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PHAY00010 > Clinical Pharmacy I > Flashcards

Clinical Pharmacy I Flashcards

Asthma, COPD, CAP, Sepsis, NEWS-2

1
Q

What is the aim of treatment for asthma patients?

A

No asthma attack

No limitations on activity

No need for rescue medicines

No daytime symptoms

No night time awakening

Minimal side effects

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2
Q

How are asthma diagnosed?

A

Present with respiratory symptoms (wheezing, cough, breathlessness, chest tightness)

Clinical assessment from history + examination of previous medical records

Classify into low, medium and high probability.

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3
Q

What are the factors to look for in clinical assessment of previous medical records for asthma diagnosis?

A

Recurrent episodes of symptoms + variability

absence of differential diagnosis

Recorded observation of wheeze

Personal and family history of atopy and asthma

Historical record of variable PEF or FEV1

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4
Q

What are the tools used for monitoring asthma treatment efficiency ?

A

RCP 3 questions <difficult sleeping, daytime symptoms, interfere with daily activities>

Asthma control questionaires

Children’s asthma control test, mini asthma quality of life questionair, peak flow diary

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5
Q

According to BTS/SIGN guidelines, what is the pharmacological management for adults with asthma?

A

SABA always given (unless using MART)

First stage: low-dose ICS

Initial add-on: inhaled LABA + low dose ICS (or use MART)

Additional controller therapy: Consider:
- ICS to medium-dose
- Add LTRAs
( if no response to LABA, withdraw)

Last stage: refer to specialist therapies)

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6
Q

What is MART?

A

Maintenance and reliever therapy

Combination of ICS and fast-acting LABA like formoterol

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7
Q

According to BTS/SIGN guidelines, what is the pharmacological management for children with asthma?

A

SABA always given

Regular preventer: very low-dose ICS OR LTRA (if < 5 y.o)

Initial add-on:
+ Very-low dose ICS and
+ LABA or LTRA (if >5 y.o)
+ LTRA (if <5 y.o)

Additional controller therapies:
+ Increase ICS to low dose OR
+ Adding LTRA or LABA (if >5 y.o)
( if no response to LABA, withdraw)

Last stage: refer to specialist therapies)

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8
Q

What can be used to indicate that the treatment for asthma need to be move up?

A

The use of reliever inhaler (SABA) to be more than 3 doses/week

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9
Q

According to NICE guidelines, what is the pharmacological management for patients with asthma?

A

SABA always given for stage 1,2,3,6,7. For Stage 4 and 5, always give MART (low dose ICS + LABA)

Stage 1: Low-dose ICS

Stage 2: Low-dose ICS + LTRA

Stage 3: Low-dose ICS + LABA (with/without LTRA)

Stage 4: Moderate-dose ICS + LABA with/without LTRA OR MART regime

Stage 5: High-dose ICS + LABA (with/without LTRA)

Stage 6: Moderate-dose ICS + trial of LAMA or theophylline

Stage 7: Refer

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10
Q

How is the scale up and down of the NICE guidelines treatment assessed?

A

To move up: control of asthma from 4 to 8 weeks.

To move down: control of asthma within 3 months

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11
Q

What are the main differences between the BTS/SIGN and NICE guidelines for asthma management?

A

Age of adult: 17 in NICE and 12 in BTS/SIGN

The use of LABA and MART in BTS/SIGN oppose with the use of LTRA in NICE

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12
Q

Define asthma exacerbation.

A

Acute episode of progressive worsening of symptoms (SOB, wheezing, cough, chest tightness)

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12
Q

Hallmarks of acute severe asthma exacerbation for initial assessment.

A

PEF ~ 33 - 50% best of predicted value

RR > = 25

HR > = 110

Inability to complete sentence in one breath.

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12
Q

Hallmarks of moderate asthma exacerbation for initial assessment.

A

Increased in symptoms

PEF > 50 - 75% best or predicted value

No features of acute severe

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13
Q

Hallmarks of life-threatening asthma exacerbation for initial assessment.

