Antimuscarinic bronchodialators, β₂-agonists

Question 1

List 5 antimuscarinic bronchodialators and state the common brands they are available in (5)

Answer 1

1) Aclidinium bromide - Eklia
2) Glycopyrronium bromide- Seebri breezhaler
3) Ipratropium bromide- Atrovent
4) Tiotropium- Spiriva, Braltus
5) Umeclidinium- Incruse ellipta

Question 2

Outline the role of antimuscarinic bronchodilators in COPD, with reference to SAMAs and LAMAs

Answer 2

1) SAMA- used to RELIEVE breathlessness e.g. brought on by exercise
2) LAMA- used to PREVENT breathlessness and exacerbations

Question 3

Outline the role of antimuscarinic bronchodilators in asthma, with reference to SAMAs and LAMAs

Answer 3

1) SAMAs- used to help relieve breathlessness during acute exacerbations
2) LAMAs- (tiotropium) can be added to high dose ICS and LABAs as maintenance treatment in patients with severe asthma

Question 4

List the common side effects of antimuscarinic bronchodilators

Answer 4

1) Dry mouth
2) Cough
3) Arrhythmias
4) Dizziness
5) Headache
6) Nausea, constipation, GI disturbance
7) Urinary retention

Question 5

Who should antimuscarinic bronchodilators be used in caution with?

Answer 5

1) Angle-closure glaucoma- can cause a dangerous rise in IOP. (Reported with nebulised ipratropium esp when given with salbutamol . Protect patients eyes from drug)
2) Those at risk of arrhythmias
3) Those at risk of urinary retention e.g. bladder outflow obstruction, prostatic hyperplasia
4) Paradoxical bronchospasm

Question 6

How often should SAMAs such as Ipratropium be taken?

Answer 6

To be taken 3-4 times a day or as needed for breathlessness

Question 7

How often should LAMAs such as tiotropium, glycopyrronium, aclidinium be taken?

Answer 7

Once or twice daily for regular administration

Question 8

What counselling should be given regarding side effects to patients taking antimuscarinic bronchodialators

Answer 8

1) Can cause dry mouth - chew or suck gum
2) When to take it: for acute symptoms, pre-emptively before exercise, or regularly for LAMAs
3) Check inhaler technique

Question 9

What was the MHRA advice provided regarding Braltus (tiotropium) inhalers?

Answer 9

Risk of inhalation of capsule if placed in the mouthpiece of the inhaler. Always store capsules in screw-top bottle provided

Question 10

Outline three indications for β₂-agonists

Answer 10

1) Asthma
2) COPD
3) Hyperkalaemia- nebulised may be used to decrease potassium concentration (along with insulin and glucose; and calcium gluconate)

Question 11

Describe how SABAs and LABAs are used in the management of asthma

Answer 11

1) SABAs: used to relieve breathlessness
2) LABA: used in chronic asthma when ICS alone are insufficient
↳ LABA must always be given in combination with ICS

Question 12

Describe how SABAs and LABAs are used in the management of COPD

Answer 12

1) SABA: used to relieve breathlessness

2) LABA: second line for COPD, to improve symptoms and reduce exacerbations

Question 13

Outline the MoA of β₂-agonists

Answer 13

β₂-receptors found in smooth muscle of the bronchi, gut, uterus and blood vessels. Stimulation of this receptor leads to smooth muscle relaxation. This improves airflow in constricted airways

Question 14

List four LABAs and state which brands they are commonly found in

Answer 14

1) Salmeterol- Serevent
2) Formoterol- Oxis turbohaler
3) Indacaterol- striverdi
4) Bambuterol- bambec

Question 15

List the common side effects caused by β₂-agonists

Answer 15

1) Tachycardia, arrhythmias, palpitations
2) Anxiety
3) Tremor
4) Headache and dizziness
5) Nausea

Question 16

Why should β₂-agonists be used in caution in diabetics?

Answer 16

1) they promote glycogenolysis and might increase glucose levels
2) hyperglycaemia and ketoacidosis especially a problem when β₂ given IV

Question 17

1) why should LABAs always be given alongside an ICS in asthma?
2) name 2 common brands of combination LABA+ICS inhalers

Answer 17

1) Without a steroid, LABAs are associated with increased asthma deaths
2) seretide and symbicort

Question 18

who should β₂-agonists be used in caution with

Answer 18

1) C/I in severe pre-eclampsia
2) Cardiovascular disease- Tachycardia might provoke angina or arrithmias ( esp careful with high doses e.g. treating hyperkalaemia )
3) Diabetes
4) Hypokalaemia- esp with high doses and by concomitant treatment with theophylline, corticosteroids, diuretics and by hypoxia

Question 19

when prescribing nebuliser therapy, you should always indicate whether the nebuliser should be driven by oxygen or air. Explain why

Answer 19

1) Oxygen should be used in asthma

2) Medical air should be used in COPD due to risk of hypoxic drive/ hypercapnia

Question 20

Outline the monitoring requirements for β₂-agonists

Answer 20

1) In sever asthma - plasma potassium concentration should be monitored (risk of hypokalaemia)
2) monitor blood glucose in diabetics

Question 21

Outline the important safety information provided by the MHRA/CHM regarding the safe use of LABAs (salmeterol and formoterol) in the management of chronic asthma

Answer 21

1) Add-on only if standard dose of ICS fails
2) Not be initiated in those with rapidly deteriorating asthma
3) Start low and monitor before increasing
4) Stop in the absence of benefit
5) Not for relief of exercised-induced asthma unless regular ICS are also used
6) Review and step down treatment when good control is achieved

Question 22

1) what is the maximum number of puffs that can be taken by adults and children in moderate and severe acute asthma using salbutamol
2) what is the duration of action of salbutamol?

Answer 22

1) 10 puffs - each puff is to be inhaled seperately, repeat every 10-20 minutes if required
2) 3 to 5 hours if inhaled

Question 23

Name two SABAs and state which brands they are commonly found in

Answer 23

1) Salbutamol: Ventolin, Salamol

2) Terbutaline: Bricanyl

Question 24

what advice should be provided to patient and carers regarding β₂-agonists

Answer 24

1) The dose, frequency and maximum number of inhalations in 24h should be stated explicitly
2) seek medical advice when the prescribed dose fails to provide the usual degree of relief