role of pharmacist in hospital

Question 1

What does a Respiratory Hospital Pharmacist do?

Answer 1

Some roles include:
Medicine Optimisation; Inhaler technique evaluation
Ward referrals for complex patients
High risk medicine monitoring service
Outpatient Clinics
Patient telephone support clinic
Respiratory drug evaluations for new medications to be added to the hospital
formulary
Clinical audits

Question 2

Drug-drug Interactions in Asthma/COPD

Answer 2

Patients already on theophylline – careful with aminophylline. infusions
• Drugs that lower potassium
• Theophylline interactions e.g. Lithium, macrolides, smoking

Question 3

Drug-disease Interactions in Asthma/COPD

Answer 3

Diseases that may be affected by drugs used in
asthma/COPD
Diabetes
Cardiovascular disease (watch potassium)
Hypertension
Prostatic hyperplasia
Glaucoma
Liver disease – reduce theophylline clearance

Question 4

what are the symptoms of severe acute asthma?

Answer 4

Tachypnea
Tachycardia
Silent chest
Cyanosis
Altered consciousness Accessory muscle use
Decreased O2 saturation 
breathlessness

Question 5

Treatment of Severe Acute Asthma Symptoms

Answer 5

Oxygen - SpO2
 of 94-98%
• β2 agonist bronchodilators eg.
Salbutamol
high doses act quickly to relieve bronchospasm
with few side effects – salbutamol 2.5mg – 5mg
can be given “back to back”
can also use repeated doses of inhaler via
spacer
nebulised route (oxygen-driven)
repeat at 15-30 minute intervals
can be given IV

• Steroids
Prednisolone 40-50mg for at least 5 days
Reduce mortality, relapses, subsequent hospital admission and
requirement for β2agonist therapy
Earlier they are given, better the outcome
Steroid tablets are as effective as injected steroids, provided they
can be swallowed and retained

Ipratropium Bromide
• greater bronchodilation than a β2agonist alone, leading to a faster recovery
and shorter duration of admission
• 500 micrograms every 4-6 hours (usually QDS)

• Magnesium sulphate
• Bronchodilator when given IV or nebulised (only IV currently recommended)
• 1.2-2g IV infusion over 20 minutes

• Aminophylline
Some patients with near-fatal asthma or life threatening asthma with a poor
response to initial therapy may gain additional benefit from IV aminophylline
Check plasma levels if taking oral theophylline (10 – 20mg/ litre)

• Antibiotics/ Leukotriene Receptor Antagonists eg. Montelukast/
Not indicated in acute asthma

Question 6

what is a nebuliser?

Answer 6

 Converts a solution of a drug into a fine
spray
 Oxygen, compressed air or ultrasonic
power is used to break up the liquid
drug
 Delivered through a face mask

Question 7

what to monitor with severe acute asthma?

Answer 7

PEFR
Oxygen saturation (Arterial blood gases if SpO2
<92%)
Heart rate
Potassium
Blood glucose
Serum theophylline

Question 8

what is MART therapy?

Answer 8

Step 3 and above
• LABA and ICS in a combination
product
• Maintenance TWICE daily dose
• Same inhaler can be used as reliever
• Review treatment plan if use as a
reliever regularly

Question 9

what are side effects of ICS - eg. Beclometasone

Answer 9

Oral candidiasis

• Dysphonia

Question 10

side effects of Long acting beta-2 agonists

eg. Formoterol

Answer 10

• Cardiovascular
stimulation
• Anxiety
• Tremor

Question 11

what are the side effects of Leukotriene receptor antagonists
eg. Montelukast

Answer 11

Abdominal pain
• Thirst
• Sleep disturbances
• Headache

Question 12

what are the advice for ICS?