A

PEF < 33% best or predicted value

SpO2 < 92%

PaO2 < 8 kPa

normal PaCO2

Silent chest

Cyanosis

Poor respiratory effort

Arrhythmia

Exhaution, altered consciousness

Hypotension

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14
Q

Summerise the management of moderate asthma attack

A

Beta bronchodilator via spacer - 1 puff/min, 10 puffs max

PEF check, if <75% -> salbutamol 5 mg neb + prednisolone 40 - 50 mg PO

Admit if signs of severe asthma or PEF < 50%

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15
Q

Summerise the management of severe acute asthma attack.

A

Salbutamol 5 mg by O2-driven neb

PEF check, if <75 % -> salbutamol 5 mg neb + prednisolone 40 - 50 mg PO

If PEF < 50% -> treat like life-threatening asthma cases

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16
Q

Summerise the management of life-threatening asthma attack.

A

Senior/ ICU help

O2 -> SpO2 94 - 98%

Salbutamol 5 mg + ipratropium 0.5 mg via O2-driven neb -> repeat after 15 mins

Prednisolone 40 - 50 mg PO or hydrocortisone 100 mg IV

ABG measured

Consider salbutamol neb 5 - 10 mg/hr

Consider IV MgSO4 1.2 - 2 g over 20 mins

Correct fluid/electrolytes balance - esp K+

Chest X-ray

Accompanied by HCPs

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17
Q

What is CAP?

A

Community-acquired pneumonia

Infection of lung tissues - air sacs filled with microorganisms, fluid and inflammatory cells

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18
Q

Symptoms of CAP.

A

Cough

Dyspnoea

Sharp chest pain

Aches and pain

Fever, sweating, shivers and chills

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19
Q

What is the tool used for assessing the severity of CAP?

A

CURB-65 (secondary care)

CRB-65 (primary care)

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20
Q

What are the features scoring a point in CURB-65?

A

Confusion

Urea level > 7 mmol/l

Respiratory rate > = 30

Systolic BP < 90 mmHg or diastolic BP < 60 mmHg

Age more than 65 years old

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21
Q

How does the CURB-65 score indicate the severity of CAP?

