; palpitations; rash; tremor

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21
Q

SABA

monitoring

A

In severe asthma, plasma-potassium concentration should be monitored (risk of hypokalaemia).

In patients with diabetes, monitor blood glucose (risk of hyperglycaemia and ketoacidosis, especially when beta2 agonist given intravenously).

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22
Q

Long Acting Muscarinic Antagonist (LAMA)

List

A

Tiotropium OD

Glycopyrronium bromide OD

Aclidnium BD

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23
Q

LAMA

SE

A

Arrhythmias; constipation; cough; dizziness; dry mouth; headache; nausea, blurred vision, glaucoma

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24
Q

Short Acting Muscarinic Antagonist (SAMA)

List

A

Ipratropium

Asthma & COPD

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25
SAMA DURATION
Onset: within 20 mints Duration 4 hrs
26
SAMA SE
Most common Dry mouth 💋 Arrhythmias; constipation; cough; dizziness; dry mouth; headache; nausea
27
Bambuterol Indication
Long acting bronchi dilator Used in asthma step 4 To be taken ON
28
LABA + ICS Not to be used :
Alone In rapidly deteriorating asthma
29
Best to be used in nocturnal asthma
LABA
30
Inhalers containing Formoterol therefore can be used as a reliever (4)
Fostair DuoResp Spiromax Symbicort
31
LABA SABA Can cause cardiovascular events therefore what has to told to pt or on RX
The dose frequency And MAX dose puffs in 24hrs
32
Usually when hyperglycaemia is present ..... is also present
HypOkalaemia
33
Hypoxia can cause
HypOkalaemia
34
HypOkalaemia Symptoms
Weakness and Fatigue. ``` Muscle Cramps and Spasms Muscle cramps are sudden contractions of the muscles Digestive Problems Heart Palpitations Muscle Aches and Stiffness Tingling and Numbness Breathing Difficulties Mood Changes ```
35
Most common ICS List & dosing
Beclometasone Budesonide Fluticasone All Taken BD Except Ciclesonide OD Mometasone BD or OD
36
ICS How do they work
Preventers Take 3-4 weeks to work
37
Beclometasone available As DRY powder inhaler (DPI) Brands include:
Pulvernal | Beclometasone easy haler
38
Beclometasone available as CFC-free inhalers Must be prescribed by brand name sue to potency List both
QVAR is twice as potent as | Clenil Modulite
39
Potency of inhalers Put them in Oder of most potent : QVAR Fostair CFC containing beclometasone inhalers Clenil module
1. Fostair 2. QVAR 3. Clenil module 4. CFC containing beclometasone inhalers
40
Minimum age For Beclometasone easyhaler
18+
41
Minimum age For QVAR
12 +
42
Minimum age For High dose Clenil Modulite 200 or 250
12+
43
An indication of incorrect inhalation technique List 2
Hoarse voice Sore throat Oral thrush
44
What is Oropharyngeal deposition
Drugs in mouth or back of throat due to poor inhalation technique
45
NICE recommends Using a spacer with pressurised metered dose inhalers for patients under...... years.
15
46
What is Paradoxical bronchospasm And they can be caused by what?
Paradoxical bronchospasm is the unexpected constriction of smooth muscle walls of the bronchi that occurs in the setting of an expected bronchodilatory response ICS It it does happen, stop and use alternative
47
Mild (Paradoxical)bronchospasm Can be avoided by:
By using SABA before an ICS Transferring from pMDI to a dry powder inhaler
48
Smoking and ICS increase or decrease dose?
Increase dose
49
Do patients on ICS need a steroid card?
Only if they are on HIGH doses; especially those on unlicensed high doses
50
Leukotriene receptor antagonists Montelukast Or Zafirlukast Indication Withdrawal side effect with on Corticosteroids
Chronic asthma Systematic relief of hayfever in asthma SE: churg strauss syndrome
51
What is Churg strauss syndrome
Churg-Strauss syndrome is a disease characterized by inflammation of the blood vessels. Churg-Strauss syndrome occurs in patients with a history of asthma or allergy. Symptoms of Churg-Strauss syndrome include fatigue, weight loss, nasal passage inflammation, numbness, and weakness It occurs on withdrawal or reduction of an concomitant ORAL corticosteroids
