R Flashcards
Define asthma?
common chronic inflammatory condition of the airways
associated with airway hyperresponsiveness
and variable airflow obstruction
Airway hyperresponsiveness in asthma means that the airways are overly sensitive and can react strongly to triggers like allergens, irritants, or exercise. This exaggerated response can lead to symptoms like coughing, wheezing, and difficulty breathing
Variable airflow obstruction in asthma means that the airflow in the lungs can fluctuate, sometimes being normal but often becoming restricted or blocked. This occurs because the muscles around the airways tighten (bronchoconstriction), the airway walls become inflamed and swollen, and excess mucus is produced, making it harder to breathe. These changes can happen quickly and vary in severity, leading to symptoms like wheezing, shortness of breath, and chest tightness.
What are the stages of treating acute asthma:
Salbutamol given as soon as possible
For children with mild to moderate acute asthma, a pressurised metered-dose inhaler and spacer device is preferred
Patients/carers of children with acute asthma at home, should seek urgent medical attention if initial symptoms are not controlled with up to 10 puffs of salbutamol via a spacer
For children with acute severe or life-threatening symptoms, administration via an oxygen-driven nebuliser is recommended
In all cases of acute asthma, children should be prescribed an adequate dose of oral prednisolone; treatment for up-to 3 days is usually sufficient
State the stages of typical standard treatment of chronic asthma in adults:
SABA (salbutamol or terbutaline)
SABA + Low dose ICS (inhaled corticosteroids)
SABA + low dose ICS + Leukotriene receptor antagonist (montelukast)
SABA+ low dose ICS+ LABA ( salmeterol or formoterol), with or without LTRA
Low dose ICS plus a LABA within a MART regimen with or without LTRA
Consider moderate dose ICS plus a LABA either within a MART regimen or as a fixed dose (or change to SABA), with or without LTRA
Consider high dose ICS plus a LABA as fixed dose, with or without LTRA with a SABA
Consider continuing moderate dose ICS regimen with a trial of an additional drug i.e LAMA(tiotropium) or m/r theophylline with a SABA or low dose ICS plus a LABA within a MART regimen
step up every 4-8 weeks, if asthma still uncontrolled by then
State which monoclonal antibodies can be used in patients with severe asthma to achieve control and reduce the use of oral corticosteroids:
Omalizumab, mepolizumab, benralizumab, reslizumab, dupilumab
Or methotrexate
State the two SABAS:
Salbutamol
terbutaline
State the two-long acting SABAs:
Salmeterol
formoterol
Which other LABAs are used for COPD:
Indacaterol, olodaterol
Vilanterol is only available as a combination with fluticasone or/and umeclidinium
Which oral LABA can potentially be of use in nocturnal asthma:
Bambuterol
Which other antimuscarinic medication can be used to relieve symptoms in chronic asthma:
¡pratropium bromide
Which four drugs are licensed for COPD:
Aclidinium bromide
glycopyronium bromide
umeclidinium
tiotropium
What is Theophlline used for?
Theophylline belongs to a drug class known as xanthines
used in asthma and stable COPD
Combination with beta agonists may increase risk of side effects such as hypokalaemia
Theophylline helps with asthma by relaxing the muscles around the airways, which makes breathing easier. It also reduces inflammation in the lungs, which helps open up the air passages.
works by inhibiting an enzyme called phosphodiesterase, which leads to increased levels of a molecule called cyclic AMP (cAMP) inside cells. This increase in cAMP causes relaxation of the smooth muscles surrounding the airways, resulting in widening of the air passages and easier breathing.
What are the symptoms of COPD:
Breathlessness
cough
sputum
airflow obstruction
What can relieve symptoms of COPD?
SABA or short acting antimuscarinic bronchodilator
If the FEV1 is 50% or higher what would you advise:
LAMA or LABA
Forced expiratory volume (FEV1) calculates the amount of air that a person can force out of their lungs in 1 second.
If the FEV1 is less than 50%:
LABA or LAMA + corticosteroid in combination inhaler
If symptoms persist or if patient is unable to use an Inhaler oral m/r aminophylline or theophylline can be use
A mucolytic may be given to those with a productive cough
During an exacerbation of chronic COPD, bronchodilator therapy can be given through a nebuliser and oxygen can be given
Short course of prednisolone is recommended if affecting daily activities
If there is persistent exacerbations or breathlessness, then you can give this for COPD:
LAMA + LABA + inhaled corticosteroid in combination inhaler (such as trimbow)
What are the symptoms of croup?
