Asthma, COPD, Cystic Fibrosis, Allergies and anaphlyaxis, Croup, CF Flashcards
what’s steps 1 - 5 in the asthma treatment pathway?
- intermittent reliever - SABA
- SABA + ICS
- LTRA (NICE) or LAMA (BTS/SGN)
- LABA if not already added - can be used with ot without LTRA. Convert fixed dose LABA + oderate ICS into MART
- Increase to high dose ICS or initiate
- theophylline
- tiotropium
- oral corticosteroids
- MAbs
what symptoms must a patient display for an ICS to be added into asthma regime?
- needing SABA 3x a week
- being symptomatic 3x a week
- night waking 1x a week
- using more than 1 inhaler a month
when can LABAs be given to children for management of aasthma?
in step 3 as per adult pathway but only for 12yrs+
whats the Clenil dose for children ?
50mcg 2PU BD
what age can tiotropium be used?
12yrs +
when is the course of action to take if child under 5 is using more than 1 inhaler a month?
urgent refferal
what is step 2 for children under 5 in the asthma pathway?
- to start ICS if symptoms uncontrolled by SABA (symptoms 3x a week, night time waking x1 a week)
- use a paediatric low dose for an 8 week trial
- if ICS not tolerated use LTRA
when can you think about stepping down asthma treatment?
when asthma has been controlled for at least 3 months
how do you step down asthma treatment?
- by maintaining patients are the lowest, effective ICS dose
- reduce by 25 - 50% every 3 months
what defines complete control in asthma?
- no daytime symptoms
- no night time waking
- no asthma attacks
- no need for rescue medication
- no limitations on activity including exercise
- normal lung function (FEV1 and/or PEF >80% predicited or best)
- minimal side effects from treatment
if someone with COPD has azithromycin prescribed as prophylaxis for the winter, what abx would you want to avoid using in thier rescue pack and why?
clarithromycin - becuase is another macrolide so use amoxicillin or doxycycline
what non-drug treatment can be used in COPD exacerbations?
positive expiratory pressure helps sputum clearance
what are the options for drug treatment in OCPD exacerbations in hosp and community?
- SAMA/SABA - withhold LAMA if SAMA given
- hospitalised - pred + other therapies (aminophylline, O2)
- community - only give pred if sevre breathlessness
why do you not give SAMA and LAMA at same time?
muscarininc SE be too much
how long do SABA work for? Name 2 examples
4 hours
salbutamol, terbutaline
how long do LABAs work for? Give 3 examples
salmeterol, vilanterol, formoterol
what are the cautions around SABAs/LABAs?
- caution in diabetes, can cause DKA especially after IV
- cause hypokalaemia, increase risk of QT prolongation, increased risk arrhythmias
alongside SABA/LABA what other drugs also increase risk of QT prolongation?
corticosteroids, diuretics, theophylline, citalopram, escitalopram
what interaction should you look out for with SABAs and LABAs (narrow TI drug)?
digoxin - increased risk of digoxin toicity due to hypokalaemia
what are the muscarininc side effects?
constipation, dry mouth, dry eye, increased ocular pressure (report halos or blurred vision)
name 5 ICS
what one is given OD?
how many times are the others given?
beclometasone, budesonisde, ciclesonide, fluticasone, mometasone
all BD except ciclesonide which is OD
what ICS must be prescribed by brand and why?
Qvar and Kalhale - this is bcause these have extra fine particles so 2x strogner than other inhalers such as clenil
what monitoring in children is needed if on prolonged ICS?
height and weight as can stunt growth - refer to paediatrician if stunted growth suspected
what are the SE of ICS?
- taste and voice aleration
- sore mouth - oral thrush
- paradoxical bronchospasam
do you manage paradoxical bronchspasams ith ICS?
- if mild: use SABA before hand to prevent it happening
- change from an aerosol to DPI
what are the side effects and MHRA warnign with montelukast?
