Management of common conditions

Question 1

When should anti-hypertensive treatment be offered?

Answer 1

Adults of any age with persistent stage 2 hypertension

Any adult with stage 1 hypertension and 1 of the following:

• Target organ damage
• Established cardiovascular disease
• Renal disease
• Diabetes
• Cardiovascular risk score greater than 10%
• Aged over 60

Question 2

When should a calcium channel blocker be offered as first line treatment for hypertension?

Answer 2

• Aged 55+ without diabetes

- Any age and Black or African-Caribbean

Question 3

When should an ACE inhibitor or ARB be offered as first line treatment for hypertension?

Answer 3

• Any age with diabetes

- Under 55 who are not Black or African-Caribbean

Question 4

What should be offered if a calcium channel blocker is not tolerated?

Answer 4

A thiazide-like diuretic

Question 5

What should be offered if hypertension is not controlled in patients taking an ACE-inhibitor or ARB?

Answer 5

Add a CCB or thiazide like diuretic

Question 6

What should be offered if hypertension is not controlled in patients taking a CCB?

Answer 6

Add a ACE inhibitor, ARB or a thiazide like diuretic

In Black/African Caribbean patients a ARB should be used not a ACE inhibitor

Question 7

What is stage 3 hypertension treatment?

Answer 7

Offer a combination of an ACE/ARB and a CCB and a thiazide like diuretic

Question 8

What is stage 4 hypertension treatment?

Answer 8

Consider spironolactone if potassium levels are less than 4.5

If more than 4.5 then an alpha or beta blocker should be started

Question 9

How should asthma be managed after initial diagnosis?

Answer 9

Offer a SABA (salbutamol) inhaler

In adults with significant symptoms on first presentation such as waking at night, or wheezing more than 3 times a week then add a ICS

Question 10

What should be added on to patients whose Asthma is not controlled by a SABA?

Answer 10

ICS

Question 11

What should be added on to a patient whose Asthma is not controlled with a SABA and ICS?

Answer 11

Leukotriene receptor antagonist

Question 12

What should be added on to a patient whose Asthma is not controlled with a SABA, ICS and LTRA?

Answer 12

Add LABA (foametrol) and consider stopping LTRA if not improving symptoms

Question 13

What is the first line inhaled treatment for COPD?

Answer 13

SABA and SAMA

Question 14

What is the second line inhaled treatment for COPD?

Answer 14

SABA, SAMA and ICS

Question 15

When should a LABA and LAMA be offered to patients with COPD?

Answer 15

Have spirometrically confirmed COPD and

Do not have asthmatic features/features suggesting steroid responsiveness and

Remain breathless or have exacerbations despite:

Having used or been offered treatment for tobacco dependence if they smoke and

Optimised non-pharmacological management and relevant vaccinations and

Using a short-acting bronchodilator.

Question 16

When should a LABA and ICS be offered to patients with COPD?

Answer 16

Have spirometrically confirmed COPD and

Have asthmatic features/features suggesting steroid responsiveness and

Remain breathless or have exacerbations despite:

Having used or been offered treatment for tobacco dependence if they smoke and

Optimised non-pharmacological management and relevant vaccinations and

Using a short-acting bronchodilator.

Question 17

When should a COPD patient with LABA and ICS be treated with a LABA, LAMA and ICS?

Answer 17

Their day-to-day symptoms continue to adversely effect their quality of life or

They have a severe exacerbation requiring hospitalisation or

They have 2 moderate exacerbations within a year

Question 18

When should a COPD patient with LABA and LAMA be treated with a LABA, LAMA and ICS?

Answer 18

• They have a severe exacerbation requiring hospitalisation or
• They have 2 moderate exacerbations within a year

Question 19

When should azithromycin be offered to patients with COPD?

Answer 19

• They do not smoke
• Have optimised non-pharmacological management, inhaled therapies, vaccinations and pulmonary rehabilitation
• Continue to have one of the following:

1. Frequent (4+ a year) exacerbations with sputum production
2. Prolonged exacerbations with sputum production
3. Exacerbations resulting in hospitalisation

Question 20

When should oxygen be provided long term for patients with COPD?

Answer 20

1. Very severe airflow obstruction (FEV1 under 30% predicted)
2. Cyanosis
3. Polycythaemia
4. Peripheral oedema
5. Raised jugular venous pressure
6. O2 sats less than 92% on air