WEEK
15
MPharm Programme
Respiratory Therapeutics
PHAM01 Clinical Seminars
1
PHAM01
Respiratory Therapeutics Seminar
WEEK
15
Learning Outcomes
• Assess and evaluate signs and symptoms of illness
• Interpret information and select an appropriate
course of action
• Perform calculations
• Propose solutions and plans:
– Refer
– Non-pharmacological management
– Pharmacological management
– Advice/counselling
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Respiratory Therapeutics Seminar
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COPD case study 1
15
• You are provided with the following prescription:
• Why would you be
concerned?
• What would you like to
clarify?
H Ferriman
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Today
PHAM01
• What course of action
could/should be taken?
Respiratory Therapeutics Seminar
WEEK
15
COPD case study 1 – Why are you co
• Theophylline is a narrow therapeutic index drug
• Care must be taken with drugs which have a ‘na
therapeutic index’.
• This is where there is a small range differen
serum concentration between therapeutic e
toxicity.
• These drugs are therefore sensitive to intera
changes in the patient’s condition.
• These medications are often subject to mon
requirements.
• You should be vigilant for and able to couns
the signs of toxicity or loss of therapeutic ef
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COPD case study 1 – Why are you concerned?
Grey arrow = median toxic dose (TD50), dose at which toxicity occurs in 50% of
population.
Solid arrow = median effective dose (ED50) = dose which is effective in 50% of
population.
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COPD case study 1 – Why are you concerned?
15
• The effects of erythromycin on theophylline are established
and well documented.
• Erythromycin is an enzyme inhibitor and potentially
decreases clearance of theophylline leading to
theophylline toxicity
• This interaction has led to cases of severe adverse
effects, including death.
• The effects can take several days to appear.
• Serious effects of toxicity are not always preceded by
milder symptoms.
• The effects are variable, it will not occur in all patients.
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COPD Case Study 1 – What to clarify?
• Can an alternative antibiotic be used?
– What are we treating?
– What has been tried before for this episode?
– Allergies, intolerances, other medications.
• Has the patient been stabilised on theophylline (i.e.
on for a long time)?
• What was the most recent serum level and what is
the target for this patient?
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COPD Case Study 1 – What course of action to take
• Change to an alternative antibiotic
• If this is not suitable:– Vigilance for signs of toxicity.
– Monitoring of serum theophylline levels.
• What are the signs/symptoms of toxicity?
• What would be your advice on monitoring?
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COPD case study 1
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• Patients exhibiting toxicity may present with nausea, vomiting,
tachycardia, arrhythmias, convulsions.
– As stated, severe adverse effects may not be preceded by
milder symptoms
• Therefore…
• Monitor theophylline concentrations
• Sample should be taken 4-6 hours after the last
modified release oral dose (not always practical).
• Elevation in serum levels can occur between 2-7 days
after initiation of the erythromycin
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COPD case study 1 – Additional considerations
•
How would the knowledge that the patient has recently stopped smoking
influence your consideration of this prescription?
• Plasma concentrations of theophylline are decreased in smokers – as
tobacco smoke induces liver enzymes – a gradual increase in serum
theophylline levels may therefore be seen in patients who stop
smoking.
•
How would the knowledge that the patient also has heart failure influence
your consideration of this prescription?
• Serum levels of theophylline are increased in patients with heart
failure and therefore the risk of toxicity increases.
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Respiratory Therapeutics Seminar
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COPD case study 2: Aminophylline
• A 51 year old male weighing 75kg is admitted to
hospital with an acute severe exacerbation of COPD.
• He is not responding to initial interventions with
bronchodilators and steroids.
• A respiratory physician asks for an aminophylline
infusion to be started.
• The ward staff ask your advice on what to do.
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COPD case study 2: Aminophylline
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• Do you require any additional information?
• Instruct the staff on how to prepare the infusion (e.g. suitable
diluent)
• Provide a suitable dose.
• Provide the infusion rate in ml/hr.
• Advise on monitoring parameters.
• What are your thoughts on the use of IV aminophylline in COPD?
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COPD case study 2: Aminophylline
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• Additional information
– DHx, already taking theophylline/aminophylline?
– Weight – use IBW in obese patients.
– Cautions, contraindications, patient disease state
• Dose
– Loading dose, if not established on oral.
• Loading dose
– slow intravenous injection, 250–500 mg
– Maximum dose 5 mg/kg
– Maintenance, adjusted according to plasma levels.
