Inhaled corticosteroids and LTRA

Question 1

How do inhaled corticosteroids improve symptoms in asthma and COPD?

Answer 1

They reduce muscosal inflammation, widen the airways and reduce mucus secretion

Question 2

What reduces the effectiveness of inhaled corticosteroids

Answer 2

Current or previous smoking- therefore higher doses are needed in these patients

Question 3

List 4 inhaled corticosteroids and state the brands they are commonly found in

Answer 3

1) Beclometasone dipropionate: Clenil, Qvar
↳(Qvar and clenil (200/250) unlicenced in under 12 years; Easyhaler® Beclometasone not for < 18 years)
2) Budesonide: Pulmicort
3) Ciclesonide: Alvesco
4) Fluticasone: Flixotide
(appear to all be as effective as each other)

Question 4

Inhaled corticosteroids and LABAs are found in combination inhalers for the prophylaxis of asthma. what ingredients are found in the following brands of inhalers:

1) Symbicort, DuoResp
2) Fostair
3) What should be discontinued when these inhalers are used as relievers?

Answer 4

1) Symbicort and DuoResp: Budesonide with formoterol
2) Fostair: Beclometasone (particles are extra fine and more potent than traditional) with formoterol
3) These inhalers can be used as relievers (instead of a SABA), in addition to their regular use for prophylaxis of asthma (MART)

Question 5

when are oral corticosteroids used in airway disease?

Answer 5

1) Severe infection
2) When airway obstruction or mucus prevent drug access to smaller airways
3) Acute asthma attack- Short course of oral steroids, starting with high dose provides good response.

Question 6

Can the treatment of a short course of oral steroids be stopped abruptly?

Answer 6

yes, can usually be stopped abruptly without tapering off. As long as the patient receives an inhaled corticosteroid in an adequate dose

Question 7

In whom might it be more useful to taper the corticosteroid dose gradually?

Answer 7

1) Patients who have needed several courses of oral corticosteroids
2) Those who the possibility of a period on maintenance therapy is being considered

Question 8

when should oral corticosteroids be taken and why?

Answer 8

1) As a single dose in the morning with food

2) To reduce disturbance of circadian cortisol secretion

Question 9

How can the dose of corticosteroids be optimised?

Answer 9

Regular peak-flow measurements. Dose should always be titrated to the lowest dose that controls symptoms

Question 10

outline the use of oral corticosteroids in COPD, stating which drug is preferred and how long it should be continued for

Answer 10

1) Acute exacerbation of COPD- prednisolone should be given

2) Prolonged treatment is of no benefit and maintenance treatment is not recommended

Question 11

Outline the MHRA alert regarding the use of inhaled corticosteroids

Answer 11

Rare risk of central serous chorioretinopathy (retinal disorder) with local as well as systemic administration. Patients should report any blurred vision or other visual disturbances with corticosteroid treatment given by any route

Question 12

Describe the main side effects of inhaled corticosteroid treatment (4)

Answer 12

1) Oral candidiasis- reduced by using spacer, also rinse mouth after inhalation
2) Hoarse voice
3) Paradoxical bronchospasm- (Discontinue); If mild it can be prevented by using SABA beforehand or changind to DPI
4) May increase the risk of pneumonia (in COPD)

Question 13

Very high doses of inhaled corticosteroids can lead to systemic absorption. List some of the side effects that may occur as a result of this. (3)

Answer 13

1) Adrenal suppression
2) Growth retardation (children)
3) Osteoporosis

Question 14

Can inhaled corticosteroids be used during pregnancy and in those breastfeeding?

Answer 14

Inhaled drugs for asthma can be taken as normal during pregnancy and breastfeeding

Question 15

what should be monitored in children who are prescribed prolonged treatment with inhaled corticosteroids and how often should this be done?

Answer 15

1) Height and weight

2) Annually- if growth is slowed, refer to pediatrician

Question 16

Who should inhaled corticosteroids be used in caution with?

Answer 16

1) High dose, particularly fluticasone should be used in caution in COPD patients with a history of pneumonia
2) Children due to growth suppression

Question 17

what is the difference between Clenil and Qvar and are these inhalers interchangeable?

Answer 17

1) Not interchangeable and should be prescribed by brand. (Clenil is also not interchangeable with generic)
2) Qvar has extra fine particles and is more potent
3) Qvar is 2x more potent than clenil

Question 18

what should be issued with high doses of inhaled corticosteroids?

Answer 18

steroid card

Question 19

1) Outline the MoA leukotriene receptor antagonists

2) Name two LTRAs

Answer 19

1) Reduce inflammation and bronchoconstriction in asthma by blocking cysteinyl leukotriene receptors in the airways and damping down the inflammatory cascade
2) Monteleukast and zafirlukast (12y+)

Question 20

Who might LTRAs be of benefit in?

Answer 20

Those with exercise-induced asthma and in those with concomitant rhinitis. They are less effective in severe asthma
↳ (More effective than standard dose of ICS. Has additive effect when given concomitantly)

Question 21

When would LTRAs be given in adults, Children 5-12 and children aged under 5 years of age?

Answer 21

1) Adults: Add-on therapy in asthma, if symptoms not controlled by ICS + LABAs
2) Children 5-12: Alternative to LABAs as an add-on therapy where ICS insufficient to control symptoms
3) Children < 5: First line preventative therapy in asthma when an ICS cannot be given

Question 22

List the common side effects of LTRAs (5)

Answer 22

1) Headache
2) Abdominal pain, diarrhoea
3) Increased rate of URTI
4) Fever
5) Churg-Strauss: Eosinophilic autoimmune disorder rarely with the use of montelukast and zafirlukast. normally occurs after withdrawal of ICS.
↳ symptoms include: eosinophilia, vasculitic rash, worsening pulmonary symptoms, cardiac complications.

Question 23

Aside from Churg-Strauss what other rare side effect can occur with the use of zafirlukast?

Answer 23

Hepatic disorders- symptoms such as persistent nausea, vomiting, malaise or jaundice may develop and indicate the development of a liver disorder

Question 24

State the does of montelukast in the following:

1) Child 6 months to 5 years
2) Child 6-14 years
3) Child 15-17 years
4) Adult

Answer 24

1) Child 6 months to 5 years: 4mg ON
2) Child 6-14 years: 5mg ON
3) Child 15-17 years: 10mg ON
4) Adult: 10mg ON