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M201 > W5 Management of Asthma > Flashcards

W5 Management of Asthma Flashcards

1
Q

Making a diagnosis of Asthma:
What tests can you carry out to confirm? (6)

A
  • Spirometry
  • Peak Expiratory Flow
  • Asthma Control Questionnaire (ACQ)
  • Asthma Control Test
  • FeNO= Fractional exhaled Nitric oxide
  • Eosinophil differential count
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2
Q

What are some Atopic conditions? (3)

A

Hx of Hayfever
Eczema (atopic dermatitis)
Asthma

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3
Q

What is the key difference between Asthma and COPD? How can you test this?

A
  • COPD is progressive whereas asthma is reversible.
    Test for airway obstruction: Prescribe a bronchodilator
    (bronchodilator reversability test)
    If: Airways opening up=Asthma
    Not opening up= COPD

Asthma is an eosinophilic disease (inflammation)- so you should prescribe inhaled corticosteroids (ICS)
(asthmatic patients have high eosinophil count)
- also could do eosinophil differential count

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4
Q

BTS/SIGN treatment guideline in
adults- Asthma
What are the steps in treatment?

A
  1. Consider monitored initiation of treatment with low-dose ICS (inhaled corticosteroids-preventer) taken all the time (brown inhaler)
  2. SABA (blue inhaler-reliever) taken prn
  3. Add inhaled LABA to low-dose ICS in one inhaler (MART- maintenance and reliever therapy)
  4. Increase ICS to med dose or add another treatment- LTRA, if no response to LABA, consider stopping LABA
  5. Refer to specialist care

Between step 1 and 2 confirm inhaler technique and adherence/compliance

LTRA aka montelukast

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5
Q

NICE Guidelines for Asthma treatment and diagnosis:

A
  1. SABA alone
  2. Add low dose ICS
  3. Add LTRA (montelukast)
  4. Add LABA with or without LTRA (responding- keep LTRA)
  5. Add MART
  6. Med dose ICS
  7. High dose ICS/ LAMA or theophylline
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6
Q

BTS/SIGN treatment guidelines in children

A
  1. SABA
  2. Consider monitored initiation of treatment with very very low dose ICS OR LTRA if <5 years
  3. Low dose ICS +
    >5= inhaled LABA OR LTRA
    <5= LTRA
  4. Inc ICS to med OR >5 Add LTRA OR LABA
    -If no response to LABA, consider stopping it
  5. Refer to specialist care
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7
Q

NICE guidelines in children treatment for Asthma
What is the treatment pathway?

A

Start on SABA
1. VERY low dose ICS (or LTRA <5years)
2. Very low-dose ICS AND Inhaled LABA or LTRA (>5) OR LTRA (<5)
3. Increase ICS to low dose OR >5 Add LTRA or LABA
-If no response to LABA consider stopping it
4. Specialist advice

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8
Q

All-Wales Adult Asthma Management and Prescribing Guidelines:

A
  1. Regular low-dose ICS + SABA
  2. Change to ICS + LABA Fixed dose/ MART Regime
  3. Trial of Montelukast
    4 Inc to moderate dose ICS/LABA
  4. Consider referral
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9
Q

Uncontrolled Asthma
What does this have an impact on?
What 3 circumstances determine if a patient has uncontrolled asthma?

A

A person’s quality of life/

  • 3 or more days a week with symptoms OR
  • 3 or more days a week with required use of a SABA for symptomatic relief OR
  • 1 or more nights a week with awakening due to asthma
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10
Q

What is MART?
What is a MART inhaler?

A

Maintenance and Reliever Therapy

  • MART is a type of asthma treatment plan.
  • If a patient is on a MART plan, they have just one inhaler to use as a preventer and a reliever.
  • A MART inhaler is a combination inhaler that contains: An inhaled steroid and a long-acting bronchodilator with a fast onset of action (Formoterol)
  • Not all combination inhalers are licensed for MART
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11
Q

Maintenance and Reliever Therapy (MART)
(for info)

A
  • MART is used for both daily maintenance therapy and the relief of symptoms as required
  • Appropriate for patients on Step 2 (Low dose ICS) or 3 (Low dose ICS) or 4 (medium dose ICS) with:
  • A Personalised Asthma Action Plan (PAAP)
  • Able to self-manage and
  • Are compliant with their own treatment and
  • Whose symptoms are uncontrolled on maintenance-only treatment with ICS/LABA using SABA as a reliever
  • The total regular dose of ICS should not be decreased
  • Patients taking regular (once a day or more), rescue doses of their combination inhaler should have their treatment reviewed
  • The use of a separate reliever inhaler (SABA) is NOT required
  • Careful education of patients about the specific issues around this management strategy is required
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12
Q

What are some examples of MART?

A

Fostair MART= pMDI
Symbicort SMART= Turbohaler
DuoResp Spiromax MART= Spiromax

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13
Q

High risk drugs – Selective B2-Agonists
What is monitored?

A

Monitoring:
* Plasma-potassium concentration in severe
asthma
* Blood glucose in diabetes

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14
Q

High risk drugs – Selective B2-Agonists (SABA)
- what are they used for?
- duration of action?

A

Inhaled short acting B2 agonist:
* Used for immediate relief of asthma symptoms:
* Duration of action 3-5 hours
* Salbutamol
* Terbutaline

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15
Q

High-risk drugs – Selective B2-Agonists (LABA)
- what are they used for?
- duration of action?
- examples?