MHRA warning = risk of neuropsychaitric reactions - seek medical attention if speech and behavioural changes occur
Churg- Strauss syndrome - eosinophillia, vasculitc rash, worsening pulmonary symptoms, cardiac complications, perihperal neuropathy
what are the main interactions with LTRA?
CYP450 enzyme substrate - thi means inducers will redcue the conc of montelukast and inhibitors will increase its conc
whats the therapeutic range for theophylline? what is this the same as?
10 - 20mg/l
same as phenytoin
when should you moniotr theophylline levels?
- 4 - 6 hours after a dose
- 5 days after starting treatment
- at least 3 days after dose adjustment (increaing dose)
do you need to prescribe by brand of theophylline?
yes - brands not bioequivelant
what are the main SE of theophylline?
vomitting, tremour, palpitation, arrhythmias
what are the interactions to look out for with theophylline?
what drugs increase and decrease the levels?
increased by: macrolides, cimetidine, ciprofloxacin (CYP inhibitors)
decreaed by: carbamazepine and st johns wort (CY{ inducers)
- drugs that cause hypokalaemia
what are signs of theophylline overdose?
(Theophylline helps astronauts hide venus) SICK AND FAST
tachycardia
hyperglycaemia
agitation
haematemesis
vomiting
what does stopping/starting smoking do to theophylline levels?
start = dose increases as smoking reduces clearance
stop smoking = dose decreases as cleared quicker
how does having a fever affect theophylline?
reduces the clearane of theophylline so may need dose reduced
whats the treatment for croup?
what setting is this often done in?
dexamethasone
usually community
whats the management for severe croup?
what if pt can’t take oral steroids?
what is steroids don’t work?
- hospital admission
- single dose of dexamethasone or pred given orally whilst awaitng admission
- if cant take oral = IM dexamethasone or nebulised budesonside
- uncontrolled by steriod = nedulised adrenaline
what antihistamine has undergone POM - P switch?
fexofenadine 120mg
what antihistamines are aslo used as antiemetics?
cinnarizine, cyclizine, promethazine
what antihistamine can be used for migraines?
buclizine
what antihistamines can be used for insomnia?
1st generation (allmemazine?, promethazine)
diphenhydramine
whats Omalizumab and when is it used?
what are the main SE’s? (also seen with LTRA)
monoclonal that binds to IgE for severe perissitent allergic asthma that cannot be controlled with ICS + LABA
SE = churg-strauss syndrome and hypersenstivity reactions
what do vaccines contain that reduce the risk of severe anaphylaxis?
beewasp venom
what is the managemt for anaphylaxis?
- use auto injection immediately (IM adrenaline)
- call 999 and state anaphylaxis - administer CPR if needed
- lie down and raise patients legs
- remove the trigger causing anaphlyactic reaction if possible
- repeat after 5min interval if no improvement
why do you raise the legs in anaphylaxis?
prevent hypovolaemic shock
how is anaphylaxis managed in hospital?
- high flow O2
- IV fluids to manage hypotension/hypovolaemic shock
- following sedation of patinet, a non-sedating antihistamine (ceterizine - IM/IV chlorphenamine in NBM)
- inhaled bronchodilator with salbutamol and/or ipratropium if problems persist
how many autoinjectors should be carried at all times?
2
whats the adrenaline dose for the following ages:
- child up to 6months
- 6months - 5yrs
- 6yrs - 11yrs
- 12yrs+
- up to 6months = 100 - 150mcg
- 6m - 5yrs = 150mcg
- 6 - 11yrs = 300mcg
- 12yrs + = 500mcg
what is cystic fibrosis?
genetic disorder affecting the lungs, pancrease, liver, intestine and reproductive organs - viscous sputum, chest infections, malaborption
what is the mucolytic used in CF?
dornase alfa
what bacteria are you trying to supress with long term antibacterial therapy in CF?
S. Aureus
what shoudl you monitor CF patients for?
bone density
liver disease
diabetes