A

0-1 -> Low

2 -> Moderate

3-5 -> High

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22
Q

Treatment for CAP with low severity

A

Treat either at home or hospital

Amoxicillin 500 mg TDS PO

Alternative:
Doxycycline 200 mg loading dose -> 100 mg PO

Clarithromycin 500 mg BD PO

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23
Treatment for CAP with medium severity
Treat in hospital Amoxicillin 500 mg - 1g TDS PO + Clarithromycin 500 BD PO If PO impossible: Combine 1/ Amoxiclline 500mg TDS IV OR benzylcillin 1.2 g QDS IV 2/ Clarithromycin 500 mg BD IV Alternative: Either Doxycycline 200 mg loading dose -> 100 mg PO Levofloxacin 500 mg OD PO Moxifloxacin 400 mg OD PO
24
Treatment for CAP with high severity.
Co-amoxiclav 1.2 g TDS IV + Clarithromycin 500 mg BD IV If Legionella, add levofloxacin Alternative: Either Benzylcillin 1.2 g TDS IV + levofloxacin 500 mg BD IV/ ciprofloxacin 400 mg BD IV Cefuroxime 1.5 g TDS IV / cefotaxime 1g TDS IV / ceftriaxone 2 g OD IV + Clarithromycin 500 mg BD IV
25
What antibiotics are used for CAP if the patients are pregnant?
Erythromycin
26
Risk factors of sepsis
Age < 1 year old OR > 75 years old Diabetes Weakened immune system Recent surgery or serious illness Women just give birth or miscarriage or abortion
27
What tool is used to assess early detection of sepsis?
NEWS-2 score
27
Response for patients depend on NEWS-2 score
0 -4 -> ward-based response Any score >3 -> urgent ward response 5 - 6 -> urgent response > = 7 -> emergency response
28
Risk factors of COPD.
Smoking Smoke from domestic fuels Occupational exposure to fumes, dust and chemical Family history
29
What are the diagnostic steps for COPD?
Present of clinical features indicative of COPD Absence of clinical features of asthma Smoking history Confirm by spirometry - look for lung capacity and lung functions
30
What are the other methods that can be used to support the diagnosis of COPD?
Chest X-ray -> rule out differential Full blood count -> assess anaemia or polycythemia BMI calculation
31
What are the indicators of COPD?
Progressive and persistent dypsnoea, getting worse over time and worse with exercise Chronic cough Chronic sputum production History of exposure to risk factors
32
What is the hallmark sign to diagnose a patient with COPD?
FEV1/FVC value < 0.7 FEV1 % will determine the severity
33
What are the 5 grades of breathlessness used to monitor COPD?
Grade 1: not troubled except on strenuous excerise Grade 2: trouble when hurrying, walking up slight hill Grade 3: Walk slower on level ground, need to stop for breathing Grade 4: Need to stop for breath after 100m or few mins walk Grade 5: Too breathless to leave the house, to dress and undress
34
What is the test used to illustrate the impact of COPD on patients?
CAT (COPD Assessment Test)
35
Why is it important to monitor BMI of COPD patients?
Impact on ability to exercise Impact on eating due to difficult breathing Impact on ability to go shopping and prepare meals
36
What changes in the BMI indicate the patients need referral?
Abnormal BMI More than 3 kg changes (in older people)
37
What is cor pulmonale?
Right-sided heart failure
38
How does COPD cause cor pulmonale?
COPD -> low oxygen levels Body response: pulmonary vasoconstriction -> prolonged high blood pressure in the pulmonary system Cause right-sided heart failure.
39
What are the symptoms to monitor to assess if COPD patients develop Cor pulmonale?
Level of fatigue Presence of swollen ankle Deterioration in exercise tolerance S.O.B Worsening of cough Cough out blood (haemoptysis)
40
According to the GOLD guidelines, what are the 3 groups that COPD patients are divided into for initiating the initial treatment?
Group A: 0 - 1 moderate exacerbations in history (none -> admission). mMRC results 0 - 1, CAT results <10 Group B: 0 - 1 moderate exacerbations in history (none -> admission). mMRC results > 2, CAT results > = 10 Group E: 2 or more moderate exacerbation OR 1 lead to hospitalisation
41
Drug choice for initial treatment for COPD patients, according to classified group. (GOLD guidelines)
Group A: Bronchodilator (preferably long-acting) Group B: LABA and LAMA (preferably in a single inhaler if possible) Group E: LABA + LAMA. Add ICS if eosinophils level is more than 300.
42
Describe how stable COPD is treated. (GOLD guidelines)
If response well to initial treatment, maintain If not: Check adherence, techniques and possible interfering comorbidities Identify the predominant trait (dypsnoea or exacerbation) -> treat it. If both to be targeted, use exacerbation pathway.
43
Describe the treatment for the dyspnoea pathway of COPD patients. (GOLD guidelines)
Initiate LABA or LAMA LABA + LAMA switch inhaler device/drug molecules + implement/escalate non-pharmacologic treatment + investigate and treat other causes
44
Describe the treatment for the exacerbation pathway of COPD. (GOLD guidelines)
