1. Obstructive airway disease

Question 1

What is asthma

Answer 1

Inflammation of the airways, due to hyperresponsiveness

Question 2

Asthma symptoms

Answer 2

• Cough - due to extra mucus
• Dyspnoea
• Wheezing
• Chest tightness

Question 3

Asthmatic triggers

Answer 3

• Infection
• Hay fever
• Dust
• Pets
• Smoking
• Chemicals
• Air pollution
• Drugs: NSAIDs, Beta-blockers

Question 4

Referral criteria that may relate to asthma

Answer 4

A cough that wakes you up at night

Question 5

Asthma guidelines (ADULTS)

Answer 5

Step 1: Reliever inhaler - SABA inhaler

Step 2: SABA + Low-dose ICS

Patients will go to step 3 if:
- they use their reliever inhaler 3x a week or more
- have asthma symptoms at least 3x a week
-asthma that waked them up at least 1x a week
-have had an asthma attack in the last 2 years that required oral steroids

Step 3: Low-dose ICS + LABA (as a fixed dose twice a day or as MART regimen composed of a steroid and a LABA)

Consider stopping LABA if there is no response and increase dose of steroid inhaler
or add leukotriene receptor antagonist

If still not controlled, refer to specialist as they may be prescribed theophylline

Question 6

Asthma drugs treatment

Answer 6

Low-dose ICS:
- Beclometasone,
- Budesonide
- Fluticasone
- Mometasone
- Ciclesonide

SABA
-salbutamol, terbutaline

LTRA
-montelukast, zafirlukast

LABA
formoterol, salmeterol

Oral steroid

Question 7

Asthma guidelines (CHILDREN)

Answer 7

Regular preventer
Step 1: Very-low dose ICS OR LTRA (for children under 5 years)

Initial add on therapy:
Step 2: Very-low ICS or LTRA and LABA or LTRA
(LTRA for children under 5 years)
If in step 1 patient had LTRA, then in step 2 they would be offered a LABA

Additional controller therapies
Step 3: Increase to low-dose ICS and LABA/LTRA

Step 4 would be seeking specialist advice

Question 8

Examples of Short-acting beta2 agonists and duration of action

Answer 8

Salbutamol
Terbutaline

Question 9

Uses of short-acting beta2 agonists

Answer 9

Commonly used as reliever inhaler in asthma and COPD

Question 10

Counselling point associated with short-acting beta2 agonists

Answer 10

Important to tell the patient that if the inhaler is not providing at least 3 hours of relief, must seek a doctor. It may mean they require a step up in treatment

Taking more doses of the inhaler may lead to CVS effects

Question 11

Short-acting beta2 agonists side effects

Answer 11

• HypOkalaemia (can lead to hyperglycaemia), (theophylline, corticosteroids also cause HypOkalaemia)
• Hand tremors (due to activation of the sympathetic system as salbutamol is a sympathomimetic)
• CVS effects

Question 12

Examples of Long-acting beta2 agonists and duration of action

Answer 12

Formoterol - BD
Salmeterol - BD
Vilanterol

Effects last for 12 hours

Question 13

LABA’s can be used alone. True or false

Answer 13

A LABA must be taken with a corticosteroid. It cannot be used alone. This is why combination inhalers are prefered. However the doses are fixed.

Question 14

Typical long-acting beta2 agonists dose

Answer 14

Twice daily (+ Reliever doses if MART)

If a previously effective dose is no longer managing symptoms, patient must visit the GP

Question 15

Inhaled corticosteroids mechanism of action

Answer 15

Directly reduce inflammation on the bronchi and take 7-14 days to work

Question 16

Inhaled corticosteroids uses

Answer 16

Asthma, COPD

Question 17

Inhaled corticosteroids typical dose

Answer 17

Twice Daily (Once-daily if Ciclesonide)

Question 18

Prescribing of beclometasone CFC free inhalers

Answer 18

Must be prescribed by brand as QVAR is more potent than Clenil-modulite. QVAR has extra fine particles that better target the lungs.

This rule also applies to combination inhalers that contain beclometasone e.g fostair more potent than other combination inhalers

Question 19

Prescribing of easyhaler

Answer 19

Not licensed in patients under 18 years

Question 20

Inhaled corticosteroids side effects

Answer 20

• Oral thrush - due to corticosteroids hitting the back of the throat when inhaling

Patients can use a spacer device or rinsing mouth/brushing teeth after using the inhaler.
It’s fine if patients use oral miconazole gel to manage this.

