Clinical Case Studies Week 3 (Epilepsy, COPD, Asthma) Flashcards
What are some non-pharmacological treatment options for epilepsy?
Lifestyle medications
Avoid stress, sleep deprivation, triggers
Seek and try to remove precipitants
Medication, alcohol
Counselling
Complianece with medications
Benefits of treatment
What is first line for:
A) focal (partial) seizures?
B) generalised tonic-clonic seziures
C) absence seizures
D) myoclonic seizures
E) infantile spasms
A)
cabamazepine
B)
valproate
C)
valproate or ethosuximide
D)
valproate
E)
prednisolone, tetracosactide
What is there a risk of with valproate?
Risk of hepatic failure (usually in 1st 6mths – can be fatal)
Which patients to avoid valproate in?
Avoid in women of child-bearing age
- Risk of birth defects and developmental delay in child
What are some AE of valproate? TDM?
Weight gain, PCO, hyperandrogenism in females, hair loss
Blood dyscrasias (esp thrombocytopenia) – FBC before tx
BMD, calcium and vitamin D
Multi-organ hypersensitivity
TDM = 40-100mg/L (up to 150mg/L in some people) Css trough level (3-5d)
Many drugs used in the treatment of epilepsy reduce the efficacy of hormonal contraception by inducing hepatic enzymes. What are examples of these drugs? How long do these effects of last for?
Carbamazepine
Oxcarbazepine
Phenytoin
- The effectiveness of these contraceptives may be reduced during therapy with, and for at least 4 weeks after stopping, enzyme-inducing antiepileptic drugs
What contraception is effective in epilepsy with women of childbearing age?
Effective contraception is provided by depot medroxyprogesterone acetate, progestin-releasing intrauterine contraceptive devices (eg Mirena) or copper intrauterine contraceptive devices.
What treatment for Tonic-clonic seizures where onset is unclear?
Use “broad spectrum antiepileptic” effective against both types –> first line – sodium valproate or levetiracetam (women of childbearing potential)
Counselling patients with epilepsy
Keep a seizure diary
Warn patients that abruptly stopping antiepileptic drugs can provoke status epilepticus
Seizures can be provoked by:
- Sleep deprivation
- Excess alcohol intake n
- Illicit drugs n
- Psychological stress n
- Other medication
> Have a management plan
> Counsel on contraception and pregnancy if appropriate
adverse reaction of AED summary
Dizziness, drowsiness and diplopia n
Hepatic failure and hyperammonaemic encephalopathy with valproate n
Agranulocytosis and ↓Na with carbamazepine n
Serious skin reactions SJS/TENS/DRESS – esp carbamazepine, lamotrigine, phenobarb, phenytoin, valproate n
Osteoporosis – phenobarb, phenytoin, carbamazepine, valproate n
Cosmetic changes with valproate and phenytoin n
Impaired cognition (esp phenobarb + topiramate) n
Suicidal ideation with AED’s n
Behavioural changes – levetiracetam, topiramate, perampanel, zonisamide n
Decreased sweating, hyperthermia – topiramate, zonisamide n
Metabolic acidosis and kidney stones – topiramate, zonisamide
Dose of carbamazepine?
Adult, oral, initially 100 mg twice daily; increase daily dose gradually by 100–200 mg every 2–4 weeks according to response
Dose of valproate?
Initially, oral 600 mg daily in 2 doses; increase every 3 days by 200 mg daily according to response.
What are some adverse reactions associated with AED’s? What to monitor for?
Dizziness, drowsiness and diplopia common adverse effects
association between some antiepileptics and an increased risk of suicidal thoughts and behaviour –> benefits will usually outweigh the risks in epilepsy
Vitamin D
Monitor Vitamin D in patients on long-term AED’s
> Risk factors for osteoporosis (↓BMD)
Agranulocytosis with carbamazepine
COPD from this card onwards
For managing a COPD exacerbation in primary care;
A) What to do when patient is feeling unwell (finding it harder to breathe than usual and experiencing either more coughing, more phlegm, thicker phlegm than usual)
B) What do when patient is feeling worse
C) What to do if infection (change in color/ volume of phlegm and with/without fever) is present along with part B
D) What do when patient is feeling better
A)
- they start using more short-acting bronchodilator (SABA) e.g. salbutamol 4-8 puffs (400-800 mcg), via MDI and spacer every 3-4 hours, titrated to response
B)
- 3-4 hourly SABA not relieving symptoms adequately
> Commence oral prednisolone 30-50mg daily for 5 days, then stop
C)
- Commence oral antibiotics (amoxicillin or doxycycline) for 5 days
D)
- Step down short-acting bronchodilator use
- Return to usual daily prescribed medicines
- Write or review and reinforce the use of the COPD Action Plan
What are the FOUR steps used in the pharmacotherapy of COPD?
