Chapter 3: Respiratory system Flashcards
How should patients used DPI inhalers?
Need to breathe in fast and strong to create enough turbulence to lift the particles
these are breath actuated inhalers. Symbicort is an example. You can get a symbicort whistle to test if the patient has the ability to use the inhaler. If they breath in strong enough it will make a noise
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 affected- has extra fine particles (beclometasone and formeterol
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 but should still be used with caution
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)
do not use a cloth to wipe as will create static
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, LABA)
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
In what degree of asthma attack should we consider the use of high flow oxygen?
If it’s severe
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)
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?
PRN SABAs
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
What is step 3 of the NICE asthma guidelines
Add a LTRA in addition to ICS and review in 4-8 weeks
Step 4 of the asthma treatment guidelines?
If asthma is uncontrolled in adults (aged 17 and over) on a low dose of ICS and an LTRA as maintenance therapy, offer a long-acting beta2 agonist (LABA) in combination with the ICS, and review LTRA treatment as follows:
discuss with the person whether or not to continue LTRA treatment
take into account the degree of response to LTRA treatment.
Step 5 of the asthma treatment guidelines?
If asthma is uncontrolled in adults (aged 17 and over) on a low dose of ICS and a LABA, with or without an LTRA, as maintenance therapy, offer to change the person’s ICS and LABA maintenance therapy to a MART regimen with a low maintenance ICS dose.
Stepping down: How often should asthma treatment be reviewed?
Every 3 months
Consider reducing ICS by 25-50% every 3 months
What age of child do the asthma guidelines become different?
NICE:
under 5
5-16
17+
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?
8 week trial of ICS
Child under 5: asthma guidelines step 3?
SABA PRN Plus 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)
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 maintenance and reliever therapy Symbicort contains 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 MART 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 use 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
Who are leukotriene receptor antagonists more effective in?
Exercise induced asthma
Those with rhinitis
When should Montelukast be given?
In the evening
What needs to be looked out for with the use of Leukotriene receptor antagonists (Montelukast)
Churg-strauss syndrome= autoimmune causing inflammation of small and medium-sized blood vesselsLook out for esonophillia, rash, worsening pulmonary symptoms, cardiac complications, peripheral neuropathy
Zafirlukast is cautioned in ______ disorder
drug no longer available ignore card
Hepatic disorders
no longer availale
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
What is step one in treating COPD (hint: PRN drugs)?
SABA or SAMA (Ipratropium) when required
SABA can be continued at all stages but SAMA must be discontinued if a LAMA is used (i.e. wouldn’t be using ipratropium and tiotropium together)
If FEV is over 50% what is the treatment plan??
LABA OR LAMA (tiotropium)If this fails then use LABA + ICS combination inhalerIf this fails triple therapy with all three: LABA + ICS + LAMA
If FEV is under 50 % what is the treatment plan?
LAMA alone or LABA/ ICS combination inhaler (consider LABA/ LAMA combo if ICS declined)If this fails triple therapy: LABA + ICS + LAMA
Name some of the LABA + ICS combination inhalers used in COPD?
LABA + ICS combos are commonly seen in COPD as they are indicated if FEV is over under 50 %Steroids are only licensed in COPD if given in combination inhalersSymbicort Turbohaler: Budesonide + Formoterol Seretide 500 Accuhaler: Fluticasone + SalmeterolNB: seretide MDI not licensed in COPD
If symptoms persist after triple therapy in COPD what should be used?
Theophyllin/ aminophylline Then Roflumilast
What duration of prednisolone is indicated for COPD exacerbations?
30mg daily 7 - 14 days Can be stopped abruptly as not over 3 weeks use
How is oxygen administered in COPD patients?
24-28 % through a venturi facemark to avoid hypercapnia88-92 % target
Why doe patients on nebulisers need to wear goggles with ipratropium nebs?!
Because acute closed angle GLAUCOMA can occur especially if used with nebulised salbutamol
What are the main side effects with anti muscarinic inhalers?
