Chronic Asthma: Adults

Question 1

List the most common symptoms associated with asthma (4)

Answer 1

1) Cough
2) Wheeze
3) Chest tightness
4) Breathlessness

Question 2

The aim of asthma treatment is to achieve control. Define what complete control of asthma looks like (7)

Answer 2

1) No daytime symptoms
2) No night time awakening due to asthma
3) No asthma attacks
4) No need for rescue medication
5) No limitations on activity/exercise
6) Normal lung function (FEV1) and/or (PEF) > 80%
7) Minimal side-effects from treatment

Question 3

outline the lifestyle changes that may lead to an improvement in asthma symptoms

Answer 3

1) Weight loss in overweight patients
2) Smoking cessation
3) Breathing exercise programmes- can be offered as an adjuvant to drug treatment

Question 4

provide a general outline of the management of asthma

Answer 4

1) step-wise approach to stop symptoms quickly and to improve peak flow
2) step down when control is good
3) provide patients with personalised self management programme

Question 5

1) Outline the intermittent reliever therapy recommended for all adults (aged 17+) with asthma, and name the drugs used
2) This might be the only treatment patients need, however what might indicate that an urgent asthma review is required?

Answer 5

1) Start SABA to be used PRN in all patients with asthma
↳ Salbutamol, terbutaline
2) If using more than one SABA device a month

Question 6

list the symptoms that indicate the need for maintenance therapy with a low dose ICS in adults (3)

Answer 6

1) Using a SABA ≥3 times a week
2) Symptomatic ≥3 a week
3) Waking at night due to asthma symptoms at least once a week
↳(BTS also recommends starting ICS in those who have had an asthma attack in the last 2 years)

Question 7

According to BTS how often should inhaled corticosteroids initially be taken?

Answer 7

1) Twice daily

2) But the same total daily dose, taken OD, can be considered in patients with milder disease with good disease control

Question 8

If asthma is uncontrolled on a low dose ICS what should be considered as initial add-on therapy according to the following guidlines:

1) NICE (patients aged 17 years +)
2) BTS/SIGN (adults apply to patients over 12 years.)

Answer 8

1) NICE: leukotriene receptor antagonist ( montelukast)
↳ review In 4 to 8 weeks.
2) BTS/SIGN: LABA- such as salmeterol or formoterol fumarate

Question 9

If initial add-on therapy with a low dose ICS + LTRA does not control symptoms in adults what should be added next?

Answer 9

LABA- such as salmeterol or formoterol fumarate

Review :
Step 1: ICS
step 2: ICS + LTRA
step 3: ICS + LABA + LTRA (If worked in previous step)

Question 10

1) What is the MART regimen?

2) Give examples of brands of these inhalers

Answer 10

1) Maintenance And Reliever Therapy—a combination of an inhaled corticosteroid and a fast-acting LABA such as formoterol in a single inhaler
2) Fostair, DuoResp, Symbicourt, Fobumix

Question 11

in adults, If asthma is uncontrolled on a low dose ICS + LABA with or without LTRA what should be considered next as maintanance therapy?

Answer 11

Change ICS and LABA maintenance therapy to a MART regimen with a low dose ICS
↳( continue LTRA if it was beneficial previously)

Question 12

1) If asthma is uncontrolled in adults on a MART regimen with a low dose ICS + LTRA whats the next step?
2) what if this is inadequate?

Answer 12

1) Increase ICS to a moderate dose (either as MART regimen or a fixed-dose of an ICS and a LABA, with a SABA as a reliever therapy)
2) If above fails: Increase ICS to high dose (only as part of a fixed-dose regimen, with a SABA used as a reliever)
↳ OR a trial of an additional drug e.g. Theophylline

Question 13

Give an overall outline of the pharmacological treatment pathway for adults (aged 17+) using the step wise approach according to NICE

Answer 13

Each add-on step is considered after a 4-8 week review
1) Intermittent reliever: SABA (as reliever)
2) Reg maintenance: Low dose ICS
3) Initial add-on: Low dose ICS + LTRA
4) Additional add-on: Low dose ICS + MART + LTRA (if response)
↳ MART also used as reliever
5) Mod dose ICS + LABA (either within MART or Fixed dose regimen) + LTRA
↳ MART as reliever/ or SABA if fixed-dose regimen
6) High dose ICS + LABA as fixed dose + LTRA
↳ SABA as reliever therapy
(OR mod dose ICS + trial of additional drug (LAMA))

Question 14

outline of the pharmacological treatment pathway for adults (aged 12+) using the step wise approach according to BTS/SIGN

Answer 14

1) Intermittent reliever: SABA as required
2) Reg maintenance: Low dose ICS
3) Initial add-on: Low dose ICS + LABA
4) Additional add-on:
a) No response to LABA- stop LABA and consider
increased dose of ICS
b) If benefit from LABA but control still inadequate- continue LABA and increase ICS to medium dose
c) If benefit from LABA but control still inadequate - continue LABA and ICS and consider trial of other
therapy - LTRA, S-R theophylline, LAMA

Question 15

According to BTS/SIGN, if SABA PRN + medium dose ICS + an additional drug (usually a LABA) is inadequate, what interventions can be considered in adults?

Answer 15

High dose therapies:
1) Increase ICS to high dose - via pMDI, a spacer should be used
Or
2) Addition of a fourth drug, eg LTRA, SR theophylline, beta agonist tablet, LAMA

Question 16

When does BTS/SIGN recommend adding a regular low dose oral corticosteroid (prednisolone) to therapy?

Answer 16

In patients with very severe asthma uncontrolled on high-dose inhaled corticosteroids, and who have also tried a LABA, a LTRA or M/R theophylline.

Question 17

When would monoclonal antibodies and immunosuppressants be considered in asthma?

Answer 17

Specialist - methotrexate [unlicensed], and monoclonal antibodies (omalizumab) may be considered in patients with severe asthma to achieve control and reduce the use of oral corticosteroids.