Asthma, Chronic Flashcards
Asthma is a common chronic inflammatory condition of the airways, associated with airway ______________ and variable _____________
hyperresponsiveness
airflow obstruction
What are the most frequent symptoms of asthma? (4)
- Cough
- Wheeze
- Chest tightness
- Breathlessness
Asthma-COPD overlap syndrome (ACOS) is characterised by ______________
persistent airflow limitation displaying features of both asthma and COPD
__________________ is characterised by persistent airflow limitation displaying features of both asthma and COPD
Asthma-COPD overlap syndrome (ACOS)
Complete control of asthma is defined as no ______________, no ______________ due to asthma, no ______________, no need for _____________, no limitations on ______________, normal lung function (in practical terms forced expiratory volume in 1 second (FEV1) and/or peak expiratory flow (PEF) > _______% predicted or best), and minimal side-effects from treatment.
daytime symptoms
night-time awakening
asthma attacks
rescue medication
activity including exercise
80
_____________ in overweight patients may lead to an improvement in asthma symptoms
Weight loss
Patients with asthma and parents of children with asthma should be advised about the dangers of ____________, to themselves and to their children
Smoking
*should be offered appropriate support to stop smoking
____________, can be offered to adults as an adjuvant to drug treatment to improve quality of life and reduce symptoms in patients with asthma
Breathing exercise programmes (including physiotherapist-taught methods and audiovisual programmes)
A stepwise approach to chronic asthma aims to stop symptoms quickly and to improve peak flow. Treatment should be started at the level most appropriate to _____________
initial severity of asthma
- The aim is to achieve early control and to maintain it by stepping up treatment as necessary and decreasing treatment when control is good.
What should be done before initiating asthma treatment with a new drug or adjusting treatment? (3)
- Consider if diagnosis is correct
- Check adherence and inhaler technique
- Eliminate trigger factors for acute attacks
A self-management programme comprising of a ______________ and education should be offered to all patients with asthma (and/or their family or carers), and should be supported with regular review by a healthcare professional
written personalised action plan
NICE (2017) treatment recommendations for adults apply to patients aged ______ years and over. BTS/SIGN (2019) treatment recommendations for adults apply to patients aged over ______ years
17
12
What is used as intermittent reliever therapy in patients with asthma?
SABA eg salbutamol or terbutaline; to be used as required
What is the drug class of terbutaline?
SABA
What drug class is salbutamol?
SABA
For those with infrequent short-lived wheeze, occasional use of ____________ may be the only treatment required
reliever therapy (SABA)
Patients using more than ________ short-acting beta2 agonist inhaler device(s) a month should have their asthma urgently assessed and action taken to improve poorly controlled asthma
one
A low-dose of ICS (maintenance therapy) should be started in patients who present with which features? (4)
- Using a SABA three times a week
- Symptomatic three+ times a week
- Waking at night due to asthma symptoms at least once a week
- Patients who have had an asthma attack in the last 2 years (BTS/SIGN 2019)
BTS/SIGN (2019) recommend that inhaled corticosteroids (except ciclesonide) should initially be taken _________ daily, however the same total daily dose taken _______ a day, can be considered in patients with milder disease if good or complete control of asthma is established
twice
once
*The dose of ICS should be adjusted over time to the lowest effective dose at which control of asthma is maintained
If asthma is uncontrolled on a low-dose of ICS as maintenance therapy, a ______________ should be offered in addition to the ICS
leukotriene receptor antagonist (LTRA—such as montelukast)
- BTS/SIGN (2019) instead recommend a long-acting beta2 agonist (LABA—such as salmeterol or formoterol fumarate) as initial add-on therapy to low-dose ICS if asthma is uncontrolled
What is the drug class of montelukast?