These are ipratropium (SAMA) and tiotropium (LAMA)Main SE’s:ARRHYTHMIAS therefore cautioned in CARDIAC DISORDERS. Also need to used with caution with drugs that cause Hypokaleamia/ hyperkaleamia as this can cause arrhythmias GLAUCOMA- Ipratropium nebs- wear goggles Antimuscarinic SEs such as dry mouth, constipation, sweating, urinary retention etc but these are more common with oral therapy.
What is the risk of INTRAVENOUS SHORT ACTING BETA 2 AGONISTS SUCH AS SALBUTAMOL in DIABETICS?
Risk of HYPERGLYCAEMIAAlso a risk of diabetic Ketoacidosis!!
What are the CHM warnings associated with the LABAs formoterol and salmeterol?
Do not prescribe alone- only add on to ICS therapy Do not initiate in rapidly deteriorating asthmaDon’t used for relief of exercise induced asthma unless regular ICS used too report symptoms of paradoxical bronchospasm
Clear improvement within 3 -4 weeks of ICS therapy indicates which COPD or Asthma?
AsthmaThis can be used to differentiate between the two
When is Ipratropium not allowed to be continued in COPD?
If patients are on a LAMA (tiotropium)
What is spiriva? How often is it given?
TiotropiumComes as either Spiriva inhalation powder (18mcg capsules) or Spiriva Respimat pressurised MDIIt is given OD (One capsule/ 2 puffs of respimat inhaler)
What is the role of ICS in COPD?
To reduce exacerbations Slight lack of evidence of ICS benefits in COPDReasonably high doses required (e.g 800mcg budesonide)Steroids only licensed in COPD if in combination inhalers
When should osteoporosis prophylaxis be considered with oral predinisolone use?
received over 3 courses of steroids lasting over 7 days in the previous 12 months All patients over 65 should receive prophylaxis
Chronic productive cough in COPD treatment?
Mucolytics:Carbocisteine/ Mecysteine
We know beta blockers are cautioned in asthma… but can they be given in COPD?
Yes… but just monitor closely monitor for broncho spasms
What is Aclidinium?
A LAMA also used in maintenance of COPD Comes as the “Genuair” inhaler- a DPI that has a little window that turns from green to red if dose is inhaled correctly
What is Glycopyrronium?
A LAMA used in COPD maintenance
What is Umeclidinium?
Another LAMA used in COPD maintenance. Comes as the Ellipta DPI - has a dose counter- also comes in a combo Ellipta inhaler: Umeclidinium with vilanterol.
Tiotropium is a LAMA used for maintenance of COPD but not suitable for treatment of _______
Acute bronchospasm
What is paradoxical bronchospasm?
paradoxical means ‘contradictory/ going against oneself’Paradoxical bronchospasm is where ICS can actually do the opposite to what they’re meant to and cause airways to constrict and breathing to get worse. This means that ICS should not be used again
We know salbutamol can cause potassium disturbance… a SABA… Can LABAs?
Yes Laba can also cause Hypokaleamia
When does ipratropium bromides maximal effects take place?
30- 60 minutes after use
DPIs are recommended in children over what age?
5 yearsHowever, between 3 and 5 years DPI can be considered if existing treatment is ineffective
What is the MHRA advice surrounding PMDIs?
Risk of airway obstruction from aspiration of loose objectsPatients should be reminded to remove the mouthpiece cover fully, shake the device and check that both the outside and inside of the mouthpiece are clear and undamaged before inhaling a dose, and to store the inhaler with the mouthpiece cover on.
What are the different types of inhalers?
DPIMDIBreath actuated
How should you clean spacer devices?
The device should be cleaned once a month by washing in mild detergent and then allowed to dry in air without rinsing; the mouthpiece should be wiped clean of detergent before use.
How often should spacers be replaced?
Every 6-12 months
What are the main nebulised drugs and their associated indications?
- A beta 2 agonist or ipratropium bromide to a patient with an acute exacerbation of asthma or of chronic obstructive pulmonary disease- A beta 2 agonist, corticosteroid, or ipratropium bromide on a regular basis to a patient with severe asthma or reversible airways obstruction when the patient is unable to use other inhalational devices- An antibiotic (such as colistimethate sodium) or a mucolytic to a patient with cystic fibrosis- Budesonide or adrenaline/epinephrine to a child with severe croup- Pentamidine isetionate for the prophylaxis and treatment of pneumocystis pneumonia.
