Respiratory System Flashcards
What side effects are associated with older antihistamines?
More sedation
More anti-muscarinic side effects
What are some older (sedating) anthistamines?
- Promethazine
- Chlorphenamine
- Cyclizine
- Hydroxyzine
- Alimemazine
Which antihistamines are MOST sedating?
Promethazine + alimemazine
What are some newer antihistamines (less sedating)?
- Cetirizine
- Loratidine
- Fexofenadine
- Acrivastine
- Desloratidine
- Mizolastine
Why do the newer antihistamines have less sedation + psychomotor impairment?
Less penetration of the BBB
Which antihistamines are used to treat N+V?
Cyclizine, promethazine, cinnarizine
Which antihistamines are used to treat insomnia?
Promethazine, diphenhydramine
In what conditions are antihistamines cautioned?
- Benign prostatic hyperplasia (BPH) - risk of urinary retention
- Glaucoma - raised intraocular pressure
- Liver impairment - sedation can precipitate hepatic coma
What are the risks associated with hydroxyzine?
Risk of QT prolongation and torsades de pointes
- contra-indicated in patients with risk of QT prolongation
- Short term use only
- Max dose 100mg/day
- Avoid in the elderly, max dose 50mg/day
How should anaphylaxis be treated in the community (medical emergency)?
- Secure the airway and maintain the BP
(lay flat and raise legs or recovery position if vomiting) - Administer adrenaline by IM injection
- Repeat adrenaline every 5 mins if necessary
Doses of adrenaline for anaphylaxis?
Adult - 500mcg
Child 6-12 - 300mcg
Child <6 - 150mcg
Risk for patients on beta blockers with anaphylaxis?
Patients on B-blockers may not respond to adrenaline
Consider treatment with a bronchodilator eg, IV salbutamol
How is adrenaline administered?
IM inj
Middle of the thigh
Can be given through clothes inc. jeans
When are mucolytics (eg, carbocisteine) contra-indicated?
In peptic ulcers
Mucolytics disrupt gastric mucosa
What do MHRA advise should NOT be given OTC to children under 6 with cough?
Antihistamines - chlorphenamine, promethazine, diphenhydramine, doxylamine, triprolidine, brompheniramine
Cough suppressants - pholcodeine, dextromethorphan
Expectorants - guaifenesin, ipecacuanha
Decongestants - psuedoephedrine, ephedrine, oxymetazoline, xylometazoline
What advice should be given to patients about care of spacers?
- Clean once a month with mild detergent and allow to air dry
- Frequent cleaning should be avoided as electrostatic charge can affect drug delivery
Which patients should be advised to use a spacer?
- All under 15s with inhalers
- Patients with high dose ICS
- Children under 5 should have a spacer with face mask
What is a sign of poorly controlled asthma that needs urgent assessment?
Use of >1 SABA inhaler per month
Outline the stepwise treatment of asthma in adults?
All patients should have a SABA, step up if using >3 times/week
1. Regular preventer - low dose ICS
2. Initial add-on - LABA (with ICS)
3. Additional add-on
If no benefit from LABA - stop + increase ICS
Benefit + poor control - continue LABA + med ICS
Benefit + poor control - continue LABA + ICS + fourth drug
4. High dose therapy - high dose ICS or addition of fourth drug (LTRA, theophylline, oral B2 agonist)
5. Regular oral steroid
How long are the short acting beta agonists duration of action?
3-5 hours
salbutamol / terbutaline
How long are the long acting beta agonists duration of action?
12 hours, used BD
salmeterol, formoterol, vilanterol
‘LABAs should not be initiated in rapidly deteriorating asthma’
True or false?
True
Which is NOT a side effect of beta agonists?
- Hypokalaemia
- Hypotension
- Hand tremors
- Bradycardia
- Arrythmias
Bradycardia - they may cause tachycardia
Which inhaled corticosteroid is not taken BD?
Ciclesonide - OD
Which ICS inhalers are NOT interchangeable as potency differs between brands?
Beclometasone
QVAR is twice as potent as Clenil - half dose should be used
What is in a Fostair inhaler?
Beclometasone + formoterol
Extra fine particles - more potent
What ages is QVAR licensed in?
12+
What ages is beclometasone easyhaler licensed in?
18+
What are the side effects of ICS?
- Hoarse voice/sore throat
- Oral candidiasis
‘Smoking can effect inhaled corticosteroids’
True or false?
True - reduces the effectiveness so higher doses may be needed
‘ICS are associated with the risk of paradoxical bronchospasm’
True or false?
True - can be offset by giving SABA before a dose
Low dose of clenil is 100mcg 2 puffs BD, what is the equivalent dose of QVAR?
Beclometasone
50mcg 2 puffs BD
What drugs are in Flutiform inhalers and what do they look like?
Fluticasone + formoterol
MDI - orange
What drugs are in Fostair inhalers and what do they look like?
Beclometasone + formoterol
Pink
MDI or nexthaler = DPI
What drugs are in a Symbicort inhaler and what do they look like?
Budesonide + formoterol
Turbohaler (cyclinders) - DPI
What drugs are in a Duoresp inhaler and what do they look like?