Leukotriene receptor antagonist (LTRA)
Response to treatment following introduction of a LTRA in addition to maintenance therapy should be reviewed after ___________ weeks
4-8
ICS + LABA therapy can either be given as fixed-dose regimens OR as a __________ regimen
MART (maintenance and reliever therapy)
Salmeterol and Formoterol are examples of ____________
LABAs
What are the advantages of a MART system? (2)
- Improve adherence
- Ensure the LABA is not taken alone without the ICS
- BTS/SIGN (2019) also recommend that a MART regimen should be considered in patients with a history of asthma attacks on a medium-dose ICS alone, or on a fixed-dose ICS and LABA regimen
If asthma is uncontrolled on a low-dose of ICS and a LTRA as maintenance therapy, a __________ in combination with the ICS should be offered with or without continued LTRA treatment, depending on the response achieved from the LTRA
LABA
If asthma remains uncontrolled on a ICS + LABA combination therapy (with or without an LTRA), offer _________________
to change the ICS and LABA maintenance therapy to a MART regimen, with a low-dose of ICS as maintenance
Beclometasone with formoterol is an example of a ____________
MART system
Budesonide with formoterol is an example of a ___________ system
MART
If asthma remains uncontrolled on a MART regimen with a low-dose of ICS as maintenance with or without a LTRA, consider ______________
increasing to a moderate-dose of ICS (either continuing a MART regimen, or changing to a fixed-dose regimen of an ICS and a LABA with a short-acting beta2 agonist as reliever therapy)
If asthma is still uncontrolled in patients on a moderate-dose of ICS as maintenance with a LABA (either as a MART or a fixed-dose regimen), with or without a LTRA, consider _______________ or ________________
Increasing ICS to high-dose as maintenance (this should only be offered as part of a fixed-dose regimen with a short-acting beta2 agonist used as reliever therapy ie NOT as a MART)
A trial of an additional drug eg LAMA or theophylline
(Or seek specialist advice)
Tiotropium is in which class of drugs?
LAMAs (long-acting muscarinic antagonists)
Under specialist care, BTS/SIGN (2019) recommend adding a regular _____________ at the lowest dose to provide adequate control in patients with very severe asthma uncontrolled on a high-dose ICS, and who have also tried (or are still receiving) a LABA, LTRA, tiotropium, or modified-release theophylline
oral corticosteroid (prednisolone)
Under specialist care, BTS/SIGN (2019) recommend adding a regular oral corticosteroid (prednisolone) at the lowest dose to provide adequate control in patients with _______________
very severe asthma uncontrolled on a high-dose ICS, and who have also tried (or are still receiving) a LABA, LTRA, tiotropium, or modified-release theophylline
Which drugs may be considered for use by specialists to achieve control and reduce the use of oral corticosteroids in patients with severe asthma? (2)
Monoclonal antibodies (omalizumab, mepolizumab, benralizumab, reslizumab)
Immunosuppressants (eg MTX)
______________ is a monoclonal antibody used for severe persistent allergic asthma
omalizumab
A _____________ should be started as maintenance therapy in children who present with any one of the following features: using an inhaled short-acting beta2 agonist three times a week or more, symptomatic three times a week or more, or waking at night due to asthma symptoms at least once a week
paediatric low-dose of ICS
If asthma is uncontrolled on a paediatric low-dose of ICS as maintenance therapy, consider a ____________
leukotriene receptor antagonist
- review the response to treatment in 4 to 8 weeks
If asthma is uncontrolled on a paediatric low-dose of ICS and a LTRA as maintenance therapy, consider ______________
discontinuation of the LTRA and initiation of a LABA in combination with the ICS
If asthma remains uncontrolled on a paediatric low-dose of ICS and a LABA as maintenance therapy, consider _____________
changing to a MART regimen
- with a paediatric low-dose of ICS as maintenance
If asthma remains uncontrolled on a MART regimen with a paediatric low-dose of ICS as maintenance, consider ______________
increasing to a paediatric moderate-dose of ICS
*either continuing a MART regimen, or changing to a fixed-dose regimen of an ICS and a LABA with a short-acting beta2 agonist as reliever therapy
If asthma is still uncontrolled on a paediatric moderate-dose of ICS as maintenance with a LABA (either as a MART or a fixed-dose regimen), consider seeking advice from an asthma specialist and the following options: (2)
- Increase the ICS dose to a pediatric high dose as maintenance (only offered as part of a fixed-dose regimen
- A trial of an additional drug eg modified-release theophylline
A ______________ as reliever therapy should be offered to children aged under 5 years with suspected asthma
short-acting beta2 agonist (such as salbutamol)
- A short-acting beta2 agonist should be used for symptom relief alongside maintenance treatment
Consider an 8-week trial of a paediatric ___________-dose of ICS in children presenting with any of the following features: asthma-related symptoms three times a week or more, experiencing night-time awakening at least once a week, or suspected asthma that is uncontrolled with a short-acting beta2 agonist alone
moderate
If suspected asthma is uncontrolled in children aged under 5 years on a paediatric low-dose of ICS as maintenance therapy, consider a _________________ in addition to the ICS
leukotriene receptor antagonist (LTRA—such as montelukast)
If suspected asthma is uncontrolled in children aged under 5 years on a paediatric low-dose of ICS and a LTRA as maintenance therapy, __________________
stop the LTRA and refer the child to an asthma specialist
Consider decreasing maintenance therapy when a patient’s asthma has been controlled with their current maintenance therapy for at least _____________
three months
Patients should be maintained at the lowest possible dose of ICS. Reductions should be considered every ___________ months, decreasing the dose by approximately __________% each time
three
25–50
Stopping ICS treatment completely can be considered in which patients?
