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Week 8 - Respiratory > Asthma treatment > Flashcards

Asthma treatment Flashcards

1
Q

What is the aim of asthma treatment?

A
  • no daytime symtpoms
  • No night time awakening
  • No need for rescue medication
  • no asthma attacks
  • No limitations on activity including exercise
  • normal lung function
  • Minimal side effects from medications
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2
Q

Who gets an intermittent reliever?

A

Anyone with diagnosis of asthma

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3
Q

What are the short acting bronchodilators?

A
  • Inhaled short acting B2 agonists
  • Inhaled ipratropium bromide
  • Theophyllines
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4
Q

When should you consider an inhaled corticosteroid for an asthmatic patient?

A
  • Asthma attack in the past two years
  • Using inhaled B2 agonist three times a week or more
  • Symptomatic three times a week or more
  • Waking one night a week
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5
Q

Explain starting a corticosteroid as preventer therapy

A
  • start at a dose appropriate to the severity of the disease
  • titrate the dose to the lowest dose at which effective control of asthma is maintained
  • Smoking previous or current reduces the effect of ICS so consider higher doses
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6
Q

What is the mechanism of action of an ICS?

A
  • Bind to activated glucocorticoid receptors

* Suppress multiple pro-inflammatory genes that are activated in asthmatic airways by reversing histone acetylation

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7
Q

What are the indications for an ICS?

A
  • Asthma

* COPD with recurrent exacerbation

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8
Q

What are the side effects of corticosteroids?

A
  • Diabetes
  • Osteoporosis
  • HTN
  • Muscle wasting
  • Peptic ulceration
  • Cataracts
  • Cushings
  • Adrenal suppression
  • Acute pancreatitis
  • Hyperlipidaemia
  • Increased appetite
  • Salt and water retention
  • Immune suppression
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9
Q

What is the first line preventer drug?

A

Inhaled corticosteroid

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10
Q

What are the non first line preventer therapies for patients taking beta 2 agonist alone

A
  • Leukotriene receptor antagonists
  • Sodium cromoglicate and nedocromil sodium
  • Theophyllines
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11
Q

If asthma is not adequately controlled with a low dose ICS what are the next steps?

A
  • Recheck adherence, inhaler technique and trigger factors
  • First choice add on in adults is an inhaled long acting beta 2 agonist
  • This should be considered before upping dose of ICS or adding leukotriene receptor antagonist
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12
Q

What is MART?

A
  • Combination of maintenance and preventer therapy

* Ensures that as the need for a reliever increases, the dose of the preventer is also increased

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13
Q

What should you do if asthma control is inadequate on medium dose of inhaled corticosteroid with a long acting beta 2 agonist or LTRA?

A

•Increase ICS to high or add LTRA (if not on) or add tiotropium/theophylline

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14
Q

Name 2 LTRAs

A
  • Montelukast

* Zafirlukast

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15
Q

What is the mechanism of action of LTRAs?

A
  • High affinity antagonist of cysteinyl leukotriene receptor inhibiting the action of LT-D4 in smooth muscle cells of the airway and airway macrophages
  • Reduces the airway oedema and smooth muscle contraction
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16
Q

Which types of asthma are LTRAs especially useful for?

A

The phophylaxis of exercise induced asthma and allergic rhinitis

17
Q

Name a short acting anti-muscarinics

A

Ipratropium bromide

18
Q

Name a long acting anti-muscarinic

A

Tiotropium

19
Q

What is the mechanism of action of the anti-muscarinics?

A
  • Antagonist of cholinergic M1 and M3 receptors in the lung
  • Stops broncho-constriction due to muscarinic receptor activation (connected to Gq-G portions, phospholipase IP3 and intracellular Ca2+)
  • On vasculature, M3 activation increases NO production causing vasodilation
20
Q

What are the indications of anti-muscarinics?

A
  • Asthma

* COPD

21
Q

What are the side effects of the anti-muscarinics?

A
  • Blurred vision
  • Dry mouth
  • Urinary retention
  • Nausea
  • Constipation
22
Q

What is a side effect specifically of nebuliser ipratroprium?

A
  • Acute angle closure glaucoma

* Use a mouthpiece not a mask

23
Q

How are anti-muscarinincs excreted?

A

Renally

24
Q

What is the mechanism of action of methxanthines?

A
  • Non selective inhibition of phosphdiesterases
  • This increases intracellular cAMP
  • Bronchial smooth muscle relaxation
  • Immunomodulatory effect - improves mucociliary clearance and anti-inflammatory effect (decreases leukotrienes and TNFa)
25
Q

Name a methylxanthine

A
  • Theophylline

* Aminophylline is a mix of theophylline and ethylenediamine

26
Q

What are the indications of methxanthines?

A

•Adjunct to inhaled therapy in asthma/IV infusion in severe exacerbations of asthma

27
Q

What are the side effects of methylxanthines?

A
  • GI upset
  • Palpitations
  • Tachycardia
  • Headache
  • Insomnia
  • Hypokalaemia
28
Q

Toxicity of methyxanthines

A
  • Severe vomiting
  • Hypokalaemia/hypocalcaemia
  • Seizure
  • Arrhythmia
  • Hypotension
29
Q

Where are methxanthines metabolised?

A

In the liver - cautioned in liver disease and with concomitant use of some antibiotics

30
Q

What increases theophylline clearance?

A

Smoking

31
Q

When should you consider the use of monoclonal antibodies in asthma?

A

In high burden of corticosteroid

32
Q

Name a monoclonal antibody used in asthma

A

Omalizumab

33
Q

What is omalizumab?

A
  • anti IgE antibody
  • Used in severe persistant allergic asthma
  • Subcutaneous injection ever 2-4 weeks
  • Risk of severe hypersensitivity reaction
34
Q

What is mepolizumab?

A 
•Anti IL-5 monoclonal antibody 
•Reduces circulating eosinophils 
•Used in severe refractory eosinophilic asthma
•Subcut every 4 weeks 
•Headache common
35
Q

Acute severe asthma

A 
Any one of 
•PEF 33-50% best or predicted
•HR >110bpm 
•RR ≥ 25/min 
•Inability to complete sentences in one breath
36
Q

Life threatening asthma

A 
Any one of: 
•Altered consciousness 
• exhaustion 
•Arrhythmia 
•Hypotension 
•Cyanosis 
•Silent chest 
•Poor respiratory effort 
•PEF <33% best or predicted 
•SpO2 < 92% 
•PaO2 <8kPa
•Normal PaCO2
37
Q

Near fatal asthma

A
  • Raised PaCO2

* And/or requiring mechanical ventilation with raised inflation pressures

38
Q

What is the management of life threatening acute exacerbation of asthma

A
  • Supplemental oxygen to maintain spO2
  • Nebulised bronchodialtors 5mg salbutamol
  • Oral prednisolone 40mg to reduce bronchial inflammation
  • Oral doxycycline 200mg if chest infection suspected
  • IV magnesium 2g - relaxation of smooth muscle and blocking histamine release from mast cells
  • Consider IV aminophylline infusion

Week 8 - Respiratory (12 decks)

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