Use a short-acting bronchodilator for short term relief of breathlessness (either a SABA or a SAMA)
For patients receiving a short-acting bronchodilator (SABA or SAMA) with persistent dyspnoea add a LABA# or LAMA* (or both if monotherapy is inadequate)
= Do not use LABA monotherapy if patients have an asthma-COPD overlap
* = If adding a LAMA the SAMA should be discontinued
- For patients with an FEV1 <50% predicted and ≥ 2 exacerbations in 12 months:
> Consider initiating an ICS + LABA/LAMA fixed dose combination
> For moderate to severe COPD with frequent exacerbations who are not receiving a LAMA consider adding a LAMA to ICS/LABA
> Balance risk of corticosteroids and risk of pneumonia
- For severe COPD (FEV1 <40% predicted), consider adding lowdose theophylline (100mg twice daily):
> Avoid long-term (>2 weeks) use of systemic corticosteroids
COPD symptoms
Characteristic symptoms are cough, sputum, and dyspnoea
Progressive with acute exacerbations
Persistent (not fully reversible: post-bronchodilator spirometry FEV1/FVC < 0.7) airflow limitations and gas-exchange abnormalities
- Smoking is the major risk factor and quitting smoking can have a major impact on disease progression
- SAMAs and LAMAs should not be used concurrently
What are the main treatment goals in COPD
Reduce symptoms
Improve exercise tolerance
Improve health related quality of life
Reduce frequency and severity of exacerbations & consequent decline in lung function
Slow disease progression
Long acting beta agonists (LABAs) –> 5 types
Formoterol (eformoterol)
Indacaterol
Salmeterol
Vilanterol (combination only)
Olodaterol (COPD only)
SAMA?
Ipratropium
Long acting muscarinic agents (LAMAs) –> 4 types
Aclidinium
Glycopyrronium (glycopyrrolate)
Tiotropium
Umclidinium
Corticosteroids –> 6 types
Beclomethasone
Budesonide
Ciclesonide
Fluticasone propionate
Fluticasone furoate
Oral prednisolone
Risk of using ICS?
ICS is reserved for later stages of treatment and their use needs to be balanced against the risk of pneumonia and other side effects.
For corticosteroids in COPD;
A) What is the main role for it? What drug is used to treat and what is the dose?
A)
The main role of oral CSs in COPD is to treat exacerbations
- 30–50 mg of oral prednisolone typically for a period of 5-10 days
What is a major complication in COPD patients? What does this result in?
Development of stable hypercapnia (elevated CO2 in the blood) –> respiratory acidosis
> Headache, confusion, anxiety, drowsiness and stupor
Smoking cessation in COPD? Why so important?
NEEDS to be a PRIORITY to prevent or limit lung damage and improve prognosis
- Therapies should include pharmacological therapies and behavioural support
- More urgent for patients with respiratory diseases to quit smoking
Why is physical activity so important in COPD?
↓ in physical activity commences early in COPD and declines substantially across all severity stages of COPD
> Decline →deterioration in lung function and health status
> There is strong evidence of benefit of regular exercise in COPD patients
Dose of SABA used in COPD?
salbutamol 100 to 200 micrograms by inhalation via pMDI with spacer (1 to 2 inhalations as required)
terbutaline 500 micrograms by inhalation via DPI (1 inhalation as required)
Dose of LABA used in COPD?
indacaterol 150 micrograms by inhalation via DPI, daily, increasing to 300 micrograms daily if required –> 1 to 2 inhalations daily
Dose of LAMA inhalers used?