people who are using a paediatric or adult low-dose ICS alone as maintenance therapy and are symptom-free
For most patients, exercise-induced asthma is an illustration of _______________
poorly controlled asthma
- regular treatment including an ICS should therefore be reviewed
What is the drug of choice for patients with exercise-induced asthma?
Inhaled SABA used immediately before exercise
It is particularly important that asthma is well controlled during pregnancy to avoid __________________
Adverse maternal or fetal complications
*should also be advised to stop smoking
Are asthma medications safe to use during pregnancy?
Short-acting beta2 agonists, LABAs, oral and inhaled corticosteroids, sodium cromoglicate and nedocromil sodium, and oral and intravenous theophylline (with appropriate monitoring) can be used as normal during pregnancy
Limited information on the use of LTRAs during pregnancy. However, where indicated, they should not be withheld
Theophylline is metabolized by the __________
Liver
The plasma-theophylline concentration is increased in ______________, ______________, and in ________________
heart failure
hepatic impairment
viral infections
The plasma-theophylline concentration is decreased in ______________, and by ______________
smokers
alcohol consumption
Differences in the half-life of theophylline are important because ________________
Of the narrow therapeutic index
Theophylline should be used with caution in which patients? (8)
- Cardiac arrhythmias or other cardiac diseases
- Elderly patients (increased plasma concentration)
- Epilepsy
- Fever
- HTN
- Peptic ulcer
- Risk of hypokalemia
- Thyroid disorder
What are the side effects of theophylline? (8)
- Anxiety, sleep disorders
- Arrhythmias, palpitations
- Headache
- Dizziness
- GI discomfort, diarrhea, N/V, GERD
- Hyperuricemia
- Seizures, tremor
- Urinary disorders
Potentially serious hypokalaemia may result from ______________ 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
beta2-agonist
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 ______________ and its derivatives, ______________, and _____________, and by ______________
theophylline
corticosteroids
diuretics
hypoxia
Plasma-____________ (electrolyte) concentration should therefore be monitored in severe asthma
potassium
What are the symptoms of theophylline overdose? (10)
- Vomiting (may be severe and intractable)
- Agitation
- Restlessness
- Dilated pupils
- Sinus tachycardia
- Hyperglycemia
- Hematemesis
- Convulsions
- Supraventricular and ventricular arrhythmias
- Severe hypokalemia
_________________ in overdose can cause vomiting (which may be severe and intractable), agitation, restlessness, dilated pupils, sinus tachycardia, and hyperglycaemia. More serious effects are haematemesis, convulsions, and supraventricular and ventricular arrhythmias. Severe hypokalaemia may develop rapidly.
Theophylline
Can theophylline be taken as normal in pregnancy?
Yes, as it is particularly important that asthma is well controlled HOWEVER
Neonatal irritability and apnea have been reported
____________ and ___________ have been reported in babies born to mothers taking theophylline
Neonatal irritability
Apnea
Can theophylline be taken as normal during breast-feeding?
