Medical History Flashcards by Emily Bryce

What is flutiform inhaler used for?

Treatment of moderate to severe asthma.

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What type of inhaler is flutiform?

Combined corticosteroid steroid inhaler.

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What are the active ingredients of flutiform?

Fluticasone Propionate- steroid

Formoterol Fumarate Dehydrate- long acting beta agonist.

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What dosage of flutiform is the patient on?

125 microgram/5 microgram actuation.
- 125 micrograms of fluticasone and 5 micrograms or formoterol fumarate.

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What questions might you want to ask someone about their asthma?

How often do you get your asthma checked? (peak flow, height, weight, BP).

What was your last peak flow measurement?

What are your asthma triggers?

How long have you been on this medication? Has the dosage increased or decreased since you were prescribed it?

When did you last have an asthma attack?

Have you ever been hospitalised for asthma?

Have you ever taken any tablets for your asthma?

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If someone is on Flutiform, what does this tell you about their asthma?

Flutiform is not used as a first line treatment for asthma- suggests that the asthma is moderate to severe.

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What are the contraindications for the use of flutiform?

Thyrotoxicosis
Phaeochromocytoma
Diabetes Mellitus
Uncorrected hypokalaemia
Patients predisposed to low serum potassium
Hypertrophic obstructive cardiomyopathy
Idiopathic subvalvular aortic stenosis
Severe hypertension
Aneurysm
Severe cardiovascular disorders- ischaemic heart disease, cardiac arrhythmias or severe heart failure.

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What are the possible systemic effects of steroid inhaler therapy?

Cushing’s syndrome
Cushinoid features
Adrenal suppression
Growth retardation in children and adolescents
Decrease in bone mineral density
Cataract glaucoma

Stomach issues?

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What are the oral side effects of inhaled corticosteroid therapy?

Dry mouth
Dry throat
Cough
Hoarseness
Candida infections

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How is fluticasone and fomoterol metabolised?

In the liver- increased exposure can be expected in patients with severe hepatic impairment.

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What is the patient’s asthma triggers?

Cold air/cold wind that hits the back of the throat
Certain smells- lavender
Hayfever

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How often does the patient get their peak flow checked?

Attends the asthma nurse once per year and gets their peak flow checked at this appointment.

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How often do they use Salbutamol?

Only required when the patient has a cold or chest infection, when their chest gets tight.

Last time he took it was at Christmas time when he had a chest infection.

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What is Salbutamol?

Short acting beta-adrenergic receptor agonist.

Causes relaxation of bronchial smooth muscles to alleviate asthma symptoms.

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What medications must you be wary of prescribing to someone who takes Salbutamol?

Fluconazole- it can induce hypokalaemia.

Betamethasone- can cause increase risk of hypokalaemia.

Beclometasone- can increase risk of hypokalaemia.

Hydroxychloroquine- it can induce hypokalaemia.

NSAIDs- can cause bronchospasm.

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What is hypokalaemia?

Deficiency of potassium in the bloodstream.

What are the signs and symptoms of hypokalaemia?

Muscle twitches

Muscle cramps

Severe muscle weakness

Low blood pressure

Faintness

Arrythmias

Polyuria

Polydipsia

What is the role of potassium in the body?

Muscle function- depolarisation during the action potential of muscles

Kidney function- potassium intake increases excretion of sodium thereby lowering blood pressure and reducing kidney damage.

Where is salbutamol metabolised?

Liver

What is the onset of action of salbutamol?

Less than 15 minutes if inhaled

What is the duration of action of salbutamol?

3-6 hours if inhaled.

What should you advise asthma patients to do to reduce the risk of oral candidiasis?

Rinse your throat out after taking your inhaler

Use a spacer

Regular dental check ups

Maintain good oral hygiene

Brush teeth immediately after using inhaler.

Why is someone at increased risk of oral candidiasis if they take a steroid inhaler?

A significant amount of the inhaler will reach the lungs but some will remain on the oral tissues- particularly the throat.

Corticosteroids act by reducing the immune system- in the mouth and throat.
- more prone to opportunistic infections.

When the immune system is weakened, candidiasis can occur.

What is the micro-organism involved in oral candidiasis?

Candida Albicans

What is the usual treatment for oral candidiasis?

Oral measures first, 0.2% chlorhexidine. Oral Fluconazole- 50mg. 1 tablet 7 times a day

What would you give someone for oral fluconazole, who was taking a corticosteroid inhaler?

Nystatin- 100,000 units per ml.

What type of drugs are fluconazole and Nystatin?

Fluconazole- Triazole antifungal - Blocks ergosterol synthesis in the cell wall. Nystatin- Polyene - Bond directly to ergosterol and create pores in the cell wall- bactericidal.

What species of candida are sensitive to fluconazole?

Candida albicans but it is not sensitive to Candida Glabrata.

What is the difference between Flutiform inhaler and salbutamol inhaler?

Flutiform is a long-acting beta agonist (acts as a bronchodilator) with a steroid to reduce inflammation. - Used as a preventer. - The steroid also reduces the risk of acute coronary syndrome. Salbutamol is a short acting beta agonist (bronchodilator) - Used for acute exacerbations or asthma.

What is the goal of asthma treatment?

Improve airway patency- dilate bronchial smooth muscle via the beta 2 agonists and then reduce inflammation via the corticosteroid.

What drugs need to be avoided in asthmatics?

Fluconazole Hydroxychloroquine Beta blockers- propranolol benzodiazepines- initiate respiratory depression

What is asthma?

Respiratory condition which causes airway narrowing due to the asthmatic triad - Bronchial smooth muscle constriction - Bronchial mucosal oedema - Excessive mucous secretion into the airway lumen.

What is the cellular response in asthma?

Allergen triggers IgE production. Causes a B cell/T cell interaction- degranulation of mast cells. Leads to the asthma triad.

What does peak expiratory flow rate represent?

Tracks airway resistance. Important to only compare a morning measurement with a morning measurement or the same for an evening appointment because asthma has diurnal variation.

What are the symptoms of asthma?

Cough Wheeze- expiratory phase noise Shortness of breath Diurnal variation- worse overnight and early in the morning Difficulty breathing out and lungs fill with air.

What are the signs of an acute asthma attack?

Inability to complete sentences in a single breath Wheeze Increased respiratory rate- greater than 25 breaths per minute Heart rate in excess of 110 bets per minute

What would you do if the patient had an asthma attack in the chair?

Sit the patient upright Improve ventilation in the room Give 100% oxygen 15L through a non-re-breathable mask. Administer patient's bronchodilator- 2 puffs. If the patient does not have their own bronchodilator- give 4 puffs of salbutamol.

If the patient reports dry mouth, what could you do?

Give the patient advice - Keep hydrated - Chew sugar free chewing gum to stimulate saliva production - Suck pieces of ice. Artificial saliva gel- 50g Artificial saliva spray- 100ml Saliva Orthana- which has fluoride supplementation.

What aspects of the treatment plan are essential for someone with asthma, given that they are at high risk of dry mouth?

Prevention- to prevent caries - Detailed OHI - High fluoride toothpaste - Fluoride varnish- depending on if they can have this or not - Tooth mousse