Barking cough that sounds like a seal
Hoarse voice
Difficulty breathing
Feverish symptoms
Often worse at night
How to treat croup?
Single dose of dexamethasone
State the treatment of epiglottis (haemophilus influenzae)?
Cefotaxime or ceftriaxone
Chloramphenicol if history of immediate hypersensitivity reaction to penicllin or to cephalosporins
Epiglottitis is usually caused by an infection with Haemophilus influenzae type b(Hib) bacteria.
The epiglottis is a flap of tissue that sits beneath the tongue at the back of the throat.
Its main function is to close over the windpipe (trachea) while you’re eating to prevent food entering your airway.
Symptoms include:
a severe sore throat
difficulty and pain when swallowing
difficulty breathing, which may improve when leaning forwards
breathing that sounds abnormal and high-pitched (stridor)
a high temperature
irritability and restlessness
muffled or hoarse voice
drooling
What are the side effects of antimuscarinics?
Cough
dizziness
dry mouth
nausea
headache
constipation
arrythmias
vision blurred
urinary disorders
What is the caution warning for patients taking ipratropium bromide:
Acute angle-closure glaucoma has been reported with nebulised ipratropium
What are beta agonists contraindicated in:
Severe eclampsia
pulmonary hypertension
cardiac disease
Eclampsia is seizures that occur in pregnant people with preeclampsia.
Pulmonary hypertension is high blood pressure in the blood vessels that supply the lungs (pulmonary arteries).
cardiac disease: heart failure, arrhythmias, high BP, stroke, angina, atheresclorosis
State some cautions for beta agonists:
Diabetes (risk of hyperglycaemia and diabetic ketoacidosis)
hypertension
hyperthyroidism
hypokalaemia
State the side effects of beta agonists:
Headache
tremor
vomiting
palpitations
dizziness
hypokalaemia
What is the duration of action for salbutamol?
3 to 5 hours
How are corticosteroids effective in asthma?
They reduce airway inflammation and hence reduce edema and secretion of mucus into the airway
Regular use of inhaled corticosteroids reduces the risk of exacerbation of asthma
They must be used regularly for maximum benefit
State the 4 inhaled corticosteroids:
Fluticasone
mometasone
beclometasone
budesonide
Which 3 brands can be used as relievers, in addition to their regular use for prophylaxis of asthma:
Budesonide + formoterol (Symbicort, Duoresp spiromax)
Beclomethasone + formoterol (fostair)
State the treatment for acute asthma attack:
High course of prednisolone - corticosteroids
Why should oral corticosteroids best have taken as a single dose in morning:
Reduce the disturbance of circadian cortisol secretion
Which parenteral corticosteroid has a role in emergency treatment of acute severe asthma:
Hydrocortisone injection
What is the use of inhaled corticosteroids in COPD:
When given with LABA it can reduce exacerbations
What is the use of oral corticosteroids in COPD:
Prednisolone oral can be given during an attack
What is the MHRA warning for corticosteroids:
Central serous chorioretinopathy - fluid accumulating under the retina
Patients should be advised to report any blurred vision and visual disturbances
What are the common side effects for corticosteroids:
Headache
oral candidiasis
pneumonia with those with COPD
taster altered
glaucoma
adrenal suppression
sleep disorder
paradoxical bronchospasm
How can you advise a patient to reduce the risk of oral candidiasis:
To use a spacer device and/or rinsing mouth with water after inhalation
Which clenil strength can dentists prescribe?
Clenil 50 mcg
Which inhalers should be prescribed by brand name:
Clenil and Qvar
Qvar has extra fine particles and is more potent than traditional beclometasone and is twice more potent than Clenil
How do leukotrine receptor antagonists work:
Blocks the effect of cysteinyl leukotrines in airways
Leukotriene receptor agonists work by blocking leukotrienes, which are chemicals in the body that can cause inflammation and tightening of airway muscles.
