Asthma Flashcards
What is chronic asthma?
Reversible obstructive airways disease
What are the symptoms of chronic asthma?
Coughing, especially at night
Shortness of breath
Chest tightness
Wheezing
What are the SABAs?
Short acting bronchodilators
Salbutamol
Terbutaline
What steps in the guidelines do you use a reliever for chronic asthma?
All steps
What are the alternatives to SABAs?
Ipratropium bromide (SAMA)
If over 12 - Theophylline or oral B2 agonist (bambuterol)
When should you step up the management of asthma?
If using inhaler or symptomatic at least 3 times a week
Night time symptoms at least once a week
Asthma attack requiring systemic steroids in last 2 years
Refer is using > 1 inhaler a month
What is step 1 of the asthma guideline?
Low dose inhaled corticosteroids
Start BD then reduce to OD if good control
What are the low dose ICS used in step 1 of asthma management?
Mometasone Fluticasone Beclometasone Budesonide Ciclesonide
What are the alternatives to low dose ICS used in step 1 of asthma management?
Leukotriene receptor antagonist
Theophylline
Inhaled sodium cromoglicate
What is step 2 of the asthma management guidelines?
Add LABA to low dose ICS
Combination inhaler
What are the LABAs used in step 2 of the asthma management?
Formoterol
Salmeterol
What is step 3 part 1 of the asthma guidelines?
No response - stop LABA and increase ICS dose
What is step 3 part 2 of the asthma guidelines?
If benefit but control still adequate
Continue LABA
Increase to medium dose ICS
What is step 3 part 3 of the asthma guidelines?
If benefit but control still inadequate
Continue LABA
Trial LTRA
LAMA
Or SR theophylline
What is step 4 of the asthma management guidelines?
Add fourth drug + high dose ICS
SR theophylline
LAMA - tiotropium bromide
LTRA - montelukast, zafirlukast
Oral B2 agonist tablet - bambuterol
What is step 5 of the asthma guidelines?
Add oral prednisolone
Single dose OM to prevent insomnia
Gradually withdraw when stepping down
What is the mechanism of action of the selective B2 agonists?
Causes bronchodilation of the bronchi
What are the inhaled short acting B2 agonists?
Salbutamol QDS PRN
Terbutaline QDS PRN
What are the inhaled long acting B2 agonists?
Formoterol BD
Salmeterol BD
What are the other LABAs used in COPD?
Olodaterol
Indacaterol
Vilanterol with umeclidinium
What is vilanterol used with in asthma?
Fluticasone
What is the oral B2 agonist tablet?
Bambuterol
What is salmeterol used for?
Long onset + long action
Not for acute relief or prevention of exercise induced asthma
What is formoterol used for?
Short onset + long action
Relievers and preventer
Rv if using more than once a day
What is in fostair?
Beclometasone + formoterol
What is in duoresp spiromax?
Budesonide + formoterol
What is in symbicort?
18 years +
Budesonide + formoterol
What are the side effects of selective B2 agonists?
Hand tremors Tachycardia Hyperglycaemia Hypokalaemia CV events
How do the inhaled corticosteroids work?
Reduces inflammation in the bronchi
Which inhaled corticosteroids have a twice daily dosing?
Beclometasone
Budesonide
Fluticasone
Mometasone (BD/OD)
Which inhaled corticosteroids have a once daily dosing?
Ciclesonide
Which ICS is a pro drug and so can be used if patient is at risk of oral thrush?
Ciclesonide
What is step 1 for asthma control in children?
Low dose ICS
LTRA if < 5
What is step 2 for asthma management in children?
Very low dose ICS
LABA if > 5
LTRA if < 5
What is step 3 part one for asthma management in children?
No response to LABA then stop and increase ICS to low dose
What is step 3 part two of asthma management in children?
If benefit from LABA but control still inadequate then continue LABA and increase ICS to low dose
What is step 3 part 3 for asthma management in children?
If benefit from LABA but control still inadequate continue LABA and ICS and consider trial of LTRA
What is step 4 for the asthma management in children?
Medium dose ICS
Add fourth drug e.g. SR theophylline
What is step 5 for asthma management in children?
Oral steroid
Maintain medium dose ICS
What are the very low dose ICS inhalers used in children?