52
Zafirlukast SE
Hepatotoxic Pts have to report symptoms of liver toxicity Abdominal Pain, itch, N+V, jaundice
53
What is theophylline Given to who?
Antimuscarinic Xanthine bronchodilator Acute and chronic asthma Chronic COPD
54
What are the ingredients in Aminophylline
Theophylline + Ethylenediamine Given by injection as it’s 20 x more soluble give IV Not given IM as it’s irritating: AVOID
55
Therapeutic range Of theophylline
10-20m/L (55-110 mmol/L) Sample 4-6hrs after dose
56
Theophylline Warning signs (Report STAT to dr)
Toxicity (Vomiting, dilated puplis,arrhythmia, restless, agitation, hyperglycaemia) Symptoms of uncontrolled asthma (Cough,wheeze,tight chest) Frequent courses of antibiotics and corticosteroids (Shows poor asthma control)
57
Theophylline Pregnancy
Benefit outweighs risk Continue taking as normal with monitoring
58
Theophylline Branding
MR preps have to be prescribed as brand as different brands have different bioavailability (If brand not specified contact prescriber)
59
Theophylline Monitoring 2
Potassium Theophylline concentration
60
Normal potassium level
3.5 and 5.5mmol/L In healthy patients
61
Theophylline Cautions
Cardiac arrhythmias or other cardiac disease; elderly (increased plasma-theophylline concentration) (in adults); epilepsy; fever; hypertension; peptic ulcer; risk of hypokalaemia; thyroid disorder
62
Theophylline SE
Anxiety; arrhythmias; diarrhoea; dizziness; gastrointestinal discomfort; gastrooesophageal reflux disease; headache; hyperuricaemia; nausea; palpitations; seizure; skin reactions; sleep disorders; tremor; urinary disorders; vomiting Side-effects, further information Potentially serious hypokalaemia may result from beta2-agonist therapy. Particular caution is required in severe asthma, because this effect may be potentiated by concomitant treatment with theophylline and its derivatives, corticosteroids, and diuretics, and by hypoxia. Plasma-potassium concentration should therefore be monitored in severe asthma.
63
Severe asthma Theophylline
Monitoring potassium level is essential! Major SE hypokalaemia
64
Theophylline Medicine causing Increased plasma concentration 7
Diltiazem Verapamil Cimetidine Ciprofloxacin Erythromycin Clarithromycin Fluvoxamine Oestrogen
65
Theophylline Conditions that cause increase plasma concentration of theophylline 4
Elderly HF Viral infection Hepatic impairment Enzyme inhibitors
66
Theophylline Reduce plasma concentration 8
``` Alcohol Smoking Enzyme inducers Carbamazepine Primidone Phenobarbital Phenytoin Ritonavir ```
67
Theophylline And smoking
Decreases theophylline concentration Dose adjustment may be necessary Inform dr if you want to start or stop smoking Continue smoking while on theophylline
68
Theophylline + What drug classes (4) causes: HypOkalaemia As major SE
Loop diuretics Thiazides diuretics Corticosteroids Beta2 agonist
69
Theophylline + ? Increased risk of seizures
Ciprofloxacin
70
Main Tx acute asthma
Short acting bronchodilators & Oral Corticosteroids
71
Tx acute asthma (ALTERNATIVE)
Short-acting beta-agonists (SABAs) Salbutamol/terbutaline Salbutamol by nebuliser (better drug delivery to the lungs 🫁 (O2 driven as BA have a SE atrial hypoxia) If symptoms persist after 12-30 mints 999 A short course of oral corticosteroids given as a single dose OM
72
Beta 2 agonist SE
Atrial hypoxia
73
Acute Asthma 12 year old on oral corticosteroids Max days? And for adults?
Up to max 3 days Adults? Atleast 5 days 40-50mg OM
74
Prednisolone for acute asthma When is gradual withdrawal required?
Can be stopped abruptly Gradual withdrawal only required if used oral corticosteroids arte taken for more than 3 weeks
75
After acute attack
Asthma meds have to be reviewed

bnf 2021 (20 decks)

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