Asthma medication

Question 1

Describe what is meant by “good control” of asthma. (6)

Answer 1

Minimal symptoms during day and night 
Minimal need for reliever medication
No exacerbation
No limitations of physical activity 
Normal lung function - FEV1 of >80% predicted or best.

Question 2

Describe the steps that should be taken before changing medications (3)

Answer 2

Check compliance with existing therapy.
Check inhaler techniques
Eliminate new trigger factors.

Question 3

Describe the requirements for starting long term therapy. (4)

Answer 3

Exacerbation requiring oral steroids
Beta 2 agonist use over 3 times per week
Symptoms over 3 times per week
Waking more than once in a week.

Question 4

Describe stage 1 of asthma control. (1)

Answer 4

Short acting beta 2 agonists.

Question 5

Name two short acting beta 2 agonists. (2)

Answer 5

Salbutamol

Terbutaline.

Question 6

Describe stage 2 of asthma control. (2)

Answer 6

Short acting beta 2 agonist.

Low dose ICS.

Question 7

Describe stage 3a of asthma control. (3)

Answer 7

Short acting beta 2 agonist.
Inhaled LABA
Low dose ICS

Question 8

Describe stage 3b of asthma control. (7)

Answer 8

Short acting beta 2 agonist.
Inhaled LABA
Low dose ICS
Then add in one of: Moderate dose ICS or LTRA or LAMA or S-R theophylline.

Question 9

Describe stage 4 of asthma control. (8)

Answer 9

Short acting beta 2 agonist.
Inhaled LABA
Moderate dose ICS
Then add one of: high dose ICS, LAMA, LTRA, Beta agonist tablets, S-R theophylline.

Question 10

Describe stage 4 of asthma control. (4)

Answer 10

Short acting beta 2 agonist.
Daily oral steroids at lowest possible dose.
High dose ICS.
Consider steroid sparing drugs.

Question 11

Describe the MoA of short active beta 2 agonists. (2)

Answer 11

Symptomatic reversal of bronchocontriction, and inhibition of mast cell degranulation.

Question 12

Explain why short acting beta 2 agonists can get less effective over time. (2)

Answer 12

Continues use can reduce control because mast cell degranulation increases.

Question 13

Name one fast onset, long duration beta 2 agonists. (1)

Answer 13

Formoterol (12h)

Question 14

Name one slow onset long duration beta 2 agonist. (1)

Answer 14

Salmeterol.

Question 15

Describe the side effects of beta 2 agonists. (4)

Answer 15

Adrenergic - tachcardia, tremour, palpitations.

Question 16

Describe the MoA of ICS. (4)

Answer 16

Upregulate anti-inflammatory things (transactivation) and downregulate pro-inflammatory things (transrepression).

Question 17

Describe why ICS are used in asthma. (4)

Answer 17

Reduce inflammation which helps to:
Improve symptoms
Improve lung function
Reduce exacerbation
Prevent death

Question 18

Which type of asthmatic has a higher response to corticosteriods? (1)

Answer 18

Eosinophilic

Question 19

Describe why LABAs are the next choice if the patient is uncontrolled at 400mcg/day of ICS. (3)

Answer 19

Reduce exacerbation
Improve symtoms
Improve lung function.

Question 20

Explain why LABAs are often combined with a low dose ICS in the same inhaler. (5)

Answer 20

LABAs are not efficacious on their own - need the ICS.
Normally prescribed in one inhaler because:
Easier - increased compliance
1 vs 2 inhalers to worry about
Cheaper to only get 1 prescription
Safer - no option to take LABA without ICS.

Question 21

Name the four options for changing prescription in Stage 4. (4)

Answer 21

High dose ICS.
Leucotriene receptor antagonists
Methylxanthines
Long acting M3 selective anticholinergics.

Question 22

Name one leucotriene receptor antagonist. (1)

Describe its MoA. (3)

Answer 22

Montelukast
Prevents the leukotrienes released by mast cells and eosinophils from causing bronchoconstriction, mucus secretion, and mucosal oedema.

Question 23

Describe the side effects of a leucotriene receptor antagonists. (6)

Answer 23

Angioedema 
Dry mouth
Anaphylaxis
Fever
Gastric disturbances
Nightmares

Question 24

Name two methylxanthines. Which is more commonly used in practice? (3)

Answer 24

Theophylline - most common

Aminophylline

Question 25

Describe the disadvantages of methylxanthines. (4)

Answer 25

Narrow therapeutic window
Frequent side effects - nausea, headache, reflux
Toxic complications - fits, arrhythmias
Common DDIs.

Question 26

Describe the MoA of methylxanthines. (1)

Answer 26

Adenosine receipt antagonists.

Question 27

Name one long acting anticholinergic that is M3 selective. (1)

Answer 27

Tiotropium bromide

Question 28

Explain why LAMAs are rarely prescribed in asthma. (1)

Answer 28

Often licenced only in COPD.

Question 29

Describe the most common treatment for stage 5 asthma. (3)

Answer 29

Oral prednisone, often in a really high dose.

Question 30

Name two biological therapies that can be used as steroid sparing agents in stage 5 asthma. State their main MoA. (4)

Answer 30

Omalizumab - anti-IgE

Mepolizumab - anti-IL-5

Question 31

What characteristics need to be present in a patient to prescribe omalizumab? How does it’s action help? (4)

Answer 31

Needs atopy and specific IgE range.

Works because IgE cannot cross link to cause mast cell degeneration.

Question 32

Describe how anti-IL-5 drugs are helpful. (1)

Answer 32

Reduces eosinophils.

Question 33

Describe how size of particle in an inhaler affects effectiveness of a drug. (4)

Answer 33

Particles need to be 1-5microns big so they settle in the small airways.
If they’re too big, they settle in the mouth and oropharynx.
If they’re too small, they don’t settle anywhere, and are breathed out again.

Question 34

Describe “acute severe asthma in adults”. (4)

Answer 34

Any one of:
Unable to complete sentences 
Pulse > 110
Resp rate > 25
Peak flow 33%-50% of best

Question 35

Describe “life-threatening asthma in adults”.

11

Answer 35

Any one of:
Pulse > 110
Resp rate > 25
Peak flow < 33% best 
sp(O2) < 92%
p(O2) < 8 kPa
p(CO2) > 4.5 kPa 
Silent chest
Cyanosis 
Feeble respiratory effort 
Hypotension, bradycardia, arrhythmia
Exhaustion, confusion, coma.

Question 36

Describe the criteria for comensing mechanical ventilation in asthma. (2)

Answer 36

p(CO2) of 6 kPa

Loss of consciousness

Question 37

Describe the treatments for asthma attacks. (5)

Answer 37

High flow oxygen.
Nebulised salbutamol driven by high flow oxygen.
Oral prednisone - 10-14 days
If severe add nebulised ipratropium bromide.
If still severe add IV aminophylline.

Question 38

Describe ipratropium bromide. (3)

Answer 38

An anticholinergic used in severe asthma for long lasting bronchodilation.