Why would you want to avoid high dose ICS in children?
Associated with adrenal suppression, growth impairment and reduced bone mineral density.
According to BTS guidelines, what should be prescribed if a patient has been diagnosed with asthma?How does this differ in children?
SABAConsider monitored initiation with low dose ICSStill use SABA but can start with a VERY low dose of ICSIf the patient is still getting symptomatic, short-lived wheezes, this ICS should be used as a regular preventer
According to BTS and NICE guidelines, in what situations would a patient need a regular preventor?
- If they are using 3 or more doses of their SABA a week- Symptomatic three times a week or more, - Waking at night due to asthma symptoms at least once a week. - Had asthma attack in the last 2 years
BTS asthma guidelines in adults:If a patient is on a regular low dose ICS and SABA yet symptoms are not being controlled, what would the next step up be?
Add inhaled LABA (normally as a combination inhaler with ICS)
BTS asthma guidelines in adults:Patient’s regular meds:Low dose ICS and LABA combinationSABAIf no response to the LABA, what would the next step be?
Stop LABA and increase dose of ICS
BTS asthma guidelines in adults:Patient’s regular meds:Low dose ICS and LABA combinationSABAIf the patient is benefitting from the LABA yet symptoms are still not being controlled, what would the next step be?
Continue LABA and increase ICS to medium doseAt this point you can also consider trials of:LTRAS-R TheophyllineLAMA
BTS asthma guidelines in adults:Patient’s regular meds:Medium dose ICS and LABA combinationSABAHas had a trial of LAMA/LTRA/SR-TheophyllineIf a patient is still symptomatic, what would the next step be?
High dose therapiesConsider trial of:High dose ICSAddition of 4th drug e.g. LTRA, SR-Theophylline, beta agonist tablet, LAMARefer to specialist care
BTS asthma guidelines in adults:After high dose therapies, what would the next step be?
Continuous or frequent use of oral steroids Use daily steroid tablet in the lowest dose providing adequate control Maintain high dose ICS Refer to specialist care
In an asthma attack, if a patient required nebulisers, is this driven by air or oxygen?
Oxygen
For asthmatic children under 5 years, what type of inhaler is recommended for bronchodilator therapy?
Pressurised metered-dose inhaler and spacer device, with a facemask if necessary
For asthmatic children under 5 years, what type of inhaler is recommended for corticosteroid therapy?
Pressurised metered-dose inhaler and spacer device, with a facemask if necessary
For asthmatic children between 5 and 15, what type of inhaler is recommended for corticosteroid therapy?
Pressurised metered-dose inhaler and spacer device
For asthmatic children between 5 and 15, what type(s) of inhalers is recommended for bronchodilator therapy?
Consider a wider range of inhalers- not just PMDIsAll down to what suits the patient and compliance
What is the target peak expiratory flow in asthma?
> 80%
- BTS asthma guidelines recommend that ICS should be initially taken how many times a day?2 .What steroid is the exception to this?
- Twice a day(However, the same total daily dose, taken once a day, can be considered in patients with milder disease if good or complete control of asthma is established)2. Ciclesonide should be taken only once daily initially (only twice daily in severe asthma)
True or false:BTS recommend that inhalers do not need to be prescribed by brand
FalseThey should be prescribed by brand
How long should be the initial trial of an ICS be in a child under 5?After this trial, in what situation would you continue the ICS?
8 weeks and then review to see if it has benefittedIf they had another exacerbation within 4 weeks of stopping, then continue
When would you consider decreasing maintenance therapy for asthma?What is the recommended dose reduction for ICS at a time and how often?
When a patient’s asthma has been controlled with their current maintenance therapy for at least three monthsReduction of 25-50% ICS dose every 3 months
Can inhaled corticosteroids be used during pregnancy for asthma?
Yes
Can oral corticosteroids be used during pregnancy for asthma?