Yes; however may cause irritability in infants/ modified-release preparations are therefore preferable
Can theophylline be used in patients with hepatic and/or renal impairment?
Caution in patients with hepatic impairment due to risk of increased drug exposure; consider dose reduction
In most individuals, a plasma-theophylline concentration of __________ mg/litre is required for satisfactory bronchodilation, although a lower plasma-theophylline concentration of _________ mg/litre may be effective
10–20
5–15
- Adverse effects can occur within the range 10–20 mg/litre and both the frequency and severity increase at concentrations above 20 mg/litre.
Adverse effects of theophylline can occur within the range _________ mg/litre and both the frequency and severity increase at concentrations above __________ mg/litre.
10–20 (same as therapeutic dose)
20
Plasma-theophylline concentration is measured __________ after starting oral treatment and at least _________ after any dose adjustment.
5 days
3 days
_____________ can increase theophylline clearance and increased doses of theophylline are therefore required
Smoking
Smoking can increase theophylline clearance and ___________ doses of theophylline are therefore required
increased
____________ are predicted to increase the risk of bronchospasm when given with theophylline
Beta blockers
Generally avoided in asthma anyway
_____________ (antiviral) is predicted to increase the exposure to Theophylline. Manufacturer advises monitor and adjust dose
Aciclovir
Also combined hormonal contraceptives
Theophylline is predicted to cause hypokalaemia (potentially increasing the risk of torsade de pointes) when given with ____________
Amiodarone
Theophylline administration should be avoided when taking other drugs that cause ______________
Hypokalemia (potentially increasing the risk of torsade de pointes)
Eg. SSRIs, macrolides, ondansetron, chlorpromazine, fluranes, biologics
Theophylline is predicted to increase the risk of ______________ toxicity when given together
Digoxin (due to risk of hypokalemia)
At recommended inhaled doses, the duration of action of salbutamol is about ____________
3 to 5 hours
MHRA/CHM advice: Pressurised metered dose inhalers (pMDI) have a risk of _____________ from ____________
aspiration of loose objects
In addition to being used in asthma and other conditions with reversible airway obstruction, salbutamol (albuterol) may be used in uncomplicated _______________ to promote smooth muscle relaxation
Premature labor (22-37 weeks gestation); IV infusion
All beta-2 adrenoceptor agonists, including salbutamol, should be used with caution in which patients? (7)
- Arrhythmias
- CVD (vs beta BLOCKERs which may be cardio-protective)
- DM (risk of hyperglycemia and ketoacidosis, especially with IV use)
- HTN
- Hyperthyroidism
- Hypokalemia
- Susceptibility to QT interval prolongation
Patients with DM who are taking beta agonists (eg salbutamol) are at an increased risk of _____________ and ____________, especially with IV use
Hyperglycemia
Ketoacidosis
What are the common side-effects of beta agonists eg salbutamol? (10)
- Arrhythmias
- Headache
- Hypokalemia (with high doses)
- Muscle spasms
- Nasopharyngitis
- Nausea
- Palpitations
- Rash
- Tremor
- Muscle cramps
What are the rare or uncommon side effects of beta agonists eg salbutamol? (2)
- Hyperglycemia
2. Paradoxcical bronchospasm
Can beta agonists eg salbutamol be used as normal in pregnancy and breastfeeding?
Women planning to become pregnant should be counselled about the importance of taking their asthma medication regularly to maintain good control
Inhaled drugs for asthma can be taken as normal during breast-feeding
What are the monitoring requirements for patients taking beta agonists eg salbutamol? (2)
In severe asthma, plasma K+ concentrations should be monitored due to the risk of hypokalemia
In patients with DM, monitor blood glucose due to risk of hyperglycemia and ketoacidosis, especially if given IV
What advice should be given to patients and carers regarding the use of a SABA?
The dose, the frequency, and the maximum number of inhalations in 24 hours of the beta2 agonist should be stated explicitly to the patient or their carer.
