Chronic asthma

Question 1

define asthma

Answer 1

Common chronic inflammatory condition of the Airways, associated with airway hyper responsiveness and variable airflow obstruction

Question 2

what is asthma-COPD overlap syndrome

Answer 2

characterised by persistent airflow limitation displaying features of both asthma and COPD

Question 3

complete control of asthma is defined by

Answer 3

• no daytime symptoms
• no night time awakening due to symptoms
• no asthma attacks
• no need for rescue med
• no limitations on activity including exercise
• normal lung function (i.e. FEV1 and/or PEF >80% predicted or best)
• minimal SE from treatment

Question 4

One of the factors for complete control of asthma includes normal lung function. What does this mean in practical terms (FEV1 and/or PEF)

Answer 4

FEV1 and/or PEF >80% predicted or best

Question 5

What is FEV1 and PEF

Answer 5

FEV1 = forced expiratory volume in one second
PEF = peak expiratory flow

Question 6

true or false - weight losss in overweight pt may lead to improvement in asthma symptoms

Answer 6

true

Question 7

for people with infrequent short lived wheeze, what is treatment

Answer 7

occasional use of reliever therapy may be the only treatment required

Question 8

if a patient is using …. SABA inhaler a month they need their asthma urgently assessed and action taken to improve poorly controlled asthma

Answer 8

more than 1 device

Question 9

adults - start low dose ICS as regular maintenance therapy in patients who present with

Answer 9

waking up at night from asthma symptoms at least once a week
OR
using SABA 3 times a week or more
OR
symptomatic 3 times a week or more

Question 10

when you give montelukast (LTRA) in adults or children, when should you review response to treatment

Answer 10

in 4-8 weeks

Question 11

Name some beclomethasone and formoterol MART inhalers

Answer 11

Foster, Luforbec

Question 12

Name some budesonide & formoterol MART inhalers

Answer 12

symbicort
duoresp
wockair
fobumix

Question 13

Mabs and immunosuppressants are specialist therapies. Name 5 Mabs and 1 immunosuppressant and explain when they can be used

Answer 13

Omalizumab, mepolizumab, benralizumab, reslizumab, dupilumab
Can be ocnisdred in certain pt with severe asthma to achieve control and reduce use of oral CCs
Immunosuprpesants e.g. MTX (unlicensed) may also be considered as recommended by BTS/SIGN

Question 14

name two Mabs and 1 immunosuppressant that can be considered in children

Answer 14

Monoclonal antibodies such as omalizumab and dupilumab can be considered in certain children with severe asthma to achieve control and reduce the use of oral corticosteroids; immunosuppressants such as methotrexate [unlicensed] may also be considered as recommended by BTS/SIGN (2019).

Question 15

For children UNDER 5, what steps would you take if a patient who has SABA as reliever presents with
- asthma symptoms 3x a week or more
- night time awakening at least once a week
- suspected asthma that is uncontrolled using SABA alone

Answer 15

• consider 8 week trial of paediatric MODERATE dose ICS
• after 8 weeks, stop ICS and monitor symptoms
• if symptoms did NOT resolve during trial, review for alternative diagnoses
• if symptoms resolved then reoccured within 4 weeks of stopping ICS, restart ICS at paediatric LOW dose as 1st line maintenance therapy
• if symptoms resolved but reoccured BEYOND 4 weeks after stopping ICS, repeat 8 week trial of paediatric MODERATE dose ICS

Question 16

If suspected asthma is uncontrolled in children UNDER 5 who are on 1st line paediatric LOW Dose ICS as maintenance, what can you consider in addition to ICS?

Answer 16

LTRA

Question 17

If suspected asthma is uncontrolled in children aged under 5 years on a paediatric low-dose of ICS and a LTRA as maintenance therapy, what do you do?

Answer 17

stop the LTRA and refer the child to an asthma specialist.

Question 18

When can you consider decreasing maintenance therapy? Which drug?