When should patients take the montelukast:
In the evening
State some common side effects of montelukast:
Diarrhea
fever
depression
drowsiness
suicidal thoughts
tremor
hallucination
State one major side effect of montelukast:
Eosinophilic granulomatosis with polyangitis
“Eosinophilic granulomatosis with polyangiitis” is a rare autoimmune disease where the body’s immune system attacks its own tissues, causing inflammation and damage to blood vessels. It often leads to symptoms like asthma, sinus problems, and damage to various organs such as the lungs and kidneys.
Which drug is churg-strauss syndrome associated with:
Montelukast
Churg-Strauss syndrome is a rare autoimmune condition where the body’s immune system mistakenly attacks its own blood vessels, leading to inflammation and damage. It typically involves symptoms such as asthma, allergic rhinitis, and inflammation of blood vessels, which can affect various organs like the lungs, skin, nerves, and kidneys.
What should you advise patients on to report whilst taking montelukast:
Vasculitis rash
worsening pulmonary symptoms
cardiac issues
peripheral neuropathy
A vasculitis rash is a skin rash caused by inflammation of blood vessels. It appears as red or purple spots on the skin and can vary in size and shape.
State the advice you would give to a patient whose child has been recently prescribed montelukast granules:
Granules may be swallowed, or mixed with cold soft food (not liquid), and taken immediately
Patients taking this tablet for severe COPD + chronic bronchitis and is displaying low mood and suicidal thoughts, what do you do? Bonus point can you name the drug?
Refer to GP
Roflumilast
are aminophylline and theophylline narrow or broad?
Narrow therapeutic medicines
State the side effects of aminophylline:
Headache
nausea
palpitations
Which electrolyte deficiency can aminophylline cause:
Loss in k+ (hypokalaemia)
State the symptoms of aminophylline overdose/toxicity:
Vomiting, restlessness, agitation, dilated pupils, hyperglycaemia and sinus tachycardia
More serious side effects are haematosis, convulsions, hypokalaemia, arrythmias
State the monitoring requirements for theophylline:
Plasma-theophylline concentrations
10-20mg (55-110 micromol/litre) is required for satisfactory dilation
Adverse effects can occur within 10-20 mg but severe side effects can occur 20mg+
If aminophylline is given intravenously, when should blood sample be taken:
4-6 hours after starting treatment
If aminophylline is given orally,when should plasma- theophylline conc be measured?
after 5 days and at-least 3 davs after any dose adjustment
State the dose adiustment for theophylline:
May be necessary if smoking is started or stopped during treatment
What are the 3 conditions in which plasma-theophylline concentration is increased in:
Heart failure, viral infections and hepatic impairment
What are the 2 conditions in which plasma-theophylline concentration is decreased:
Smoking and alcohol consumption
What are the signs of theophylline toxicity/overdose?
Vomiting, agitation, restlessness, hyperglycaemia, hypertension, dilated pupils, tachycardia
More serious effects: convulsions, hypokalaemia, haematosis
Which antihistamines can be used in nausea and vomiting:
Cyclizine, promethazine, cinnarizine
Which older antihistamines may be more sedating than others:
Promethazine, alimemazine
Which antihistamines are non-sedating and why:
Cetirizine, loratadine, desloratadine, acrivistine, bilastine, mizolastine, levocetrizine, fexofenadine,
All of the above cause less sedation and psychomotor symptoms as they can cross the blood-brain barrier only to a slight extent
State the dose and ages for IM injection of adrenaline/epinephrine/ EpiPen:
Child 1 month - 5 years = 150 mcg
6 years - 11 years = 300 mcg
12-17 years = 500 mcg
Adult = 500 mcg
Must know above!
State the MHRA warning with hydroxyzine:
Hydroxyzine is contraindicated in patients with prolonged QT interval or those who have risk factors for prolonged QT interval
In kids the maximum dose is 2mg/kg
In adults the maximum dose is 100 mg
In elderly the maximum dose is 50 mg
The lowest effective dose for shortest period of time should be prescribed
What is the non-drug treatment for cystic fibrosis?
Regular exercise improves lung function and overall fitness
What is the drug treatment of choice for cystic fibrosis:
Dornase-alfa (kept in the fridge, special line product)
A patient complains of dark urine, pruritus and jaundice. Which drug is responsible?
