MODULE 1


Anti-inflammatory agents • Corticosteroids-ICS


• Beclomethasone • Fluticisone • Mometasone • Prednisolone


• Compound preparations ICS/LABA


• Budesonide/Formoterol • Fluticasone/Formoterol • Fluticasone/Salmeterol • Fluticasone/Vilanterol • Beclomethasone/formoterol


Corticosteroids suppress and inhibit all elements of the inflammatory response; they stop mediators being released from inflammatory cells and suppress the activity of these mediators.


They are particularly effective in the


late asthmatic response and have been demonstrated to;


• Have an anti-inflammatory effect on the bronchial mucosa


• Reduce airways hyper- responsiveness


• Reduce bronchial oedema.


SE’s of the drug, especially following chronic use, are greatly reduced by use of the inhaled route.


These include growth suppression in children, adrenal suppression and effect on bone metabolism.


Leukotriene receptor antagonists (LTRA)


• Montelukast • Zafirlukast


These drugs act by blocking the effects of leukotriene (mediators) in the airways and thus have an anti- inflammatory effect. They are not for use in acute attacks.


Montelukast has not been shown to be more effective compared to corticosteroids but the two drugs appear to have an additive effect.


SE’s include GI disturbances, dry mouth, thirst and hypersensitivity reactions as well as CNS effects.


CSM has advised that patients prescribed LTRAs should be alert to the development of eosinophilia, vasculitic rash, worsening pulmonary symptoms, cardiac complication and peripheral neuropathy.


BTS/SIGN Guidance on Management of Asthma in Adults It is recommended to start at a step appropriate to initial severity of the condition.


Step 1. Infrequent short lived wheeze


Inhaled short-acting bronchodilator, as required.


Consider monitored initiation of treatment with low dose ICS


Move to step 2 (if uncontrolled*) Step 2. Regular Prevention


Inhaled short-acting bronchodilator, as required.


Start Inhaled Corticosteroid at low dose Move to step 3 (if uncontrolled*) Step 3. Initial add on therapy


Add inhaled LABA to low dose ICS (usually a combination inhaler) Move to step 4 (if uncontrolled*)


Step 4. Additional add-on therapies


If no response to LABA-stop LABA and consider increase dose ICS If benefit to LABA but control still inadequate -continue LABA and increase ICS to medium dose If benefit to LABA but control still inadequate -continue LABA and ICS and consider addition of LTRA, SR Theophyline or LAMA


Move to step 5 (if uncontrolled*) Step 5. High -dose therapies


Consider trials of: • increasing ICS to high dose • Addition of 4th Agent e.g. LTRA, SR Theophyline, Beta agonist tablet, LAMA


Refer Patient for specialist care


(*only consider step up once compliance has been assured and correct inhaler technique verified)


Stepping down should only occur where the patient has been stable for 3 months. Rescue oral steroids can be used at any step to manage severe asthma exacerbations.


SCOTTISH PHARMACIST - 23


Drug delivery and Inhaler Technique Not all inhalers are equal, there are two specific types:


1. Metered Dosage Inhalers (MDI’s) including Soft Mist Inhaler, and Breath activated versions including K-haler, Easi-Breathe and Autohalers.


2. Dry powder inhalers (DPI’s) which are essentially all breath activated devices (BA).


The inhalation techniques/ Inspiratory effort needed for each are very different:


• MDI-Slow, steady and deep (Aerosol made by device) Inspiratory effort needed is low (optimally 30l/min)


• DPI-Hard, fast and deep (patient generates the aerosol by using their breath to aggregate the drug particles to a small enough size to reach the lower parts of the lung). Inspiratory effort needed depends on the device (optimally 60- 90l/min.)


Inspiratory flow is checked using an In-Check Dial device.


A spacer device should be used with MDIs to co-ordinate actuation and promote better lung drug delivery whilst reducing the oral deposition of drug.


The breathe actuated MDI devices should be considered when inhalation technique demonstrated is slow and steady but the co-ordination of inspiration and depressing the canister is poor. These automatically release the aerosol when the inspiration reaches the optimum level.


TAKE THE 5


MINUTE TEST To receive your CPD logsheet and certificate;


Visit www.scottishpharmacist.co. uk/education


Register your details for the relevant module; Asthma, Module 1


Having studied the module and without referring to it again complete the 5 minute test. If you need to refer to the text to answer the questions then you may need to study the module again.


ASSESSMENT: Upon completion of the test your answers will be scored and if you are successful you will be issued with your CPD certificate.


*Downloadable PDF of this module is available online the Scottish Pharmacist Website for your records


Compliance with the inhaler and dosing regimen are critical aspects of achieving maximal therapeutic outcomes.


The patients’ ability to use any device is a key aspect of inhaler selection. Manual dexterity, understanding of how to use the device, along with knowledge of why they need to use are also of significant importance.


Nebulisers are no more efficient than an MDI device used with a spacer (10 separate puffs delivered over 5-10 minutes) but for some patients, those with only shallow breathing, there might be benefit.


Page 1  |  Page 2  |  Page 3  |  Page 4  |  Page 5  |  Page 6  |  Page 7  |  Page 8  |  Page 9  |  Page 10  |  Page 11  |  Page 12  |  Page 13  |  Page 14  |  Page 15  |  Page 16  |  Page 17  |  Page 18  |  Page 19  |  Page 20  |  Page 21  |  Page 22  |  Page 23  |  Page 24  |  Page 25  |  Page 26  |  Page 27  |  Page 28  |  Page 29  |  Page 30  |  Page 31  |  Page 32  |  Page 33  |  Page 34  |  Page 35  |  Page 36  |  Page 37  |  Page 38  |  Page 39  |  Page 40  |  Page 41  |  Page 42  |  Page 43  |  Page 44  |  Page 45  |  Page 46  |  Page 47  |  Page 48