Initiate LABA or LAMA If not work, LABA + LAMA. Add ICS if eosinophils level more than 300. If patient have pneumonia or susceptible to ICS side effects, only use LABA + LAMA If eosinophil level < 100, use roflumilast (if FEV1 < 50%) OR azithromycin (in former smokers) If eosinophil level > 100, add ICS regardless. If not work, add roflumilast and azithromycin as described
45
What are the non-pharmacological treatment for group A COPD patients?
Essential: Smoking Cessation Recommended: Physical activity Vaccination (flu, pneumococcal, pertussis, COVID-19, Shingles)
46
What are the non-pharmacological treatment for group B COPD patients?
Essential: Smoking cessation + Pulmonary Rehabilitation Recommended: Physical activity Vaccination (flu, pneumococcal, pertussis, COVID-19, Shingles)
47
Name the fundamentals of COPD care (NICE guidelines).
Treatment and support to stop smoking Pneumococcal and flu vaccinations Pulmonary rehab if indicated Co-develop individualised plan Optimise treatment for the comorbidities
48
When is inhaled therapies started with COPD patients? (NICE guidelines)
All the fundamentals of care are offered Inhaled therapies are needed to relieve breathlessness and exercise limitations Patients trained well to use inhalers and demonstrate techiniques
49
Describe the inhaled therapy for COPD patients. (NICE guidelines)
SABA or SAMA - as required If no asthmatic features + no features suggesting steroid responsiveness -> LAMA + LABA -> not work -> 3 months trial of LABA + LAMA + ICS (revert if not work) If asthmatic features + features suggesting steroid responsiveness -> LABA + ICS -> not work -> LABA + LAMA + ICS.
50
Name some new LABA drugs.
Indacaterol Olodaterol Fluticasone furoate/vilanterol
51
Name some new LAMA drugs
Aclidinium Glycopyrronium Umeclidinium
52
When can theophylline be considered to be use in COPD?
After a trial of short-acting bronchodilators and long-acting bronchodilators In patients who are unable to used inhaled therapy
53
Why is mucolytics effective in management of COPD?
Mucolytics = Carbocisteine Reduce the viscosity of mucus Reduce mucus excretion Espc considered in patients with chronic cough productive of sputum Continue if improvement NOT for preventing exacerbation
54
How is oral corticosteroids recommended in COPD management?
Help to manage acute exacerbations Not rec in maintenace - except for advanced cases req oral corticosteroids - keep lowest possible dose
55
What is the main concern for using oral corticosteroids in COPD patients?
Osteoporosis -> appropriate prophylaxis GI bleeding -> PPIs
56
What prophylactic antibiotic is considered for COPD patients?
Azithromycin (250 mg three times a week) If meet certain criteria Need specialist advice
57
Describe the pulmonary rehabilitation in COPD management
Multidisciplinary programme - individualised Exercise programme and education 2 supervised sessions weekly and 1 unsupervised 6 - 12 weeks Regular physical activity 5 times a week, 30 mins each time Include muscle resistance and aerobic training
58
Definition of COPD exacerbation. (GOLD guidelines)
acute worsening of respiratory symptoms - result in additional therapy 3 classes: mild, moderate and severe
59
How are different classes of COPD exacerbation managed? (GOLD guidelines)
Mild: short-acting bronchodilator Moderate: short-acting bronchodilator + antibitocs (+ antibiotics if needed) Severe: hospitalisations needed
60
Define COPD exacerbations. (NICE guidelines)
Sustained worsening of symptoms from usual stable state Acute in onset
61
What are the commonly reported symptoms that worsen during COPD exacerbation?
Breathlessness Cough Increased sputum production Change in sputum color
62
What measurement is required to do in patients experiencing COPD exacerbation?
arterial blood gas (ABG) - assess pH values, PaCO2 values and PaO2 values Bicarbonate levels Assess acidosis or alkadosis present.
63
What are the indicators used to assess the severity of exacerbation?
RR Use of accessory respiratory muscles Mental status ABGs measurement Chest radiograph ECG White blood cells count U&E
64
How are COPD exacerbation managed? (GOLD guidelines)
Supplement O2 therapy Bronchodilator option: - Increase dose and freq of SABD - Combine SABA and anticholinergics - Consider LABD when patients are stable - Use spacers and air-driven nebulisers when appropriate Consider oral corticosteroids Consider oral antibiotics when signs of infection Consider non-invasive mechanical ventilation At all time: - Obtain ABGs, VBGs, pulse oximetry measurements - Consider s/c heparin or LMWH for thromboembolism prophylaxis, esp immobilised patients - Identify and treat associated conditions
65
What are the advantages of using nebulisers?
No inspriatory effect req No breath coordination is needed High doses of drugs can be delivered
66
What are the disadvantages of using nebulisers?
Time consuming Req electricity supply Must be clean and maintained regularly Expensive compared to other inhaled Source of infection Few benefit from high-dose delivery - side effects Patients become psychologically dependent Mask deterioration symptoms

PHAY00010 (4 decks)

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