Budesonide + formoterol
Green or Blue DPI
What drugs are in a Seretide inhaler and what do they look like?
Fluticasone + salmeterol
Evohaler - purple MDI
Accuhaler - purple, round DPI
What drugs are in a Relvar inhaler and what do they look like?
Fluticasone + vilanterol
Yellow ‘egg shape’ DPI
Which is ciclesonide not used first line?
More expensive but fewer oropharangeal side effects
Outline the treatment of asthma in children
All patients should have SABA
1. Regular preventer- Very low ICS (paed dose) or if UNDER 5 - LTRA
2. Initial add-on therapy - very low dose ICS + LTRA (under 5) OR LABA (over 5)
3. Additional add-on therapy
No response to LABA - stop + incr ICS to low dose
Benefit + poor control - continue LABA + ICS to low dose
Benefit + poor control - LTRA + ICS + LABA
4. High dose therapy - ICS to medium dose or add theophylline
5. Oral steroid tablets
Which is the only LAMA licensed in asthma?
Spiriva respimat
What are the leukotriene receptor antagonists and how do they work?
Montelukast + Zafirlukast
Reduce bronchoconstriction and inflammation
When should montelukast be taken?
In the evening
3-4 hours to peak plasma conc, worse symptoms at night
Which asthma oral drugs are associated with Churg-Strauss syndrome?
LTRA - montelukast + zafirlukast
Associated esp after withdrawal of oral steroids
What are the signs of Churg-Strauss syndrome?
Eosinophilia, vasculitic rash, worsening pulmonary symptoms, cardiac complications, peripheral neuropathy
What is a major side effect/caution of Zafirlukast?
Risk of liver toxicity
Patients should report signs of liver toxicity such as N+V, jaundice, abdo pain, itching
What are the xanthines?
Theophylline + aminophylline
What is the target plasma concentration of theophylline?
10-20 mg/L
When should theophylline levels be taken?
Sample taken 4-6 hours post dose
Take levels 5 days after initiation or 3 days after dose changes
What may increase the concentrations of theophylline/aminophylline?
Liver impairment - metabolised by liver Heart failure Viral infections Elderly Enzyme inhibitors
What may decrease the concentrations of theophylline/aminophylline?
Smoking
Alcohol
Enzyme inducers
‘Theophylline and aminophylline should always be prescribed by brand’
True or false?
True
What are the signs of theophylline toxicity?
FAST + SICK
- Nausea, vomiting, GI disturbance
- Tachycardia, CNS stimulation (agitation, restlessness, mydriasis)
- Arrythmias, convulsions
- HYPOkalaemia
- Hyperglycaemia, heamatemesis
Can theophylline be used in pregnancy?
Yes- xanthines can be used in pregnancy/breastfeeding but may cause neonatal irritability
Can aminophylline be given IM?
No - too irritant
Do patients who take oral theophylline need a loading dose with IV aminophylline?
No
How should weight-based doses for aminophylline be calculated?
Using IBW if appropriate
Which medicines interact with theophylline + aminophylline?
- Risk of hypokalaemia - loop/thiazide diuretics, B2 antagonists, corticosteroids
- Risk of convulsions - quinolones
- Enzyme inhibitors (conc incr) - macrolides, CCBs, phenytoin, fluconazole
- Enzyme inducers (conc dec) - Rifampicin, St johns wort
How should an acute asthma attack be treated in the community?
- Give a salbutamol inhaler via large vol. spacer, 2-10 puffs every 10-20 mins PRN
- Give O2 driven SABA nebs every 20-30mins if possible
- If symptoms persist over 15-30 mins call 999
Are steroids always needed post-asthma attack?
Yes - prednisolone or IV hydrocortisone
Children - 3 days
Adults - min 5 days (40-50 mg)
What is the NICE (in the BNF) stepwise treatment for COPD?
- SABA (at all stages) or SAMA
- If FEV >50% - LABA or LAMA
If FEV <50% - LAMA or LABA + ICS - Triple - LABA + LAMA + ICS
What drug is a short-acting muscarinic antagonist?
Ipratropium
How regularly are SAMAs usually used?
3-4 times per day
Name some long-acting antimuscarinics?
- Tiotropium
- Glycopyrronium
- Aclidinium
- Umeclidinium
How long do SAMAs take to work?
Onset 30-60 mins
Duration of action 3-6 hours
In which conditions should inhaled antimuscarinics be used with caution?
Benign prostatic hyperplasia - risk of urinary retention
Glaucoma - increased intraocular pressure
What are the side effects of inhaled antimuscarinics?
- Dry mouth
- Paradoxical bronchospasm
When can LABAs be used ALONE?
For treatment of COPD
In asthma only licensed with ICS
Which LABAs can be used in COPD?
- Formoterol
- Salmeterol
- Vilanterol
- Olodaterol
What drug is in a Seebri inhaler?
Glycopyrronium 55mcg
Orange + white DPI
What drug is in an incruse ellipta inhaler?
Umeclinidium 55mcg
Grey egg w. green lid
What drug is in an Anoro ellipta inhaler?
Umeclinidium with vilanterol
Grey egg w. pink lid
What drug is in an Ultibro breezhaler inhaler?
Glycopyrronium with indacterol
Yellow + white DPI
