Asthma Flashcards

Question

What are the key features of ICS? (5)

Answer 1

Prevention. All asthma px given ICS. E.g. Beclometasone dipropionate, Budesonide, fluticasone fumarate. ICS given in a combination inhaler = Beclometasone/budesonide only ICS with formoterol. Brand prescribing: Beclometasone monotherapy (ICS monotherapy first line in children under 12 yrs. May also be seen in adults.)

Answer 2

Oral thrush: Rinse mouth out and use of spacers (pMDI)

Answer 3

Leukotriene receptor antagonist: - Used later in asthma management if initial tx is ineffective (preventer) - E.g. Montelukast, roflumilast. Montelukast: - Given OD at night - 10mg in adults - 5mg children 6-14 yrs (chewable tablets) - 4mg children 6m-5 yrs (chewable tablets) - Main px counselling: Neropsychiatric reactions - Useful if FeNO = very high - Useful if allergen induced symptoms / exercise-induced.

Answer 4

E.g. Tiotropium - Given as one dose in the morning (5mcg) - Often given as a Respimat device - Main s/e = dry mouth.

Answer 5

Not in new guidelines but can be seen in old guidelines. High risk medication - narrow therapeutic index (10-20mg/L): - Metabolised by CYP450 enzymes prone to enzyme induction and enzyme inhibition interactions = fluctuating concentrations. - Concentration also affected by viral disease, HF, smoking. Plasma levels needed upon initiation (5 days after starting) Plasma levels needed after every dose change (3 days after)

Answer 6

Hyperglycaemia Tachycardia Hypokalaemia Dilated Pupils Restlessness Agitation

Answer 7

No: - Daytime symptoms - Night time awakening due to asthma - Need for rescue medication - Asthma attacks - Activity limitations including exercise Normal lung function Minimal s/e from medications.

Answer 8

Main management strategy Prevents asthma symptoms including regular dosing i.e. BD. Each preventative regimen must has a baseline ICS. When using new guidelines, ICS always given in a combination inhaler with a LABA. May also use PTRA or lAMA as adjunctive therapy depending on control.

Answer 9

Acute symptoms management: - Aims to relieve symptoms when present e.g. new onset SOB, coughing, wheezing. Used prn throughout the day. Under new guidelines, choice of reliever is formoterol and given with ICS.

Answer 10

Does px known the difference between preventer and reliever? Px may take preventer only when they feel symptomatic - not appropriate. Preventers are for regular use. Px may take reliever regularly even if not symptomatic - not appropriate. Reliever for prn use.

Answer 11

Initial management: Low dose ICS / formoterol combination inhaler: - Taken as needed for symptom relief (AIR = anti-inflammatory reliever) - DuoResp Spiomax 160/4.5mcg (budesonide/formoterol): 1 puff to be inhaled prn up to max 8 puffs per day (12+) - Symbicort Turbohaler 100/6mcg (Budesonide/formoterol); 1 puff to be inhaled prn up to a max 8 puffs per day (12+) Only recommended when px is newly diagnosied and mild symptoms. Only budesonide/formoterol containing inhalers are currently licensed for AIR therapy. Others are unlicensed. If px newly diagnosed with asthma is highly symptomatic, can move straight to low dose MART.

Answer 12

Nocturnal symptoms. Frequent daytime symptoms Recent acute attack Impacted QofL.

Answer 13

Applicable to px who are 12+ and previously on low dose ICS-formoterol prn and still poorly controlled. On diagnosis, highly symptomatic. New tx consists of low dose MART regimen. If control continues to be poor despite low dose MART regime = Increase to moderate dose MART regime.

Answer 14

DuoResp Spiromax 160/4.5mcg (Budesonide-formoterol): 1 puff in the morning and night for prevention and 1 puff prn for relief (max 8 puffs/24 hrs). Symbicort Turbohaler 100/6mcg (budesonide-formoterol): 1 puff in morning and at night for prevention AND 1 puff prn for relief (max 8 puffs in 24 hrs) Symbicort Turbohaler 200/6mcg (budesonide-formoterol): 1 puff in morning and at night for prevention AND 1 puff prn for relief (max 8 puffs in 24 hrs)

Answer 15

DuoResp Spiromax 160/4.5mcg (budesonide/formoterol): 2 puffs in morning and at night for prevention and 1 puff prn for relief (max 8 puffs in 24 hrs) Symbicort Turbohaler 200/6mcg (budesonide/formoterol): 2 puffs in morning and at night for prevention and 1 puff prn for relief (max 8 puffs in 24 hrs). Fostair 100/6mcg evohaler/NEXThaler (budesonide/formoterol): 1 puff in morning and at night for prevention and 1 puff prn for relief (max 8 puffs in 24 hrs) - Extra-fine particles -> more potent -> higher doses.

Answer 16

One inhaler used as both reliever (PRN use) and preventer (BD use) MART regimes contain LABA and ICS but LABA must be rapid acting so it can act as a reliever (formoterol).

Answer 17

12+ (budesonide inhalers) - DuoResp 160/4.5, Symbicort 100 or 200/6. 18+ (Beclometasone inhalers) - Fostair 100/6 Failed initial tx or highly symptomatic px. Must have the right dose for right step of asthma pathway. *High dose of Beclometasone and budesonide aren’t used for MART.*

Answer 18

Keeps inflammation in airways to min. Every PRN dose also comes with a dose of ICS. Gives ongoing symptom relief e.g. breathlessness or chest tightness. Acts quickly to manage symptoms and reduce risk of developing an asthma attack and reduces risk of hospital admission. As px uses more extra reliever doses, the requirements will reduce with time due to extra antiinflammatory effects of ICS and provides longer term control of asthma.

