Asthma management

Question 1

Give a summary of the treatment ladder from BTS

Answer 1

1. Add a short-acting beta 2 agonist inhaler as required for infrequent wheezy episodes
2. Add a regular low dose inhaled corticosteroid
3. Add LABA inhaler. Continue the LABA only is the patient has a good response
4. Add a leukotriene receptor antagonist (Montelukast), oral beta-2 agonist, theophylline or LAMA (tiotropium)
5. Increase the inhaled corticosteroid to a ‘high dose.’ Combine additional treatments from step 4. Refer to specialist
6. Add low dose oral prednisolone

Question 2

Give a summary of the treatment ladder from NICE

Answer 2

1. SABA
2. SABA + low-dose ICS
3. SABA + low-dose ICS + LTRA
4. SABA + low-dose ICS + LABA
   Continue LTRA depending on patient’s response
5. MART regime
6. MART + moderate-ICS
7. MART + high-ICS/theophylline, LAMA
8. Refer to specialist

Question 3

What is Maintenance and Reliever therapy (MART)?

Answer 3

Combination of ICS and LAMA

• Use twice daily
• Use as required

Question 4

What does uncontrolled asthma look like?

Answer 4

• 3+ days / week with symptoms
• 3+ days / week with required use of SABA for symptomatic relief
• 1+ nights / week with awakening

Question 5

What does well controlled asthma look like?

Answer 5

No symptoms

Question 6

What are the reasons for uncontrolled asthma?

Answer 6

• Alternative diagnoses
• Lack of adherence
• Bad inhaler technique
• Smoking
• Occupational exposures
• Psychosocial factors
• Seasonal factors

Question 7

What do beta 2 adrenoreceptor agonists do?

Answer 7

Relax bronchial smooth muscle

Question 8

Give an example of a SABA

Answer 8

• Salbutamol

- Terbutaline

Question 9

Give an example of a LABA

Answer 9

• Salmeterol

- Formoterol

Question 10

What do corticosteroids do?

Answer 10

Decrease bronchial mucosal inflammation by increasing cAMP levels

Question 11

Give an example of an inhaled corticosteroid

Answer 11

• Beclometasone
• Budesonide
• Fluticasone
• Ciclesonide
• Mometasone

Question 12

Give an example of an oral corticosteroid

Answer 12

Prednisolone

Question 13

What does aminophylline do?

Answer 13

Inhibits phosphodiesterase to decrease bronchoconstriction by increasing cAMP levels

Question 14

What are the risks with aminophylline?

Answer 14

It has a narrow therapeutic ratio causing:

• Arrhythmias
• GI upsets
• Fits

Question 15

What should you routinely check with aminophylline?

Answer 15

• Check levels
• Do ECGs
• Check plasma levels after 24hrs if IV therapy has been used

Question 16

What do leukotriene receptor antagonists do?

Answer 16

Block the effects of cysteinyl leukotrienes in the airways by antagonising the CystLT1 receptor

Question 17

Give an example of a leukotriene receptor antagonist

Answer 17

Monteleukast

Question 18

What is a low, moderate and high ICS dose?

Answer 18

Low = ≤ 400 micrograms
Moderate = 400-800 micrograms
High = >800 micrograms