Answer 18

asthma has been controlled with their current maintenance therapy for at least 3 months.
when deciding which drug to decrease first and at what rate, consider pt pref; severity of asthma; SE treatment; duration on current dose; beneficial effect achieved.
ensure to regularly review pt when decreasing treatment.

Question 19

decreasing treatment of ICS - when should you consider dose reductions, and at what rate

Answer 19

• should be maintained at lowest possible dose of ICS
• consider reductions every 3 months, decreasing dose by ~ 25-50% each time
• reduce dose SLOWLY as pt deteriorate at different rates

Question 20

only consider stopping ICS treatment for patients who are…

Answer 20

using a paediatric or adult low-dose ICS alone as maintenance therapy and are symptom-free.

Question 21

true or false - for most pt, exercise induced asthma is an illustration of poorly controlled asthma and regular treatment including ICS should therefore be reviewed

Answer 21

True.

Question 22

If exercise is a specific problems in pt already taking ICS who are otherwise well controlled, what is step up treatment you can consider

Answer 22

Cnsider adding either a LTRA, a LABA, sodium cromoglicate or nedocromil sodium, or theophylline.
A SABA used immediately before exercise is the drug of choice.

Question 23

Can asthma medication be used as normal during pregnancy? Which ones ?

Answer 23

SABAs
LABAs
oral and inhaled CCs
sodium cromoglicate
nedocromil sodium
oral and IV theophylline
LTRA - limited info, but do not withhold where indicated to achieve adequate control

Question 24

Define what paediatric low dose is (budesonide)

Answer 24

less than or equal to 200mcg budesonide or equivalent

Question 25

define what paediatric moderate dose is (budesonide)

Answer 25

more than 200mcg to 400mcg budeosnide or equivalent

Question 26

define paediatric hig dose ICS (budesonide)

Answer 26

> 400mcg budesonide or equivalent

Question 27

pMDI beclomethasone - what is paediatric low, medium and high dose?

Answer 27

low: 100mcg 2 puffs BD
medium: 200mcg, 2 puffs BD
high: 200mcg, 4 puffs BD

Question 28

a 7 yr old is currently on the following inhalers for asthma. Clenil 100mcg 2 puffs BD and Ventolin evohaler 2 puffs up to 4 times a day PRN. They are still having to use their reliever inhaler more than 3 times a week, therefore their asthma is not controlled. What is the next step in treatment.

Answer 28

Add montelukast, 5mg OD, dose be taken in the evening.
review response in 4-8 weeks

Question 29

Doses of montelukast for prophylaxis of asthma

Answer 29

6 months - 5 yrs: 4mg OD in evening

6 yrs - 14 yrs: 5mg OD in evening

15-17 yrs and adults: 10mg OD in evening

Question 30

dose of montelukast for 5 yr old

Answer 30

4mg od in evening

Question 31

dose of montelukast for 14 year old

Answer 31

5mg od in evening

Question 32

A 8 yr old is currently taking the following for asthma, but asthma is still uncontrolled so what is the next step.

Clenil 100mcg 2 puffs BD (low dose paediatric)
Salamol 2 puffs QDS prn
Montelukast 5mg take one at night

Answer 32

Consider stopping montelukast and start LABA alongside ICS as maintenance therapy (e.g. formoterol, salmeterol)

Question 33

A 9 yr old is takin the following for asthma but it is still uncontrolled, what do you do

Clenil 100mcg 2 puffs bd (low paediatric ICS)
Salmeterol 50mcg, one puffs BD

Answer 33

Consider changing to MAR - combination of paediatric low dose ICS and LABA

e.g. symbicost 100/6 turbohaler 1-2 puffs BD, reduce to 1 puff daily if control maintained

Question 34

What is the ONLY MART inhaler that is licensed for children from 6-17 (the rest of 12-17)

Answer 34

Symbicort 100/6 turbohaler for maintenance therapy of asthma (Not reliever)