Asthma guidance & drugs Flashcards
How should patients used DPI inhalers?
Need to breathe in fast and strong to create enough turbulence to lift the particles
Why should Beclometasone CFC-free MDIs (QVAR and CLENIL) have their brand endorsed on prescriptions?
What is the combination inhaler also effected by this?
Because they are not interchangeable:
QVAR has extra fine particles that can reach the lungs faster and quicker therefore its more potent (QVAR is 2 x as potent as Clenil)
FOSTAIR also effected- beclometasone and formeterol - its the same as QVAR- has extra fine particles so more potent
Which beta blockers would we be most worried about in asthmatic patients? (5)
Non-cardioselective beta blockers, as these may be more likely to constrict airways:
Propranolol Sotolol Labetolol Carvedilol Timolol
The cardioselective ones (atenolol, bisoprolol) are less of a worry
How should a spacer be cleaned?
Wash it in mild detergent and allow to air dry, wipe mouthpiece free of detergent
Do this once a month (more frequently will effect the electrostatic charge)
How often should a spacer be replaced?
Every 6-12 months
When would nebuliser adrenaline or budesonide be needed?
Child with severe croup
Not severe: oral beclometasone or prednisolone usually used
When should nebulisers be considered in long term management of COPD or asthma?
Remains breathless after two weeks of correctly using optimal therapy
What proportion of nebulised drug will reach lungs?
10-30%
Diluent usually used in nebulisers: NaCl 0.9%
What ages are spacers recommended in children?
Up till the age of 5 for bronchodilators (saba, labas)
Ages 5-15 for ICS
What is the standard length of treatment with steroids for an asthma attack?
Does this differ in children?
Prednisolone oral for 5 days in adult
Prednisolone oral for 3 days in child
IF NBM- IV hydrocortisone every 6 hours until conversion to oral
Can usually abruptly stop the steroid unless the patient has been on oral corticosteroids previously (step 5) for over three weeks
What degree of asthma attack should we consider the use of high flow oxygen?
If it’s severe
We use SABA (e.g. Salbutamol) nebs plus high flow oxygen
Only Saba nebs needed if moderate
If oxygen, SABA and prednisolone are not sufficient for an asthma attack what can be considered?
Ipratropium bromide
IV aminophylline
Magnesium sulphate
If an attack is LIFE-THREATENING: immediately give ipratropium (don’t wait to see if response is poor as with severe asthma attacks)
Which patients are most likely to benefit from an aminophylline infusion in an asthma attack?
Those that have been taking theophylline oral
What is step 1 of the Asthma guidelines
When should a patient be moved on to step 2?
SABA PRN
SABAs used: salbutamol or Terbutaline
Move up if needed more than TWICE a week or woken up once per week
What is step 2 of the asthma guidelines ?
SABA PRN + standard dose of ICS
Recommended starting dose for adults:
400mcg beclometasone daily
Do not go over 800 mcg daily
Max of 2 drugs permitted at step 2
What is step 3 of the asthma guidelines? (Hint: 3 different steps involved)
1) Firstly add in a LABA (salmeterol, formoterol) to the ICS + PRN SABA
2) After addition of LABA can increase ICS dose to 800mcg daily (NB: this is not max dose, just upper end of standard dose range)
If above not worked:
3) stop LABA if no benefit, continue if some benefit
IF LABA STOPPED Consider adding:
Leukotriene receptor agonist (montelukast)
Theophylline MR
Oral MR beta agonists (e.g. Salbutamol tablets/ solution) do not use this in under 12 years
Max of 3 different drugs permitted at this stage
Step 4 of the asthma treatment guidelines? (4 drugs)
The patient will already be on:
SABA PRN + regular standard dose ICS
LABA
1) increase ICS to a over standard dose = regular high dose ICS
Add in a 6 week trial of one or more of:
Leukotriene receptor antagonist (montelukast)
MR theophylline
Oral MR oral beta agonist
Patient on at least 4 drugs at step 4
Step 5 of the asthma treatment guidelines? What 5 different drugs will the patient be on?
Add in regular corticosteroid tablets (prednisolone) refer to a respiratory specialist
Patient will be on: PRN SABA Regular high dose ICS LABA One or more of the leukotriene antagonists, theophylline MR, MR oral beta agonist Regular prednisolone
Stepping down: How often should asthma treatment be reviewed?
Every 3 months
Consider reducing by up to 50% every 3 months
What age of child do the asthma guidelines become different?
Age 5
Child under 5: asthma guidelines step 1?
SABA PRN
Consider moving to step 2 if child needs SABA more than twice per week, is woken at night once a week or had an exacerbation in last 2 years (same as adult guidance)
Child under 5: asthma guidelines step 2?
