Pharma 6

Question 1

Short-acting β 2 -agonists
fast onset

Answer 1

salbutamol, terbutaline)

Question 2

salbutamol, terbutaline)

Use

Answer 2

• Used for symptom relief through reversal of bronchoconstriction
• Prevention of bronchoconstriction i.e. on exercise
• Short-acting β 2 -agonists should only be used on an as-required basis
• If used regularly, they reduce asthma control

Question 3

Fast onset long duration

Answer 3

inhaled formoterol

Question 4

slow onset, short duration

Answer 4

oral terbutaline oral salbutamol oral formoterol

Question 5

Slow onset long duration

Answer 5

inhaled salmeterol

oral bambuterol

Question 6

Regular preventer therapy in asthma

Answer 6

Inhaled corticosteroids

Question 7

Beclomethasone

Answer 7

Ics ,,absorb through the gut&lung

Question 8

Budesonide and fluticasone

Answer 8

Ics,, undergo extensive first-pass metabolism

Question 9

Step 3
 


Add-on therapy
for asthma

Answer 9

First choice – long-acting β 2 -agonists
 (formoterol, salmeterol)

Question 10

Combined inhalers containing both an ICS and long-acting β 2 -agonist

Answer 10

• Budesonide/formoterol (Symbicort)
• Fluticasone/formoterol (Seretide)
• Beclomethasone/formoterol (Fostair)

Question 11

Alternative step 3/step 4 add-ons

Answer 11

• High dose ICS
• Leukotriene receptor antagonists
• Theophylline

Question 12

Leukotriene Receptor Antagonists

Answer 12

Montelukast, Zafirlukast)

LRAs block the effect of cysteinyl leukotreines in the airways at the CysLT1 receptor

Question 13

Methylxanthines


(theophylline, aminophylline

Answer 13

1. Antagonise adenosine receptors
2. Inhibit phosphodiesterase – increase cAMP – unlikely to be relevant in vivo
3. As with LTRAs, often poorly efficacious
4. Narrow therapeutic window (10-20 mmol/L)
5. Frequent side-effects – nausea, headache
6. Potentially life-threatening toxic complications – arrhythmias, fits
7. Important drug interactions – levels increased by cytochrome p450) inhibitors eg erythromycin, ciprofloxacin

Question 14

Step 5

Answer 14

💥💥💥Use daily steroid tablet in the lowest dose providing adequate control
💥💥💥 maintain the highest dose of ICS
💥💥💥 Consider other treatments to minimize use of steroid tablets
• Oral steroids

• Step 5+, Anti-IgE

– Strict criteria for use, very expensive. Potentially reduces exacerbation rates in patients not controlled on oral steroids

Question 15

Treatment of acute severe asthma

Answer 15

1. Oxygen, high flow
2. Nebulised salbutamol – continuous if necessary, oxygen driven
3. Oral prednisolone ~40 mg daily for 10-14 days
   - can be stopped without tailing down
4. If not responding, add nebulised ipratropium bromide
5. Consider i.v. magnesium sulphate 1.2-2.0 g over 20 min
6. Consider IV aminophylline if no improvement and life threatening features not responding to above treatment (BEWARE if taking oral theophylline ).

Question 16

Anticholinergic

Answer 16

Iprotropium bromide ( ATROVENT )

A quaternary anticholinergic agent

Bronchodilation develops more slowly and less intense than adrenergic agonists. Response may last up to 6 hours.

Useful add-on in actute severe asthma not responding to high dose β 2 -agonists

Question 17

Step one 👩🏻‍⚕️

Answer 17

Short-acting β 2 agonists as required – consider moving up if using three doses a week or more

Question 18

Step 2 👩🏻‍⚕️

Answer 18

Low dose ICS

Question 19

Step 3 👩🏻‍⚕️

Answer 19

• LABA + ICS = usually the combination
• No response to LABA stop LABA and consider increased dose of ICS
• If benefit from LABA but control still inadequate – continue LABA and increase ICS to medium dose
• If benefit from LABA but control still inadequate – continue LABA and ICS and consider trial of other therapy – LTRA, SR theophylline, LAMA

Question 20

Step 4-

Answer 20

#Increasing ICS up to 💥high dose
#Addition of a fourth drug, eg LTRA, SR theophylline, beta agonist tablet, LAMA