The patient or their carer should be advised to seek medical advice when the prescribed dose of beta2 agonist fails to provide the usual degree of symptomatic relief because this usually indicates a worsening of the asthma and the patient may require a prophylactic drug
For inhalation by nebuliser, the dose given by nebuliser is substantially ____________ (lower/higher) than that given by inhaler
Higher
*Patients should therefore be warned that it is dangerous to exceed the prescribed dose and they should seek medical advice if they fail to respond to the usual dose of the respirator solution
Healthcare professionals are advised to be alert for _____________ reactions in adults, adolescents, and children taking montelukast
neuropsychiatric; including speech impairment and obsessive-compulsive symptoms
What are the common or very common side effects of montelukast? (5)
- Diarrhea, N/V, GI discomfort
- Fever
- Headache
- Skin reactions
- URTI
________________ has occurred very rarely in association with the use of montelukast; in many of the reported cases the reaction followed the reduction or withdrawal of oral corticosteroid therapy
Eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome)
*Prescribers should be alert to the development of eosinophilia, vasculitic rash, worsening pulmonary symptoms, cardiac complications, or peripheral neuropathy
Is montelukast safe to use during pregnancy and breastfeeding?
Advice unless essential in both cases
In what form is montelukast administered?
Orally; granules or tablets
Leukotriene receptor antagonist
To ensure safe use, the CHM has advised that for the management of chronic asthma, long-acting beta2 agonist (salmeterol) should be added only if regular use of standard-dose _______________ has failed to control asthma adequately
inhaled corticosteroids
To ensure safe use, the CHM has advised that for the management of chronic asthma, long-acting beta2 agonist (salmeterol) should not be initiated in patients with ______________ asthma
rapidly deteriorating
To ensure safe use, the CHM has advised that for the management of chronic asthma, long-acting beta2 agonist (salmeterol) should be introduced at a _________ dose and the effect properly monitored before considering dose increase
low
To ensure safe use, the CHM has advised that for the management of chronic asthma, long-acting beta2 agonist (salmeterol) should be discontinued in the absence of ___________
benefit
To ensure safe use, the CHM has advised that for the management of chronic asthma, long-acting beta2 agonist (salmeterol) should not be used for the relief of ____________ asthma symptoms unless regular inhaled corticosteroids are also used
exercise-induced
Advise patients that salmeterol should not be used for ____________
relief of acute attacks
What type of drug is tiotropium?
Long-acting antimuscarinic bronchodilator
The MHRA have received reports of patients who have inhaled a Braltus® (tiotropium) capsule from the mouthpiece into the back of the throat, resulting in coughing and risking aspiration or airway obstruction. Patients should be trained in the correct use of their inhaler and told to store capsules in the _____________ provided (never in the __________) and to always check the mouthpiece is clear before inhaling.
Screw-top bottle
inhaler
All antimuscarinic eg Tiotropium should be prescribed with caution in which patients? (8)
- Bladder outflow obstruction
- Paradoxical bronchospasm
- Prostatic hyperplasia
- Susceptibility to angle-closure glaucoma
- Elderly
- Arrhythmias (requiring intervention in the last 12 mo)
- HF (requiring hospitalization in the last 12 mo)
- MI in the last 6 mo
Side effects of antimuscarinics eg tiotropium include … (7)
- Arrhythmias
- Constipation
- Cough
- Dizziness
- Dry mouth
- Headache
- Nausea
(Less commonly, dysphonia, glaucoma, palpitations, urinary disorders, blurred vision, increased risk of infection)
Are antimuscarinics eg tiotropium safe to use in pregnancy and breastfeeding?
Avoid in both
Are antimuscarinics safe to use in hepatic and/or renal impairment?
If Cr clearance is less than or equal to 50 mL/min, use only if potential benefits outweigh risk
Patients or carers should be advised that the Respimat® (tiotropium) inhaler device is re-usable and can be used with a total of ___ cartridges before it needs to be replaced
6
What is the drug class of terbutaline?
Beta 2 agonist
Beta agonists may cause ____________ or ______________ rarely with parenteral use
Pulmonary edema
Lactic acidosis (high doses)
What is the mechanism of action of omalizumab?
Binds to free IgE in the serum so it cannot bind receptors on mast cells and basophils