SABA PRN Plus standard dose regular ICS OR MONTELUKAST (leukotriene receptor antag)
Child under 5: asthma guidelines step 3?
If under 2 years old REFER to specialist
SABA PRN
Plus regular standard dose ICS
Plus montelukast
Child under 5: asthma guidelines step 4?
Refer to specialist
What is standard dose ICS for adults?
Equivalent to beclometasone 400-800 mcg daily (200-400mcg BD)
What is standard dose ICS for children aged under 12?
200-400 mcg beclometasone daily
100-200mcg BD
What is high dose ICS for adults?
800-2000mcg daily (400-1000 mcg BD)
What is high dose ICS in children? What age range can high dose be used in?
400-800mcg beclometasone daily
Can only be used in 5-12 years (under 5 years cannot receive high dose ICS)
Which ICS is not recommend in children under 12?
Mometasone
What ORAL drugs used in asthma can be taken as normal in pregnancy and breast feeding? (2)
Prednisolone
Theophylline
NB: all inhaled drugs can be taken as normal too, where possible use inhaled therapy over oral therapy
What oxygen level are we aiming for when oxygen is given in acute exacerbation of asthma?
94 - 98%
Remember it is lower in COPD (88-92%) due to risk of T2 respiratory failure/ higher levels of CO2 in blood
What are the two SABAs that are used at step 1 of asthma treatment?
Salbutamol
Terbutaline
Should LABAs be used for the relief for exercise induced asthma symptoms?
No unless regular ICS also used
Which LABAs are only licensed for COPD (i.e. not also in asthma)?
Indacterol and Olodaterol
What electrolyte disturbance can result from theophylline and salbutamol use together?
Hypokaleamia
In management of acute exacerbations of asthma, which is
used out of aminophylline and theophylline?
Aminophylline
This is just the injectable form of theophylline (it consistS of theophylline plus ethylenediamine) which is 20 times more soluble (and therefore potent) than theophylline
Theophylline levels are monitored with aminophylline therapy
What is paradoxical bronchospasm a side effect of? (This is sudden constriction of the airways)
Inhaled corticosteroids
It can be prevented by using a SABA beforehand or using a DPI instead
How long does it take to see improvement with ICS?
3 - 7 days
What does SMART stand for?
What does this mean?
What inhalers are involved?
Symbicort Preventer and reliever therapy
Symbicort contains bother a preventer (budesonide) and a reliever (formeterol)
It is supposed to take away the need for PRN reliever- salbutamol- as you instead use this as the reliever at an increased dose if you get symptoms of breathlessness
Other examples of smart inhalers:
Duoresp spiromax (also budesonide and formoterol)
Fostair (beclometasone and formoterol)
What age group can use the SMART regime?
Adults and children aged 12-18 years
Children just to used symbicort
How does smoking effect ICS?
Current or previous smoking reduces the effect of ICS (as smoking is an enzyme inducer) and higher doses may be needed
This is also the case with COC’s! and theophylline
Who are leukotriene receptor antagonists more effective in?
Exercise induced asthma
Those with rhinitis
Used in children under 5 at step 2 onwards
When should Montelukast be given?
In the evening
What needs to be looked out for with the use of Leukotriene receptor antagonists (Montelukast + Zafirlukast)?
Churg-strauss syndrome
= autoimmune causing inflammation of small and medium-sized blood vessels
Look out for esonophillia, rash, worsening pulmonary symptoms, cardiac complications, peripheral neuropathy
Zafirlukast is cautioned in ______ disorder
Hepatic disorders
What are sodium chromoglycate and nedocromil used in?
Allergic asthma
Inhaled drugs
caution: these can cause paradoxical bronchospasm
What is Omalizumab used in?
It is a monoclonal antibody that binds to immunoglobulin E
Used for sensitivity to inhaled allergens/ allergic asthma
Churd-strauss syndrome also been associated with this drug
What 3 conditions can effect plasma theophylline concentration?
Heart failure
Hepatic impairment
Viral infections!
What electrolyte disturbance can aminophylline and theophylline cause?
Hypokaleamia
What is the target level of theophylline?
10 - 20 mg/ L
What should be monitored when giving IV Beta 2 agonists (IV salbutamol)?
K+ in severe asthma
Blood glucose in diabetics as can cause hyperglycaemia and DKA!!!!
What is the dose of salbutamol inhaler in asthma?
100- 200 mcg (1-2 puffs) up to 4 times a day for persistent symptoms (max 8 puffs a day)
What are the symptoms of Oral thrush (caused by ICS)?
white patches (plaques) in the mouth that can often be wiped off, leaving behind red areas that may bleed slightly
loss of taste/ unpleasant taste
redness inside the mouth
cracks at the corners of the mouth
a painful, burning sensation in the mouth