• 500–700 micrograms/kg/hour, adjusted according to plasmatheophylline concentration.
• Reduced in the elderly
• Diluent
– Glucose 5% or Sodium Chloride 0.9%
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COPD case study 2: Aminophylline
• Loading dose = 75*5 = 375mg
– Add dose to 100mL of a compatible infusion fluid
– Administer using a rate controlled infusion pump over 20
minutes
– Rapid administration can cause palpitations, tachycardia,
hypotension. Ideally the patient should be cardiac monitored
during the loading dose for these reasons.
• Maintenance dose
– 75 x 500 = 37500mcg/hr or 37.5mg/hr
– Infusion made to 500mg in 500ml (keep it simple)
• 1mg/ml
– Volume to be given each hour = 37.5ml/hr
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COPD case study 2: Aminophylline
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•
Monitoring parameters ~(often consult a local policy)
– Normal therapeutic range = 10 to 20 mg/L
– Try to get a baseline level in those already on oral.
– Measure levels 4-6 hours after the start of the intravenous infusion and
checked on a daily basis thereafter.
– Also monitor serum potassium levels, response to therapy, and cardiac
monitoring (BP, HR, consider ECG/telemetry).
• Use of IV aminophylline in COPD?
– Evidence of benefit in COPD is weak
– Complex pharmacokinetics significantly effected by patient disease states
(liver, HF, weight), multiple drug interactions.
– Severe adverse events occur at serum concentration levels close to those of
therapeutic effect
– Should only be started on advice of senior clinician e.g. registrar or consultant.
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COPD case study 3
15
• You are presented with a prescription for:• Prednisolone 5mg tablets
• Take SIX tablets daily
• 30 tablets
• The patient’s PMR shows that they have had 6 short
courses of prednisolone in the previous 3 months. What
must you now consider?
• What would you like to clarify?
• What action could/should be taken?
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COPD case study 3
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• What is the indication of the prescription?
• Is this the patients first course or have they had a number of
courses?
• What other medication are they prescribed, have they been
taking these as advised?
• If they smoke, offer brief intervention (recommendation to
stop, where to go for advice, discuss NRT).
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COPD case study 3
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• You should note the potential risk of adrenal suppression. There are no clear
guidelines for these cases and a clinical decision should be taken on a caseby-case basis.
• Symptoms of this include:- severe tiredness, joint pain, vomiting and dizziness.
• Adrenal suppression requires immediate medical intervention.
•
BNF guidelines:
•
Gradual withdrawal of systemic corticosteroids should be considered in those
whose disease is unlikely to relapse and have:
–
–
–
–
–
–
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Received more than 40mg prednisolone daily for more than 1 week
Been given repeated doses in the evening
Received more than 3 weeks treatment
Recently received repeated courses (particularly if taken for more than 3 weeks)
Taken a short course within 1 year of stopping long term therapy
Other possible causes of adrenal suppression
PHAM01
Respiratory Therapeutics Seminar
WEEK
COPD case study 3
15
• What are the other potential long term
consequences of such frequent courses of
steroids?
• What else might we consider or want to
discuss with the patient?
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Respiratory Therapeutics Seminar
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COPD Case Study 3
• Prolonged use can exaggerate some of the normal
physiological actions of corticosteroids.
• Mineralocorticoid side effects
– Hypertension, sodium retention, water retention,
potassium loss, calcium loss.
• Glucocorticoid side effects
– Diabetes, osteoporosis, muscle wasting, peptic
ulceration and perforation (weak link), psychiatric
reactions.
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COPD Case study 3
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• Lifestyle advice
• Smoking
• Exercise
• Vaccinations
• Inhaler technique
• Understanding of the above
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Respiratory Therapeutics Seminar
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COPD case study 4
• You are a pharmacist working on the
admissions unit of a general hospital.
• You are on the consultant ward round
and about to see the next patient, Mrs
PB, 77 years old.
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PHAM01
Respiratory Therapeutics Seminar
WEEK
COPD case study 4
15
•
PC: SOB, +++ cough with sputum, oCP,oN+V, “feeling rough”.
•
PMH: COPD, OA (mainly in hands & shoulders), depression
•
SH:
•
•
•
•
Smokes 10-15 cigarettes per week, No EtOH, Husband died 2 years ago, 2 daughters live locally
•
Carers 1xdaily for housework (can’t manage housework mainly because hands get too painful)
•
H = 155cm, W = 50kg
Allergies: NKDA
DHx:
–
–
–
–
Incruse Ellipta© 1 inhalation, once daily
Relvar 92/22 Ellipta© 1 inhalation once daily
Salbutamol 100mcg pMDI 1-2 puffs qds prn
Paracetamol soluble tablets 1g qds
OBS
– T 37.1C, BP 125/85 mmHg, RR 25.