Yes
What is 1st line for acute asthma in adults?How does the administration route differ with non-life threatening vs life threatening?
High dose inhaled SABA (salbutamol or terbutaline) and oral prednisolone once daily for at least 5 days or until recovery Non-life threatening - PMDI recommendedLife-threatening - oxygen driver nebuliser recommended
In what situation would you use IV beta 2 agonists for acute asthma in adults?
If inhaled therapy cannot be used reliably
In severe acute adult asthma, if the patient has poor response to nebulised SABA, what can be added?
Nebulised ipratropium
What kind of drug is ipratropium?
SAMA
What kind of drug is tiotropium?
LAMA
Are brands of ICS interchangeable?
No- all contain different doses of different steroids
Is LABA monotherapy recommended in asthma?
NoShould always have an ICS or combination inhaler with ICSAssociated with ADRs and death
What type of inhaler is an accuhaler?
DPI
What type of inhaler is an evohaler?
MDI
What is a disadvantage of a DPI?
Breath actuated, need to have respiratory effort for itIf not, MDI is more appropriate
What is the only LAMA licensed for asthma?
Tiotropium
Which tiotropium inhaler is licensed in asthma?
Spiriva Respimat 2.5 mcg (2 puffs OD)The following are only licensed in COPD:Braltus 10 microgram capsules (Zonda inhaler)Spiriva 18 microgram capsules (Handihaler)
What is the only Seretide licensed in COPD?
Seretide 500 AccuhalerThe lower dose Seretide accuhalers and the evohalers are not licensed(But all Seretides are licensed for asthma)
In children of all ages, what do you give for acute asthma?
Inhaled SABAOnce daily dose of oral prednisolone, usually for 3 days or until recovery
In children of all ages in acute asthma, if an inhaled SABA is not sufficient, what else can be given?
Nebulised ipratropium combined with SABA
BTS guidelines:In paediatric asthmatic patients, if they are on a SABA and a very low dose ICS, what would the next step be?
<5 years: Add LTRA5 years and above: Add inhaled LABA
BTS guidelines for paediatric asthmaIf a patient is on:SABAVery low dose ICS LABAHowever there is no response to the LABA, what would the next step be?
Stop LABA and increase ICS to a low dose
BTS guidelines for paediatric asthmaIf a patient is on:SABAVery low dose ICS LABA/LTRAIf there is benefit from the LABA but control still inadequate, what would the next step be?
Continue LABA but increase ICS to a low doseAlso consider trial of other therapy e.g. LTRA if not on already
BTS guidelines for paediatric asthmaIf a patient is on:SABALow dose ICS LABALTRAWhat would the next step be?
Refer for specialist careConsider trials of medium dose ICSAddition of 4th drug e.g. SR-theophyllineIf these do not work, may need daily steroid tablet at lowest dose providing control
How would you treat mild croup?
Mostly self-limitingSingle dose of corticosteroid e.g. dexamethasone may be helpful
How would you manage severe croup?
Hospital admissionSteroid- dexamethasone or prednisolone before admissionIn hospital- give oral/IV dexamethasone or nebulised budesonideIf this does not provide control- nebulised adrenaline
If someone needed oxygen therapy, in what group of patients would you give low concentration rather than high?
COPDCFOverdose of opioid and benzosLung scarring by TB
Theophylline is given as an injection as what drug and why?
Aminophylline, a mixture of theophylline with ethylenediamine, which is 20 times more soluble than theophylline alone
Beta agonists can cause deficiency in what electrolyte?In what group of patients would this be a particular caution?
Can cause hypokalaemia if high doses usedSevere asthma- may be potentiated by concomitant treatment with theophylline, corticosteroids
What are the common side effects of beta agonists?
ArrythmiasDizzinessHeadacheHypokalaemia (high doses) Tremor PalpitationsHyperglycaemia - needs monitoring in diabetics
What is the important safety info on the use of formoterol and salmeterol in asthma?
