Pharmacological treatment of asthma and COPD

Question 1

Approach to treatment fo asthma

Answer 1

• Start at appropriate level
• Achieve early control
• Maintain control by stepping up when needed and down when control is good
AND
• Check concordance/compliance/adherence

Question 2

advantages of inhaled administration

Answer 2

• direct delivery to site of action
• Rapid response with rescue medication
• allows smaller doses than systemic route
• reduces side-effects
• Efficacy of route depends on type and severity of asthma, particle size of medicine and inhaler technique

Question 3

inhaler devices

Answer 3

• MDI = metered dose inhaler
• Breath-actuated
• (e.g. autohaler, easibreathe)
• Accuhaler – dry powder
• Via spacer / aerochamber

Question 4

Nebulised route:

Answer 4

Nebulised route:
Use O2, compressed air or ultrasonic power to break up drug solutions into fine mist.
Facemask/mouthpiece
Give high doses quickly of “reliever” meds in acute asthma to get fast response
Risk of side-effects higher

Question 5

Pharma management 5 steps – up and down

Answer 5

1. Intermittent reliever therapy
2. Regular preventer therapy
3. Initial add-on therapy
4. Additional controller therapy
5. Specialist therapies

Question 6

Monitoring plans

Answer 6

• Peak Expiratory Flow Rate
• If<50% predicted – severe asthma
• Nocturnal dip often present

Question 7

Recommended for all COPD patients

Answer 7

• Smoking cessation –offer support - psychological + nicotine replacement /buproprion/varenicline
• Early use of long-acting bronchodilators (modest response only)
• ICS - depends on FEV1 and response
• Immunise – Pneumovax plus Flu vax
• Pulmonary rehab
• Self-management plan
• Optimise treatment for co-morbidities

Question 8

Inhaled corticosteroids in COPD

Answer 8

• limited benefit
• inflammatory cells responsible for COPD (macrophages and neutrophils) less responsive than lymphocytes and eosinophils to the actions of corticosteroids.
• Use if FEV1< 50% predicted and have 2 or more exacerbations in a year which require antibiotics or oral steroids
• High doses may increase risk of pneumonia and osteoporosis

Question 9

Assessment of COPD

Answer 9

• Primarily based on patient symptoms, ADL, exercise capacity, speed of symptom relief with SABA
• Changes in lung function – Spirometry •Risk of exacerbations

Two exacerbations or more within the past year or FEV1 < 50 % predicted are indicators of high risk

Question 10

Asthma - COPD overlap syndrome (ACOS)

Answer 10

• Difficult to distinguish from asthmatic smokers who have airway remodelling
(ie reduced FVC)
• Higher eosinophil count
• FEV1 swings
• Diurnal variation in PEFR
• Respond better to steroids (reducing exacerbation rate)
• More reversible to b2 agonists

Question 11

Acute, severe COPD exacerbations

Answer 11

Nebulise SABA/SAMA (on air) • + oral prednisolone
• + antibiotic if infected
• Physio
• 24-28% Oxygen (with care! – watch PaO2/PaCO2)
• Extreme – NIV, Intubation