- aclidinium 322 micrograms by inhalation via DPI, twice daily
- glycopyrronium 50 micrograms by inhalation via DPI, daily
- tiotropium 13 or 18 micrograms [Note 3] by inhalation via DPI, daily
- umeclidinium 62.5 micrograms by inhalation via DPI, daily
Dose of LABA + LAMA dual therapy for COPD?
- formoterol+aclidinium 12+340 micrograms by inhalation via DPI, twice daily
- Indacaterol+glycopyrronium 110+50 micrograms by inhalation via DPI, daily
- Olodaterol+tiotropium 5+5 micrograms by inhalation via mist inhaler, daily
- vilanterol+umeclidinium 25+62.5 micrograms by inhalation via DPI, daily
> improves lung function and quality of life compared with LAMA or LABA monotherapy
> reduces exacerbations
A) Triple therapy can be given as an ICS+LABA fixed-dose combination inhaler plus a separate LAMA inhaler. What is the dose?
B) Triple therapy, or as a single fixed-dose combination inhaler containing all three drug classes. What is the dose?
A)
LAMA + ONE OF THE FOLLOWING ICS+LABA FIXED-DOSE COMBINATIONS
- budesonide+formoterol 400+12 micrograms by inhalation via pMDI with spacer or via DPI, twice daily
- fluticasone furoate+vilanterol 100+25 micrograms by inhalation via DPI, daily
- fluticasone propionate+salmeterol 500+50 micrograms by inhalation via pMDI with spacer or via DPI, twice daily
B)
- fluticasone furoate+umeclidinium+vilanterol 100+62.5+25 micrograms by inhalation via DPI, daily
Summary for COPD
COPD
- Characteristic symptoms are cough, sputum, and dyspnoea
- Progressive with acute exacerbations
- Persistent (not fully reversible: post-bronchodilator spirometry FEV1/FVC < 0.7) airflow limitations and gas-exchange abnormalities
> Smoking is the major risk factor and quitting smoking can have a major impact on disease progression
> Give vaccines, influenza vaccines reduce hospitalisations and death in COPD patients.
> Comorbidities can increase the complexity of managing COPD
> Pulmonary rehabilitation programs improve outcomes
> Pharmacotherapy is used in a stepped approach according to disease severity
> SAMAs and LAMAs should not be used concurrently
> The small benefits of ICS need to be balanced against the risks of pneumonia
> You need to consider patient characteristics when considering the most appropriate inhaler device (pressured metered-dose inhaler, use with a spacer at all times)
> Have a written COPD action plan –> outlines initial measures patient should take in response to an increase in symptoms:
- adjusting bronchodilator therapy to control symptoms
- starting oral corticosteroid therapy if breathlessness increases and interferes with activities of daily living
- antibiotics if exacerbation caused by bacterial infection
——> keep corticosteroids and antibiotic tablets at home for use as part of self-management
Asthma from this card onwards…
What are the key features of asthma?
Asthma is a chronic inflammatory disorder involving the airways
Inflammation results in asthma symptoms:
- Wheezing
- Breathlessness
- Chest tightening
- Coughing
- Airways hyper-responsiveness
Symptoms are often worse at night or early in the morning
Airway obstruction is usually reversible
What are the symptoms of asthma in an acute attack?
- Acute attack – a sudden worsening of symptoms
- Severe wheezing when breathing in and out
- Coughing that won’t stop
- Very rapid breathing
- Chest tightness or pressure
- Tightened neck and chest muscles (retractions)
- Difficulty talking
- Feelings of anxiety or panic
- Pale, sweaty face
- Blue lips of fingernails (cyanosis)
- Confusion, lethargy, loss of consciousness
- Worsening symptoms despite medication use
Who writes asthma action plans? What benefits does it provide?
GPs develop and write plans - other health care professionals review and reinforce plans
Benefits
- Increase in asthma control
- Decrease in exacerbations
- A decrease in hospitalisation, ED visits, emergency GP visits
- Decrease in days off work or school
How to achieve and maintain clinical control in asthma treatment?