- Be added only if regular use of standard-dose inhaled corticosteroids has failed to control asthma adequately;- not be initiated in patients with rapidly deteriorating asthma;- be introduced at a low dose and the effect properly monitored before considering dose increase;- be discontinued in the absence of benefit;not be used for the relief of exercise-induced asthma symptoms unless regular inhaled corticosteroids are also used;- be reviewed as clinically appropriate: stepping down therapy should be considered when good long-term asthma control has been achieved.
What combination is in a Fostair inhaler?
Beclometasone and formoterol
What is a caution in nebulised ipratropium? (what can it cause)?How can the risk of this be reduced?
Acute angle closed glaucoma, especially in combination with nebulised salbutamol. Need to protect the patient’s eyes from nebulised drug or powder. If nebulised iptratropium is needed in a glaucoma patient, they need a very tight fitting nebs mask ALSO cautioned in enlarged prostate and bladder outflow obstruction
What is the MHRA advise regarding Braltus tiotropium inhalation capsules?
Reports of patients who have inhaled a Braltus capsule from the mouthpiece into the back of the throat, resulting in coughing and risking aspiration or airway obstruction
What combination is in a Relvar Ellipta (92/22)?
ICS LAMAFluticasone and vilanterol
What combination is in a Seretide?
ICS LAMAFluticasone and salmeterol
What combination is in a Symbicort Turbohaler?
ICS LAMABudesonide and formoterol
What combination is in a Flutiform MDI?
ICS LAMAFluticasone and formoterol
What are the LABAs licensed in asthma?
SalmeterolFormoterolIndacaterolVilanterol
If a patient is on the following:SABASAMAICSLABAAnd they are prescribed a LAMA, what medicine should be stopped?
Their SAMA
What LAMAs are licensed in asthma?
Tiotropium Spiriva Respimat 2.5 micrograms (dose 2 puffs -5 micrograms)
What SABAs are licensed in asthma?
SalbutamolTerbutaline
What ICS inhalers are licensed in asthma?
Clenil (beclomethasone)Pulmicort (budesonide)Flixotide (fluticasone)
What steroid is in Clenil?
Beclomethasone
What steroid is in Pulmicort?
Budesonide
What steroid is in Flixotide?
Fluticasone
What ICS/LABA is licensed in asthma?
Relvar ElliptaSeretide and SirduplaSymbicort and DuorespFlutiformFostair
What LAMAs are licensed in COPD?
GlycopyyroniumTiotropiumAclidiniumUmeclidiniumTiotropium
What combination is Ultibro Breezhaler?
LAMA LABAGlycopyrronium/indacaterol
What combination is Anoro Ellipta?
LAMA LABAUmeclidium/vilanterol
What combination is Duaklir Genuair?
LAMA LABAAclidinium/formoterol
What combination is Spiolto Respimat?
Tiotropium/Olodaterol
True or false:ICS monotherapy is recommended in COPD patients
False - always prescribe in combination with LABACan cause pneumonia, increased ADRs and increased mortality
What is the difference between how to take MDI vs DPI?
MDI - slow and steadyDPI - fast and deep
What are the side effects of inhaled antimuscarinics (SAMA and LAMA)?
Dry mouth, headaches, nausea, arrythmias, nose bleeds
What is a contraindication to beta agonists?Hint- pregnancy
Severe pre-eclampsia
What LABAs are licensed in COPD?
FormoterolSalmeterolIndacaterolOlodaterol
What is the MHRA advice surrounding corticosteroids?
Rare risk of central chorioretinopathy with local and systemic administrationPatients should report any blurred vision/disturbances
What are the common side effects of ICS?
- Oral thrush- Altered voice- Cushing’s syndrone- Epistaxis - Throat irritation- Bronchospasm
What monitoring requirement is needed in children on regular ICS?
Annual height and weight
What is the important safety information surrounding beclometasone inhalers Qvar and Clenil?
They are not interchangeable as Qvar is more potentNeeds to be prescribed by brand
Is Qvar or Clenil beclometasone inhaler more potent?
QvarHas extra fine particles and is approx twice as more potent as Clenil
- When switching a patient with well controlled asthma from a 200 mcg Clenil to a Qvar, what starting dose should you start with?2. How does this differ if the patient has poor control asthma and the patient is on 100 mcg Clenil?
