Clinical Pharmacy I Flashcards
Asthma, COPD, CAP, Sepsis, NEWS-2
What is the aim of treatment for asthma patients?
No asthma attack
No limitations on activity
No need for rescue medicines
No daytime symptoms
No night time awakening
Minimal side effects
How are asthma diagnosed?
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.
What are the factors to look for in clinical assessment of previous medical records for asthma diagnosis?
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
What are the tools used for monitoring asthma treatment efficiency ?
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
According to BTS/SIGN guidelines, what is the pharmacological management for adults with asthma?
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)
What is MART?
Maintenance and reliever therapy
Combination of ICS and fast-acting LABA like formoterol
According to BTS/SIGN guidelines, what is the pharmacological management for children with asthma?
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)
What can be used to indicate that the treatment for asthma need to be move up?
The use of reliever inhaler (SABA) to be more than 3 doses/week
According to NICE guidelines, what is the pharmacological management for patients with asthma?
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
How is the scale up and down of the NICE guidelines treatment assessed?
To move up: control of asthma from 4 to 8 weeks.
To move down: control of asthma within 3 months
What are the main differences between the BTS/SIGN and NICE guidelines for asthma management?
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
Define asthma exacerbation.
Acute episode of progressive worsening of symptoms (SOB, wheezing, cough, chest tightness)
Hallmarks of acute severe asthma exacerbation for initial assessment.
PEF ~ 33 - 50% best of predicted value
RR > = 25
HR > = 110
Inability to complete sentence in one breath.
Hallmarks of moderate asthma exacerbation for initial assessment.
Increased in symptoms
PEF > 50 - 75% best or predicted value
No features of acute severe
Hallmarks of life-threatening asthma exacerbation for initial assessment.
PEF < 33% best or predicted value
SpO2 < 92%
PaO2 < 8 kPa
normal PaCO2
Silent chest
Cyanosis
Poor respiratory effort
Arrhythmia
Exhaution, altered consciousness
Hypotension
Summerise the management of moderate asthma attack
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%
Summerise the management of severe acute asthma attack.
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
Summerise the management of life-threatening asthma attack.
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
What is CAP?
Community-acquired pneumonia
Infection of lung tissues - air sacs filled with microorganisms, fluid and inflammatory cells
Symptoms of CAP.
Cough
Dyspnoea
Sharp chest pain
Aches and pain
Fever, sweating, shivers and chills
What is the tool used for assessing the severity of CAP?
CURB-65 (secondary care)
CRB-65 (primary care)
What are the features scoring a point in CURB-65?
Confusion
Urea level > 7 mmol/l
Respiratory rate > = 30
Systolic BP < 90 mmHg or diastolic BP < 60 mmHg
Age more than 65 years old
How does the CURB-65 score indicate the severity of CAP?
0-1 -> Low
2 -> Moderate
3-5 -> High
Treatment for CAP with low severity
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
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
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
What antibiotics are used for CAP if the patients are pregnant?
Erythromycin
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
What tool is used to assess early detection of sepsis?
NEWS-2 score
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
Risk factors of COPD.
Smoking
Smoke from domestic fuels
Occupational exposure to fumes, dust and chemical
Family history
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
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
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
What is the hallmark sign to diagnose a patient with COPD?
FEV1/FVC value < 0.7
FEV1 % will determine the severity
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
What is the test used to illustrate the impact of COPD on patients?
CAT (COPD Assessment Test)
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
What changes in the BMI indicate the patients need referral?
Abnormal BMI
More than 3 kg changes (in older people)
What is cor pulmonale?
Right-sided heart failure
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.
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)
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
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.
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.
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
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
What are the non-pharmacological treatment for group A COPD patients?
Essential: Smoking Cessation
Recommended: Physical activity
Vaccination (flu, pneumococcal, pertussis, COVID-19, Shingles)
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)
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
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
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.
Name some new LABA drugs.
Indacaterol
Olodaterol
Fluticasone furoate/vilanterol
Name some new LAMA drugs
Aclidinium
Glycopyrronium
Umeclidinium
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
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
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
What is the main concern for using oral corticosteroids in COPD patients?
Osteoporosis -> appropriate prophylaxis
GI bleeding -> PPIs
What prophylactic antibiotic is considered for COPD patients?
Azithromycin (250 mg three times a week)
If meet certain criteria
Need specialist advice
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
Definition of COPD exacerbation.
(GOLD guidelines)
acute worsening of respiratory symptoms - result in additional therapy
3 classes: mild, moderate and severe
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
Define COPD exacerbations.
(NICE guidelines)
Sustained worsening of symptoms from usual stable state
Acute in onset
What are the commonly reported symptoms that worsen during COPD exacerbation?
Breathlessness
Cough
Increased sputum production
Change in sputum color
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.
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
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
What are the advantages of using nebulisers?
No inspriatory effect req
No breath coordination is needed
High doses of drugs can be delivered
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