Zafirlukast
Which one is a LABA used in COPD patients only:
Vilanterol
Which drug causes rebound nasal congestion when used for more than 7 days:
Xylometazoline
Which group of patients should avoid carbocisteine:
Patient with active gastrointestinal ulcers
Which antihistamine causes QT prolongation:
Hydroxyzine
What are the steps in treating uncontrolled asthma in children?
- SABA alone
- paediatric low dose ICS with a SABA
- paediatric low dose ICS with a SABA + LTRA
- paediatric low dose ICS with a SABA + LABA (the LTRA would be stopped)
- paediatric low dose ICS + LABA within a MART regimen
- paediatric moderate dose ICS plus a LABA (either as a fixed dose+ add SABA or MART)
- consider seeking advice from a healthcare professional woth expertise in asthma. They can prescribe steps 8 and 9
- paediatric high dose ICS plus a LABA as a fixed dose + SABA
- paediatric moderate dose ICS with a SABA OR paediatric low dose ICS plus a LABA within a MART regimen + a trial of an additional drug e.g theophylline
Which age group does the licensing of most inhalers start from?
from my own research dont take my word for it but seen in past paper
5 onwards
For children 12- 16 years, we can use either a paeditriac or adult dose for their inhalers. How do we decide which dose to use?
- severity of illness
- body size
On changing from a pMDI inhaler to a dry powder inhaler, what might a patient experience?
patients may notice a lack of sensation in the mouth and throat previously associated with each actuation
coughing may also occur
A patient has an inhaler without a dose counter. How can they keep track of how many doses they have left with their inhaler?
there is no accurate way to gauge the remaining number of therapeutic
other than by either recording every actuation used
or by calculating when the inhaler is likely to become ‘empty’ according to their standard usage.
Shaking, weighing or floating the inhaler device, or using it until it no longer actuates are NOT accurate and nNOT RECOMMENDED
MHRA/CHM advice: Pressurised metered dose inhalers
The MHRA have received reports of patients who have inhaled objects into the back of the throat—in some cases objects were aspirated, causing airway obstruction.
Patients should be reminded to remove the mouthpiece cover fully
shake the inhaler device
and check that both the outside and inside of the mouthpiece are clear and undamaged before inhaling a dose
and to store the inhaler with the mouthpiece cover on.
Why is a spacer device useful Who is it useful for?
Spacer devices remove the need for coordination between actuation of a pMDI and inhalation
Spacer devices are particularly useful for patients such as those with poor inhalation technique, elderly patients, those requiring high doses of inhaled corticosteroids, and for patients prone to candidiasis with inhaled corticosteroids
How should a spacer device be cleaned?
The spacer device should be cleaned once a month
by washing in mild detergent and allowed to air-dry
the mouthpiece should be wiped clean of detergent before use.
Some manufacturers recommend more frequent cleaning, but this should be avoided since any electrostatic charge may affect drug delivery.
How often should a spacer device be replaced?
every 6–12 months
What are the indications for the use of a nebuliser?
A nebuliser converts a solution of a drug into an aerosol for inhalation via a face mask or a mouthpiece. It delivers higher doses of drug to the airways than is usual with standard inhalers
Indications for use of a nebuliser include:
to deliver a beta2 agonist or ipratropium bromide to a patient with an acute exacerbation of asthma or of chronic obstructive pulmonary disease
to deliver a beta2 agonist, corticosteroid, or ipratropium bromide on a regular basis to a patient with severe asthma or reversible airways obstruction when the patient is unable to use other inhalational devices
to deliver an antibiotic (such as colistimethate sodium) or a mucolytic to a patient with cystic fibrosis
to deliver pentamidine isetionate for the prophylaxis of pneumocystis pneumonia.
Which inhalers are not licensed to be used by children?
Easyhaler® Beclometasone Dipropionate
Easyhaler Salbutamol 5+ only
Formoterol is 6+
Fostair NEXThaler should not be used in children aged 5-11 years, because of safety concerns.
Fostair NEXThaler 200/6 micrograms should not be used in children and adolescents below 18 years.
Tiotropium 6+
theophylline 2+
Clenil Modulite® 200 and 250
Neovent ® not licensed for use in children under 12 years
Terbutaline tablets are not licensed for use in children under 7 years
Ciclesonide is only for children 12-17
Salmetereol only children 5 +
Montelukast 6 months +