Answer 12

Patients on prolonged high-dose ICS
are at risk of systemic side effects
(≥1000 micrograms beclomethasone
or equivalent)
Issue steroid treatment card
Advise healthcare team if fall ill
Visit GP if experience symptoms such
as worsening fatigue, muscle
weakness, loss of appetite, dizziness
etc.
Reduce dose gradually

Question 13

treatment for COPD

Answer 13

• SABA or SAMA
• asthmatic - LABA + ICS
• non asthmatic - LAMA ANd LABA
• LAMA + LABA +ICS

Question 14

what are the advantages of combined inhaler in COPD?

Answer 14

Once or twice daily administration
depending on product
Less expensive than combined cost
Convenience of one inhaler
Cannot always use spacer

Question 15

example of • Phosphodiesterase type-4 inhibitor

and use

Answer 15

Anti-inflammatory; Adjunct to bronchodilators for maintenance treatment
Treatment with roflumilast should only be started by a specialist in respiratory
medicine
Doesn’t reduce decline in lung function
Dose: 500 micrograms OD
Side effects – mainly GI. Causes weight loss - patients should monitor body
weight
Not overly expensive for a new drug (£37.71/ pack) but still restricted by NICE
because of lack of significant evidence and doesn’t reduce mortality

Question 16

what are treatment options for COPD?

Answer 16

Oral Mucolytics
 Chronic cough
 High sputum production
 Carbocisteine
 Breaks up phlegm

Oral Corticosteroids
 Exacerbations
 Rescue packs
 Try to avoid long term

Oral Theophylline
 Narrow therapeutic index
 Many interactions

Antibiotics
 Treatment
 Prophylactic
 Rescue packs

Nebulisers
 Severe disease

Home oxygen
 Severe disease with optimal
therapy
 Risk Assessment

Question 17

what are symptoms of COPD

Answer 17

Marked dyspnoea and tachypnoea
Pursed-lip breathing
Use of accessory muscles at rest
Acute confusion
New-onset cyanosis or peripheral oedema
Marked reduction in activities of daily living

Question 18

what are the possible options for managing COPD exacerbation?

Answer 18

 Inhaled therapy
 Increased doses of short-acting bronchodilators (nebs)

 Oral therapy
 Systemic corticosteroids eg. Prednisolone 30mg OD for 7 – 14 days
Antibiotics
Empirical
Exacerbations of COPD associated with more purulent sputum

Intravenous therapy
Theophylline and other methylxanthines

Ventilation/Oxygen therapy

Question 19

what are the side effects of LABA + SABA?

Answer 19

temor 
headache 
palpation 
cough 
muscle cramps
tachycardia

Question 20

side effects of LAMA and SAMA

Answer 20

dry mouth 
headache 
cough 
UTI 
constipation

Question 21

what is the side effect of ICS

Answer 21

candidiasis of mouth and throat 
pneumonia 
bronchitis
blurred vison 
anxiety 
sleep disorder

Question 22

can you you optimize treatment?

Answer 22

Optimize treatment:
 Address non-adherence and review inhaler technique
 Consider stepping-up or stepping down treatment
 Flag excessive use of reliever medication
 Provide a spacer if necessary and ensure it is compatible with device(s)

 Review self-management education and written action plan:
 Review understanding of how to recognize an exacerbation and what to
do
 If the patient is asthmatic and has a PAAP, ensure he or she
understands it and is happy to action it when necessary
 May need bone protection with long term steroids and rescue packs of
steroids for exacerbations

Question 23

what kind of counselling points can be given to a COPD patient?

Answer 23

• Explain when and how to use inhalers, demonstrate correct technique for using them
• Preventer vs reliever; importance of using preventer inhaler regularly even when well
• Know when inhaler needs to be changed and how to replace it
• Using a spacer and mouth-rinsing will avoid the most common side effects of ICS
• Provide steroid cards as appropriate and counsel patients on side-effects
• Cleaning their spacer correctly, once a month, non-ionic detergent, air dry, replace
once visible deposits on spacer wall
• Aware of any asthma triggers (e.g. dust mites, pet hair), how to avoid/ cope with
them
• Discuss personal asthma action plan (PAAP) and how to respond at first sign of an
exacerbation
• Lifestyle advice, vaccinations