No daytime symptoms (twice or less/week)
No limitations on daily activities (including exercise)
No nocturnal symptoms or awakening from asthma
No need for reliever treatment (twice or less/week)
Normal or near-normal lung function (PEF or FEV1)
No exacerbations
Poor control of asthma?
three or more of
Daytime symptoms >2 days per week
Need for reliever >2 days per week*
Any limitation of activities
Any symptoms during night or on waking
What is S.M.A.R.T therapy? What does it consist of? What are the advantages?
Symbicort Maintenance And Reliever Therapy (SMART)
Symbicort® (budesonide and eformoterol)
- Can be used as both maintenance and reliever medication due to the rapid onset of action of eformoterol
What are THE FOUR STEPS to asthma control
- Few patients –> as needed SABA alone
2.
Budesonide/formoterol (low dose as needed) SYMBICORT= MOST PATIENTS
OR
regular daily maintenance ICS (low dose) + SABA reliever as needed = MOST PATIENTS
3.
> Budesonide/formoterol, maintenance and reliever therapy, l_ow dose as regular daily maintenance plus low dose as needed_ = SYMBICORT
OR
> regular daily maintenance ICS + LABA combination (low dose) + SABA reliever as needed
4.
> Budesonide/formoterol, maintenance and reliever therapy, medium dose as regular daily maintenance plus low dose as needed = SYMBICORT
OR
> regular daily maintenance ICS-LABA combination (medium-high dose) + SABA reliever as needed
What are the local and systemic effects of ICS?
Local side effects
- Hoarseness
- Pharyngeal candidiasis
- Dissolution of tooth enamel
Side effects (systemic)
- Short-term suppression of linear growth
- Clinically significant adrenal insufficiency reported
What are the types of inhaler devices used in asthma? THREE main types.
- Standard metered-dose inhalers (e.g.Ventolin®)
- Breath activated metered dose inhalers
> Autohaler® (e.g. Qvar®)
- Dry powder inhalers
>Accuhaler® (breath actuated dry-powder inhaler) (e.g. Seretide®)
> Turbuhaler® (e.g. Pulmicort®)
Which inhaler device is spacers used in? What is the importance of spacers?
Always encourage the use of spacers with MDIs
- improve drug deposition (~10-12% to 30%)
- Reduce oral complications of ICS
> use one puff into a spacer at a time - NOT multiple puffs
Dose for step 1?
budesonide+formoterol 200+6 micrograms by inhalation via pMDI with spacer or via DPI, as required
OR
salbutamol 200 micrograms by inhalation via pMDI with spacer, as required
OR
terbutaline 500 micrograms by inhalation via DPI, as required
Dose for STEP 2?
Symbicort: budesonide+formoterol 200+6 micrograms by inhalation via pMDI with spacer or via DPI, as required
ICS with SABA reliever therapy
> saba as required
plus
- beclometasone 50 or 100 micrograms by inhalation via pMDI with spacer, twice daily
- budesonide 100 or 200 micrograms by inhalation via DPI, twice daily
- ciclesonide 80 or 160 micrograms by inhalation via pMDI with spacer, once daily
- fluticasone propionate 50 or 100 micrograms by inhalation via pMDI with spacer or via DPI,
OR
monetlukast 10mg orally
Dose for step 3
Dose for step 4?
Budesonide + formoterol (symbicort) 400 + 12 microgram formulation not suitable for use as reliever therapy
Use 200+6 microgram device for both maintenance and reliever therapy
Asthma summary
- There is significant morbidity associated with asthma and death rates have remained stable in recent years.
- There is no single reliable test to diagnose asthma
- Asthma is a heterogenous disease with many phenotypes
- Asthma is characterised by variable and reversible airways obstruction
- Patients need to know their triggers and know how to respond to worsening asthma control
- Asthma control is the key measure to determine if asthma is being effectively managed and to determine pharmacotherapy required
- Guideline based care and appropriate use of medications could reduce the burden of asthma
- International and national guidelines recommend stepped management of asthma based on asthma control
- Written asthma action plans can improve health outcomes for people with asthma and provide the necessary information for patients to appropriately adjust pharmacotherapy when required in response to symptoms or lung function
- Poor inhaler technique is a frequent reason for poor asthma control and inhaler technique training should be provided to patients regularly.