• Hoarse voice and sore throat
• Bronchospasm due to paradoxical effects. if this occurs, STOP treatment
  If it is mild: use SABA before use or dry powder inhaler

Question 21

Leukotriene receptor antagonist mechanism of action

Answer 21

Block leukotriene receptors in the lung —-> bronchodilation + anti-inflammatory

Question 22

Leukotriene receptor antagonist uses

Answer 22

Used in asthma, can only be used in hay fever

Question 23

Leukotriene receptor antagonist - Montelukast dose

Answer 23

Taken at night

Montelukast is the only leukotriene receptor antagonist available in the UK

Question 24

Leukotriene receptor antagonist - Montelukast side effects

Answer 24

-Neuropsychiatric reaction
presenting as speech impairment.
Patients must seek medical help if speech, behaviour changes, obsessive-compulsive disorders

-Churg-Strauss syndrome
Inflammation of blood vessels, restricting blood flow to organs/tissues
Usually occurs when steroid dose is stopped or withdrawn

Question 25

Theophylline mechanism of action

Answer 25

Causes bronchodilator

Question 26

Theophylline uses and dose

Answer 26

Severe asthma, COPD Theophylline must be taken every 12 hours orally

Question 27

Theophylline therapeutic index

Answer 27

10-20mg/L Plasma concentration is taken every 4-6 hours Once stabilised, no need for continuous level monitoring

Question 28

Factors which impact theophylline levels

Answer 28

Smoking can increase clearance of theophylline and reduce theophylline levels Heart failure, viral infection, elderly, liver impairment can increase theophylline levels

Question 29

Prescribing theophylline

Answer 29

Must be prescribed by brands, as brands are not bio equivalent

Question 30

Signs of theophylline toxicity

Answer 30

C - convulsons, CNS dilated pupils H - HypOkalaemia, HypERglycaemia A - arrhythmias T - tachycardia V - vomiting (severe haematemesis)

Question 31

Theophylline interactions

Answer 31

Theophylline is metabolised by cytochrome P450 enyzmes Enzyme inhibitor Drugs which increase theophylline levels: cimetidine, clarithromycin, erythromycin Enzyme inducer drugs which increase theophylline levels: carbamazepine, phenytoin, rifampicin, st John's wort Interacts with beta blockers. Beta blockers cause bronchospasm which antagonises the bronchodilating effect of theophylline Theophylline interacts with ciprofloxacin, to increase the risk of seizures. Seizures are also a side effect of both drugs Interacts with drugs which also cause hypOkalaemia: loop and thiazide diuretics, cortiosteroids, beta 2agonists e.g salbutamol Interacts with drugs that prolong the QT interval: antipsychotic drugs, anti-arrhythmic drugs (amiodarone, sotalol), clarithromycin, erythromycin, citalopram, escitalopram, clomipramine, hydroxyzine, lithium, methadone, quinolones, 5-HT3 antagonists e.g ondansetron As drugs which prolong the QT interval and drugs which cause hypokalaemia, when combined, increase the risk of torsades de pointes

Question 32

Types of inhaler devices

Answer 32

1. Pressurised metres-dose inhaler Requires breathing in slow and steady whilst actuating Important for patients to remove cover, shake inhaler before use and check mouthpiece to check for loose objects. Then replace cover 2. Dry-powder inhaler Requires you to breathe in fast and deep No coordination needed between breathing and actuation However can cause coughing 3. Breath-actuated inhaler Requires to breath in slow and steady Automatically releases a dose when breathing in, so overcomes co-ordination problem

Question 33

Benefits of a spacer

Answer 33

Spaces reduce the speed of the inhaler and prevent it from hitting the back of the throat (ideal for preventing oral thrush)

Question 34

How to use a spacer

Answer 34

Inhale ASAP after dose actuation Must be replaced every 6-12 months Can be cleaned once a month with warm water and mild-detergent then Air-dry. Specific to certain devices

Question 35

What is 'peak expiratory flow'

Answer 35

How quickly you can blow air out of your lungs, following a deep breath

Question 36

PEF (peak expiratory flow) targets

Answer 36

Good asthma control PEF > 80% If PEF<80%, patients must quadruple ICS dose, to prevent an asthma attack and reduce the risk of needing oral steroids PEF < 60%, patient must start oral steroids PEF<50%, URGENT MEDICAL ADVICE

Question 37

Medical emergency acute asthma

Answer 37

Mild-moderate cases - Salbutamol pMDI AND spacer Take 2-10 puffs every 10-20 minutes or PRN - Oral prednisolone Adult and child 12+: 40-50mg OD for at least 5 days Children 11 and under: up to 3 days Severe, life-threatening, below 2 years or unresponsive: -Hospital

Question 38

A serious side effect of tiotropium

Answer 38

Glaucoma Patient's must report blurred vision, red eyes, rings around lights Acute angle closure-glaucoma has been reported with nebulised ipratropium