Beclometasone - 200mcg
Budesonide - 200 mcg
Fluticasone - 100 mcg
What are the medium dose ICS inhalers used in children?
Beclometasone - 400-900 mcg
Budesonide - 800 mcg
Fluticasone - 500 mcg
Ciclesonide - 320 mcg
What are the LTRAs used in children?
Montelukast
Zafirlukast
What are the LABAs used in children?
Vilanterol
Formoterol
Salbmeterol
What are the oral steroids used in children for asthma?
Prednisolone
What are the low dose ICS used in adults for asthma?
Beclometasone - 100-400 mcg
Budesonide - 400 mcg
Fluticasone - 200-400 mcg
Mometasone - 400 mcg
Ciclesonide - 180 mcg
What are the high dose ICS used in asthma for adults?
Beclometasone - 800-2000 mcg
Budesonide 1800 mcg
Fluticasone - 1000 mcg
What are the LAMAs used in asthma for adults?
Tiotropium bromide
How long does ICS need to be used for to have an effect on the prevention of asthma?
Must take regularly for 3-4 weeks
Which inhalers do you need to prescribe by brand name?
Beclometasone
Qvar and clenil are not interchangeable
Qvar is twice as potent as clenil as has extra fine particles
Fostair is even more potent than Qvar
What age are the beclometasone easyhalers licensed in?
18+
What age are the qvar inhalers licensed in?
12+
What are the side effects of ICS?
Hoarse throat
Sore throat
Oral candidiasis
Paradoxical bronchospasm
How do you prevent oral thrush with ICS?
Rinse mouth and brush teeth after using
Treat with daktarin gel
Who should you use a large volume spacer for?
High dose ICS
Patients under 15
What do you do if paradoxical bronchospasm occurs with ICS?
Stop and give alternative
Mild bronchospasm - use SABA before or transfer from pMDI to dry powder inhaler
Which inhalers should be refrigerated?
Trimbow
Fostair
Does smoking reduce or increase effectiveness of ICS?
Reduces effectiveness
Patient may need higher dose
What is the mechanism of action of leukotriene receptor antagonists?
Blocks action of leukotriene on the cysteinyl leukotriene receptor in the lungs and bronchi
Reduces bronchoconstriction and inflammation
What are montelukast and zafirlukast used for?
Chronic asthma
Symptomatic relief of hay fever in asthma
What are the side effects of the LTRAs?
Churg Strauss syndrome - occurs on withdrawal or reduction of ICS
Zafirlukast - liver toxicity
What are the counselling points for zafirlukast?
Report signs of liver toxicity
What is theophylline?
Xanthine bronchodilator
Is aminophylline given IM or IV?
20x more soluble and too irritant to give IM
What is the range for theophylline?
10-20 mg/L
Sample 4-6 hours after dose
What increases the Cp of theophylline?
Heart failure Hepatic impairment Viral infections Elderly Enzyme inhibitor
What decreases the Cp of theophylline?
Smoking
Alcohol
Enzyme inducers
Does theophylline need to be prescribed by brand?
Yes
What are the toxicity signs of theophylline?
Vomiting and GI
Tachycardia, CNS stimulation
Arrhythmias, convulsions, hypokalaemia
Fast and sick
What are the interactions that cause an increased risk of hypokalaemia when used with theophylline?
Loop/thiazide diuretics
Corticosteroids
B2 agonists
What are the interactions that cause an increased risk of convulsions when used with theophylline?
Ciprofloxacin
Quinolones are enzyme inhibitors and they lower seizure threshold
What are the interactions that cause an increased plasma concentration and risk of toxicity when used with theophylline?
Verapamil CCB Cimetidine Phenytoin Fluconazole Macrolides
What are the interactions that cause a reduced plasma concentration when used with theophylline?
St Johns Wort
Rifampicin
Is an acute asthma attack an emergency?
Yes
Failure to respond requires transfer to hospital
How do you treat acute asthma?
Salbutamol aerosol inhaler 2-10 puffs every 10-20 mins PRN
OR
Salbutamol/terbutaline nebuliser every 20-30 mins or PRN
If symptoms persist after 15-30 mins - 999
Repeat above and add nebulised ipratropium bromide
What do you give in all cases of acute asthma?
Prednisolone tablets or IV hydrocortisone
Children < 12 - up to 3 days
Adult - at least 5 days (40-50mg OD)