- Start with 100 mcg Qvar2. Same dose as Clenil- 100 mcg
Are Clenil and Qvar inhalers licensed in COPD?
No- but beclometasone is licensed if in combination with formoterol (+/- glycopyrronium)Beclometasone and formoterol - FostairBeclometasone and formoterol and glycopyrronium - Trimbow
What is the Fostair 100/6 (including nexthaler) licensed for?
COPD and asthma
What is the Fostair 200/6 (including nexthaler) licensed for?
Asthma onlyNot COPD
True or false:Only the higher strength Fostair (200/6) is licensed in COPD
FalseIt is only the 100/6 that is licensed
What is the beclometasone (non-extra fine particles) equivalent of 100mcg Fostair (extra fine particles)?
250 mcg Fostair is more potent as it comtains extra fine particles
What combination is a Trimbow inhaler?
Beclometasone and formoterol and glycopyrronium
What is Trimbow licensed in?
COPD only
True or false:Symbicort 100/6 is licensed in COPD
FalseThose licensed in COPD:200/6400/12
Is Flutiform licensed in COPD?
No
What is Trelegy licensed in?
COPD only
What combination is Trelegy?
Fluticasone, umeclidinium and vilanterol
Are any inhalers just containing ICS licensed in COPD?
NoRecommended to prescribe ICS/LABA or trio inhaler as ICS monotherapy not recommended in COPD
What is a rare but serious side effect of montelukast?
Eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome - a disorder marked by blood vessel inflammation) Has occurred very rarely in association with the use of montelukast; in many of the reported cases the reaction followed the reduction or withdrawal of oral corticosteroid therapy. Prescribers should be alert to the development of eosinophilia, vasculitic rash, worsening pulmonary symptoms, cardiac complications, or peripheral neuropathy.
What are the side effects of aminophylline?
Arrythmia (more common if IV given too rapidly)HeadacheNauseaSeizure (more common if IV given too rapidly)May potentiate hypokalaemia in beta 2 agonist therapy
With IV aminophylline, when should a blood sample be taken?
4-6 hours after starting treatment
What is the ideal plasma concentration for theophylline?
10-20 mg/L - above this can lead to severe side effects
When would you measure plasma theophylline levels in a) starting oral therapy and b) after a dose adjustment?How many hours after an oral dose?
Measured 5 days after starting oral treatment and at least 3 days after any dose adjustment. 4-6 hours after
How does smoking interact with theophylline and how does this affect the dose needed?
Smoking can increase theophylline clearance and increased doses of theophylline are therefore required
What is the MHRA advice surrounding OTC chlorphenamine in children?
Children under 6 years should not be given over-the-counter cough and cold medicines containing chlorphenamine
What is the MHRA advice surrounding hydroxyzine (sedating antihistamine)?
QT prolongation
What is the MHRA advice surrounding OTC promethazine in children?
Children under 6 years should not be given over-the-counter cough and cold medicines containing promethazine
What drug class do you use to treat hereditary angiodema?
C1 esterase inhibitor
What is the 1st line mucolytic in CF?What can be added if inadequate response?
Dornase alfaHypertonic sodium chloride
What is the MHRA advice surrounding OTC pholcodine in children?
Children under 6 years should not be given over-the-counter cough and cold medicines containing pholcodine6-12 years- if needed, restrict to max 5 days
What are the symptoms of theophylline toxicity?
Vomiting, and vomiting up blood AgitationRestlessessDilated pupilsSinus tachycardiaHyperglycaemia ConvulsionsVentricular arrhythmias Hypokalaemia
Should theophylline be prescribed by brand?
Yes as rate of absorption can vary between brands
How does theophylline interact with quinolones?
Increased risk of convulsions
How does theophylline interact with St John’s Wort?
Theophylline concentration reduced by St John’s Wort (enzyme inducer)
How does theophylline interact with rifampicin?
Theophylline concentration reduced by rifampicin
How does theophylline interact with cimetidine?
Theophylline concentration increased by cimetidine
How does theophylline interact with fluconazole?