A

Long-acting B2 agonists (LABA)
* Always used in combination with an ICS for prophylactic treatment
* Duration of action 12 hours
* Salmeterol & Formoterol
* Used in COPD: olodaterol, indacaterol, vilanterol

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16
Q

What is the important safety information for Selective B2 agonists?

A

MHRA/CHM advice: Pressurised metered dose inhalers (pMDI):
risk of airway obstruction from aspiration of loose objects

CHM advice on LABAs:
* be added only if regular use of an ICS has failed to control asthma adequately
* Not be initiated in patients with rapidly deteriorating asthma
* be introduced at a low dose and be discontinued in the absence of benefit

17
Q

What are the cautions for SABAS and LABAS? (4)

A

Cautions:
* Arrhythmias (tachycardia)
* Cardiovascular disease (prolonged QT interval, hypotension)
* Risk of hyperglycaemia and ketoacidosis in diabetes
* Hypokalaemia- effect potentiated by theophylline,
corticosteroids, diuretics and by hypoxia

18
Q

What is prophylaxis?
What is a prophylactic drug?

A
  • Measures designed to preserve health and prevent the spread of disease
  • Drugs used to prevent a disease or condition
19
Q

High risk drugs – Inhaled corticosteroids (ICS)
-What is their function?
- How can they be monitored?

A

They reduce airway inflammation and reduce oedema and secretion of mucus into the airway
Current and previous smoking reduces the
effectiveness of ICS and higher doses may be necessary

Monitoring
* The weight and height of children receiving
prolonged treatment with ICS should be monitored annually; if growth is slowed refer to paediatrician

20
Q

High risk drugs – Inhaled corticosteroids (ICS)
What are some examples?

A

Inhaled corticosteroids:
* Beclometasone dipropionate
* Budesonide
* Fluticasone
* mometasone furoate

21
Q

High risk drugs – Inhaled corticosteroids (ICS)

What are the important safety information?

A

MHRA/CHM advice: Pressurised metered dose inhalers (pMDI):
risk of airway obstruction from aspiration of loose objects

MHRA/CHM advice: beclometasone inhalers (Qvar and Clenil) are not interchangeable and should be prescribed by brand.
Qvar is approximately twice as potent as clenil

MHRA/CHM advice: rare risk of central serous chorioretinopathy (CSC) with local as well as systemic administration

Cautions
* Systemic absorption may follow inhaled administration
* Candidiasis: risk can be reduced by using a spacer and rinsing the mouth with water after inhalation
* Paradoxical bronchospasm: Use a bronchodilator beforehand or ICS should be discontinued

22
Q

ICS Doses (for info)

A

ICS doses and their pharmacological strengths vary across different formulations.

In general, people with asthma should use the smallest doses of ICS that provide optimal control for
their asthma, in order to reduce the risk of side effects.

For ADULTS aged 17 and over:
* less than or equal to 400 micrograms budesonide or equivalent would be considered a low dose
* more than 400 micrograms to 800 micrograms budesonide or equivalent would be considered a moderate dose
* more than 800 micrograms budesonide or equivalent would be considered a high dose

For CHILDREN and young people aged 16 and under:
* less than or equal to 200 micrograms budesonide or equivalent would be considered a paediatric low dose
* more than 200 micrograms to 400 micrograms budesonide or equivalent would be considered a paediatric moderate dose
* more than 400 micrograms budesonide or equivalent would be considered a paediatric high dose

23
Q

High risk drugs – Theophylline
What type of drug is it?

A

Xanthine bronchodilator:
* Narrow therapeutic drug:
10-20 mg/L (55-110 micromol/L)
* Sample should be taken 4-6 hours after an oral dose

24
Q

High risk drugs – Theophylline
What are the overdose symptoms? (8)

A
  • Severe vomiting
  • Agitation
  • Restlessness
  • Dilated pupils
  • Sinus tachycardia
  • Hyperglycaemia
  • Convulsions
  • Severe hypokalaemia
25
Q

High risk drugs – Theophylline

What are the pharmacokinetics??
When is plasma conc dec/inc?

A

Pharmacokinetics
* Dose adjustment may be necessary if smoking started or stopped during treatment
* Plasma concentration is decreased in smokers, alcohol consumption and enzyme inducers.
* Plasma concentration is increased in heart failure, hepatic impairment, viral infection, elderly and enzyme inhibitors

26
Q

High risk drugs – Theophylline

What are the cautions?

A
  • Cardiac arrhythmias or other cardiac disease
  • Elderly
  • Epilepsy
  • Hypertension
  • Peptic ulcer
  • Risk of hypokalaemia - increased with B2-agonists
27
Q

Leukotriene Receptor Antagonists (LTRA)
What is the other name for them?
What is the MHRA advice?
Can it be used in pregnancy?

A
  • Montelukast
  • MHRA/CHM advice: (singular) reminder of the risk of neuropsychiatric reactions,
    including speech impairment and obsessive-compulsive symptoms
  • Eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome)- lookout
    for eosinophilia, vasculitic rash, worsening pulmonary symptoms, cardiac
    complications, or peripheral neuropathy
  • Avoid in pregnancy unless essential
28
Q
A

M201 (81 decks)

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