Answer 19

If px in moderate dose MART and remains poorly controlled: - Check FeNO +/or blood eosinophils. If raised = specialist. - If FeNO +/or eosinophils aren’t raised = add on therapies. Add in Montelukast 10mg once at night (LRTA) or add in LAMA e.g. tiotropium. If despite adding LTRA or LAMA px remain poorly controlled, add in other. A px count be taking concurrently: - Moderate dose MART - LTRA - LAMA

Answer 20

Asthma attack in the last 2 years. Using reliever inhalers 3x/week or more. Symptomatic 3x/week or more. Waking 1 night/week Asthma affecting daily activities.

Answer 21

Shift to using ICS-formoterol combination inhalers from point of diagnosis for both relief and prevention in adults and children > 12 yrs. New diagnosis for asthma in adults and children > 12 yrs, no longer given ICS monotherapy for prevention and SABA for relief. - ICS (prevention) and SABA (relief) key to managing children.

Answer 22

Px may still be using inhaler regimens in accordance to previous set of guidelines. As long as the px is well controlled, it’s not necessary to transfer them to the new guidelines. Only consider moving them to the new guidelines if px is poorly controlled. Old guidelines: - ICS monotherapy given BD for prevention and salbutamol given prn for relief: Clenic Modulite (Beclometasone) + salbutamol, Pulmicort (Budesonide) + salbutamol. - LABA/ICS combination therapy given BD for prevention and salbutamol given prn for relief: Fostair 100/6 or 200/6 + salbutamol, Seretide 250/25 + salbutamol, DuoResp 160/4.5 or 320/9 + salbutamol.

Answer 23

Offer BD paediatric low dose ICS given BD as preventative tx: e.g. Clenil modulite (Beclometasone dipropionate) 500mcg/puff 1-2 puffs BD. Offer prn SABA as relief: e.g. salbutamol 100mcg/puff: 2 puffs prn. If poor control consider: - Using a paediatric low dose MART regime (off label) OR - Montelukast trialled for 8-12 weeks with SABA followed by addition of low dose LABA/ICS with SABA if poor control.

Answer 24

Overuse of SABA: - Deterioration = higher mortality. - Well controlled px = 3 Rx/year - If px use excessive salbutamol = step up tx. Salbutamol pMDI: no dose counter - Empty = no drug - Residual propellant in device - High mortality of using when no medication present. - Advice in usage and monitoring of usage essential.

Answer 25

Adherence Frequency of reliever doses Inhaler technique Symptoms (daytime/nighttime/activities) Asthma control questionnaire Triggers/ smoking status Acute asthma frequency Does px have a PAAP Consider FeNO Is px aware they can increase reliever dose when symptoms acutely deteriorate?

Answer 26

Well controlled px who are eligible for deprescribing. If decreasing therapy, do so in order that takes into consideration effectiveness of tx at time of introduction. Consider px preference. Don’t reduce anymore frequently than every 8-12 weeks. Only decrease if satisfied the px has complete control and stable long-term.

Answer 27

PMDI (standard/easi-breathe): - Salbutamol evohaler/breath-actuated - Fostair evohaler (formoterol/beclometasone), seretide evohaler (salmeterol/fluticasone) - Standard pMDI suitable for use with spacer devices. Soft mist (Respimat): - Spiriva Respimat (Tiotropium) Dry Powder Inhalers: - Turbohaler - Symbicort (Formoterol/budesonide), Pulmicort (budesonide) - Breath actuated - DuoResp (formoterol/budesonide) - NEXThaler - Fostair (formoterol/beclomethasone) - Accuhaler - seretide (salmeterol/fluticasone) - Ellipta - Incruse (umeclidinium) - Breezehaler (Sebring (glycopyrrinium) - Genuair (Eklira (aclidinium) Rightbreathe

Answer 28

Poor inhaler technique associated with poor control. Must review technique annually. Manage px expectations. Determine specific px problems with using inhalers: perceived lack of benefit, dexterity issues, are, difficulty handling, improper inhalation technique etc. Needed px centred approach.

Answer 29

Common brands, active ingredients, types of inhaler regimens. Inhaler choice based on technique, lowest environmental impact, px inspiratory effort and px preference. If px on multiple inhalers, maintain same device type. For children, preferred to have them on pMDI can be used with spacers also can use Easi/breathe forms.

Answer 30

Aero chamber plus Volumetric with/without paediatric mask. Works with pMDI inhalers only Useful for those: - With difficulty using pDMI due to technique problems. - Who experience oral thrush regularly with ICS . Replaced every 6-12 months. Cleaned once per month (Warm soapy water must be left to air dry.)

Answer 31

All px given a personalised asthma action plan: - Written instructions on how to improve control during short term deterioration. Aims to prevent deterioration of acute asthma. - Based on PEFR, Symptom control. - Clearly outlines px specific triggers - Annually reviewed

Answer 32

Diagnosis difficult in objective testing. 8-12 weeks trial of low-dose ICS BD with prn SABA. Can increase to moderate paediatric ICS dose if remains poorly controlled. Can add it paediatric dose of Montelukast if symptoms remain poorly controlled, trailled for 8-12 weeks.