Theophylline concentration increased by fluconazole
How does theophylline interact with disulfiram?
Metabolism of theophylline is inhibited by disulfiram and therefore there is an increased risk of theophylline toxicity (hyperglycaemia, dilated pupils and haematemesis)
What type of inhaler is a Turbohaler?
DPI
What is the difference in Fostair Nexthaler and Fostair inhaler?
Nexthaler- DPIFostair normal - pMDI
How do you calculate pack years?
(Number of cigs smoked a day/20) x number of years smoked
When should you refer a COPD patient for pulmonary rehabilitation?
If they are functionally disabled by COPD (usually Medical Research Council (MRC) dyspnoea scale grade 3 or above)
What is the purpose of pulmonary rehab for COPD patients?
- Can improve quality of life, increase exercise capacity safely and effectively, and reduce breathlessness.- Programmes usually comprise 2–3 sessions/week and last for 6–12 weeks.- Pulmonary rehabilitation should involve physical training; disease education; and nutritional, psychological, and behavioural interventions tailored to the person’s needs.
Long term oxygen therapy prolongs life in COPD patients. How many hours a day at least must they be on oxygen?
15 hours
True or false:In COPD, if a patient is regularly using a SAMA 4 times a day, a LAMA should be offered instead
TRUE
What class of drug is bambuterol?What formulation does it come in?
LABATablet
What age is QVAR inhalers licensed in?
12 years
What is the adrenaline dose in anaphylaxis in:i) Children < 6 yearsii) Child 6-12 yearsiii) > 12 years and adults
IM injection (1 in 1000 solution) repeated every 5 minutes if necessaryAdminister into thigh i) Children < 6 years: 150 microgramsii) Child 6-12 years: 300 microgramsiii) > 12 years and adults: 500 micrograms (For EpiPen brand it is 300 micrograms)
Patients on what medicine may not respond to adrenaline?What could be an alternative
Beta blockersIV salbutamol could be an alternative
What is the MHRA advice with adrenaline auto-injectors?
It is recommend that 2 adrenaline auto-injectors are prescribed, which patients should carry BOTH at all times.Check expiry dates
What time of the day should LTRA be taken?
Evening
A patient requesting more than how many SABAs a month prompts a referral?
> 1 a month
True or false:Lung function measurements are used to guide asthma treatment of all ages
FalseNot reliable in <5 years old
Are Ellipta inhalers DPI or MDI?
DPI
Can Clenil Modulite MDI be used in children?Is there any cut off age?
Yes - all ages
What type of inhaler is Clenil Modulite?
MDI
What type of inhaler is an Easyhaler?
DPI
What age is a a Beclometasone Easyhaler licensed in?
> 12 years
Can a Beclometasone Easyhaler be used in a 7 year old?
No >12 years only
What age is a Qvar inhaler licensed in?
> 12 years
What type of inhaler is an Autohaler?
MDI
What age is Fostair licensed in?
> 18 years
What age is Pulmicort turbohaler licensed in?
5 years and over
What age is Symbicort for maintenance therapy licensed in?
6 years and over
What age is Symbicort for maintenance AND reliever therapy licensed in?
12 years and over
What is the only strength Seretide Evohaler licensed in children and what is the cut off age?
25/50 licensed in children from 4 years
What are the 3 strengths of Seretide Evohaler?
25/5025/12525/250
What are the 3 Strengths of Seretide Accuhaler?
50/10050/25050/500
What is the only strength Seretide Accuhaler licensed in children and what is the cut off age?
50/100 licensed in children from 4 years
What are the 3 inhalers licensed in MART therapy and the ages they are licensed in?
Fostair 100/6 for 18 years + (This is NOT the nexthaler)Symbicort 100/6 and 200/6 for 12 years +Duoresp Spiromax 160/4.5 for 18 years +
What is the inhaler that is shaped like an egg?
Spiriva Handihaler 18 micrograms tiotropium
What does a whistling when a patient is using their inhaler mean?
They are breathing in too fast
When should you issue a steroid card to a patient on an ICS?
If on high dose ICS
