Answers List:
A. Oral Montelukast
B. Inhaled Tiotropium
C. Oral Prednisolone
D. Inhaled Becolomethasone Dipropionate
E. Oral Amoxycillin
F. Oral Theophylline
G. Inhaled Salmeterol
H. Oral Cetirizine
Question Stems:
From the list below please select the most appropriate treatment option for each of the following patients:
1. A 20 year old non-smoking asthmatic presents with persistent cough and wheeze, especially at night, despite taking frequent puffs of salbutamol alone.
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D – This young chap is taking only a short acting beta-agonist, and is having persistent symptoms. He is being treated at step 1 of the BTS asthma algorithm, yet is uncontrolled, so step up to step 3 therapy is indicated. The addition of inhaled corticosteroid is the first line therapy for uncontrolled asthma currently treated as step 1.
2. A 60 year old smoker with COPD who is getting frequent exacerbations and increasingly breathless on exertion, despite taking a combination inhaler containing a corticosteroid and long acting beta-2 agonist.
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B – Uncontrolled COPD. Combination inhalers are indicated for patients with symptomatic COPD and an FEV1 of less than 50 % of that predicted. Patients uncontrolled on this therapy can be stepped up initially to long acting anti-cholinergic therapy, tiotropium. In the 2010 NICE guideline on COPD an alternative pathway suggests starting initial COPD therapy with tiotropium, adding in combination inhalers if control is poor. Either approach is acceptable. Next step therapies are currently mucolytics, theophyllines, and roflumilast. All patients should undergo pulmonary rehab, and receive advice on smoking cessation.
3. A 40 year old asthmatic who is admitted acutely to hospital with SaO2 of 80% on air, and a peak flow of 50% predicted, despite taking numerous puffs of his salbutamol inhaler.
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C – this patient is having a severe asthma attack. First line therapy is inhaled beta agonist, either multidose inhaler, or nebulised. All patients who are having a severe asthma attack should have oral steroid administered as soon as possible, unless they are unable to swallow, in which case they should have intravenous hydrocortisone. Although the major effects of steroids take a few hours to take effect, by altering gene transcription, and subsequently up and down regulation of anti- and pro-inflammatory proteins, there are direct effects of steroids on the NF-kappa-B pathway that provide more immediate anti-inflammatory activity.
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