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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
Q

Treatment for CAP with medium severity

A

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

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24
Q

Treatment for CAP with high severity.

A

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

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25
Q

What antibiotics are used for CAP if the patients are pregnant?

A

Erythromycin

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26
Q

Risk factors of sepsis

A

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
Q

What tool is used to assess early detection of sepsis?

A

NEWS-2 score

27
Q

Response for patients depend on NEWS-2 score

A

0 -4 -> ward-based response

Any score >3 -> urgent ward response

5 - 6 -> urgent response

> = 7 -> emergency response

28
Q

Risk factors of COPD.

A

Smoking

Smoke from domestic fuels

Occupational exposure to fumes, dust and chemical

Family history

29
Q

What are the diagnostic steps for COPD?

A

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
Q

What are the other methods that can be used to support the diagnosis of COPD?

A

Chest X-ray -> rule out differential

Full blood count -> assess anaemia or polycythemia

BMI calculation

31
Q

What are the indicators of COPD?

A

Progressive and persistent dypsnoea, getting worse over time and worse with exercise

Chronic cough

Chronic sputum production

History of exposure to risk factors

32
Q

What is the hallmark sign to diagnose a patient with COPD?

A

FEV1/FVC value < 0.7

FEV1 % will determine the severity

33
Q

What are the 5 grades of breathlessness used to monitor COPD?

A

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
Q

What is the test used to illustrate the impact of COPD on patients?

A

CAT (COPD Assessment Test)

35
Q

Why is it important to monitor BMI of COPD patients?

A

Impact on ability to exercise

Impact on eating due to difficult breathing

Impact on ability to go shopping and prepare meals

36
Q

What changes in the BMI indicate the patients need referral?

A

Abnormal BMI

More than 3 kg changes (in older people)

37
Q

What is cor pulmonale?

A

Right-sided heart failure

38
Q

How does COPD cause cor pulmonale?

A

COPD -> low oxygen levels

Body response: pulmonary vasoconstriction -> prolonged high blood pressure in the pulmonary system

Cause right-sided heart failure.

39
Q

What are the symptoms to monitor to assess if COPD patients develop Cor pulmonale?

A

Level of fatigue

Presence of swollen ankle

Deterioration in exercise tolerance

S.O.B

Worsening of cough

Cough out blood (haemoptysis)

40
Q

According to the GOLD guidelines, what are the 3 groups that COPD patients are divided into for initiating the initial treatment?

A

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
Q

Drug choice for initial treatment for COPD patients, according to classified group.
(GOLD guidelines)

A

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
Q

Describe how stable COPD is treated.
(GOLD guidelines)

A

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
Q

Describe the treatment for the dyspnoea pathway of COPD patients.
(GOLD guidelines)

A

Initiate LABA or LAMA

LABA + LAMA

switch inhaler device/drug molecules + implement/escalate non-pharmacologic treatment + investigate and treat other causes

44
Q

Describe the treatment for the exacerbation pathway of COPD.
(GOLD guidelines)

A

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
Q

What are the non-pharmacological treatment for group A COPD patients?

A

Essential: Smoking Cessation

Recommended: Physical activity

Vaccination (flu, pneumococcal, pertussis, COVID-19, Shingles)

46
Q

What are the non-pharmacological treatment for group B COPD patients?

A

Essential: Smoking cessation + Pulmonary Rehabilitation

Recommended: Physical activity

Vaccination (flu, pneumococcal, pertussis, COVID-19, Shingles)

47
Q

Name the fundamentals of COPD care (NICE guidelines).

A

Treatment and support to stop smoking

Pneumococcal and flu vaccinations

Pulmonary rehab if indicated

Co-develop individualised plan

Optimise treatment for the comorbidities

48
Q

When is inhaled therapies started with COPD patients?
(NICE guidelines)

A

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
Q

Describe the inhaled therapy for COPD patients.
(NICE guidelines)

A

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
Q

Name some new LABA drugs.

A

Indacaterol

Olodaterol

Fluticasone furoate/vilanterol

51
Q

Name some new LAMA drugs

A

Aclidinium

Glycopyrronium

Umeclidinium

52
Q

When can theophylline be considered to be use in COPD?

A

After a trial of short-acting bronchodilators and long-acting bronchodilators

In patients who are unable to used inhaled therapy

53
Q

Why is mucolytics effective in management of COPD?

A

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
Q

How is oral corticosteroids recommended in COPD management?

A

Help to manage acute exacerbations

Not rec in maintenace - except for advanced cases req oral corticosteroids - keep lowest possible dose

55
Q

What is the main concern for using oral corticosteroids in COPD patients?

A

Osteoporosis -> appropriate prophylaxis

GI bleeding -> PPIs

56
Q

What prophylactic antibiotic is considered for COPD patients?

A

Azithromycin (250 mg three times a week)

If meet certain criteria

Need specialist advice

57
Q

Describe the pulmonary rehabilitation in COPD management

A

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
Q

Definition of COPD exacerbation.
(GOLD guidelines)

A

acute worsening of respiratory symptoms - result in additional therapy

3 classes: mild, moderate and severe

59
Q

How are different classes of COPD exacerbation managed?
(GOLD guidelines)

A

Mild: short-acting bronchodilator

Moderate: short-acting bronchodilator + antibitocs (+ antibiotics if needed)

Severe: hospitalisations needed

60
Q

Define COPD exacerbations.
(NICE guidelines)

A

Sustained worsening of symptoms from usual stable state

Acute in onset

61
Q

What are the commonly reported symptoms that worsen during COPD exacerbation?

A

Breathlessness

Cough

Increased sputum production

Change in sputum color

62
Q

What measurement is required to do in patients experiencing COPD exacerbation?

A

arterial blood gas (ABG) - assess pH values, PaCO2 values and PaO2 values

Bicarbonate levels

Assess acidosis or alkadosis present.

63
Q

What are the indicators used to assess the severity of exacerbation?

A

RR

Use of accessory respiratory muscles

Mental status

ABGs measurement

Chest radiograph

ECG

White blood cells count

U&E

64
Q

How are COPD exacerbation managed?
(GOLD guidelines)

A

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
Q

What are the advantages of using nebulisers?

A

No inspriatory effect req

No breath coordination is needed

High doses of drugs can be delivered

66
Q

What are the disadvantages of using nebulisers?

A

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

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