•
O/E
– Mild pitting oedema to ankles
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Respiratory Therapeutics Seminar
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COPD case study 4
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• We will use medical abbreviations throughout this case–
what do those used so far mean?
• Comment on the values where appropriate – are they
significant?
• List the possible likely diagnoses based on this initial
presentation, what have you based these assumptions on?
• What other information/tests/investigations do you need to
help make your diagnosis?
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COPD case study 4
Abbreviations
• PC = presenting complaint
• SOB = shortness of breath
• PMH = past medical history
• HTN = hypertension
• COPD = chronic obstructive pulmonary disease
• OA = osteoarthritis
• SH = social history
• EtOH = alcohol intake
• NKDA = no known drug allergies
• pMDI = pressurised metered dose inhaler
• O/E = observations& examinations
• BP = blood pressure
• RR = respiratory rate.
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COPD case study 4
• Values from examination/observation of patient:
– Temperature is normal (36.5°C and 37.5°C))
– Blood pressure below target for control of
hypertension – no cause for concern
– Respiratory rate (or breaths per minute) moderately
raised (normal ~12-20 bpm).
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COPD case study 4
• Differential diagnosis:
– Likely COPD exacerbation (PMHx COPD)
– Minimal evidence to suggest it is an infective
exacerbation – temperature normal, sputum
normal
– HF - Not in the PMH – although SOB and oedema
need to be investigated
– PE - less likely (WELLs’ criteria for PE)
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COPD case study 4
• Investigations required to confirm diagnosis/illness
severity:
– FBC (red cells, white cells, platelets)
– Inflammatory markers – CRP
– U&Es
– CXR (illustrate lung pathologies)
– ECG (may need echocardiogram or BNP test if HF
suspected)
– O2sats – Peripheral oxygen saturation levels
– ABG - Arterial blood gas sample
– Sputum C&S
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COPD case study 4
• Results of above indicate NIexCOPD
• F1 Rx’s usual medication.
• Tx started
– Salbutamol 5mg neb qds
– Ipratropium 500 mcg neb qds
– Prednisolone 30mg mane
• Screen the therapy for suitability
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Respiratory Therapeutics Seminar
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COPD case study 4
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• Treatment
– There are no clinically significant drug interactions with
these new medications.
• Giving SAMA with the LAMA will increase the risk of
antimuscarinic side effects.
• Suggest suspend the LAMA whilst on nebules.
– A course length for prednisolone should be stated 5 days
*course length is new to 2019 guidelines.
– No indication for antibiotics (non-infective exacerbation).
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Respiratory Therapeutics Seminar
WEEK
COPD quick questions
15
• A patient with a previous history of GI bleed is prescribed
carbocisteine because they have significant sputum
production. What are the risks of this prescribing?
• What is the starting dose of carbocisteine, when would
you review the treatment?
• A patient is prescribed a Seretide™ 500 inhaler – what
should they be provided with and why?
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COPD quick questions
• Mucolytics should be used with caution in those with a history
of peptic ulceration as they may disrupt the gastric mucosal
barrier.
• Initially 2.25g daily in divided doses, then 1.5g daily in divided
doses as the condition improves. Stop if there is no benefit
after a trial of 4 weeks.
• This patient is receiving 500mcg fluticasone twice daily (TDD
1mg) which is equivalent to 2mg beclomethasone daily – risk
of adrenal suppression – patient should be aware of this and
carry a steroid card.
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COPD quick questions
• A patient undergoes spirometry to aid diagnosis. The
results are as follows: Male, Caucasian, 75, 175cm
FVC:
FEV1
Predicted = 3.91
Measured = 2.75 = 70 % (Low)
Predicted = 2.93
Measured = 1.70 = 58 % (Low)
FEV1 /FVC Predicted = 0.75
Measured = 0.61
**This image is an example of a flow
volume loop and does not correlate with
the results on the right
How do these results inform your diagnosis?
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Respiratory Therapeutics Seminar
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COPD quick questions
• A spirometry result in a patient with an obstructive
disease (i.e asthma or COPD) typically shows a
significantly reduced FEV1 with a normal or reduced FVC.
– Therefore the FEV1/FVC will be reduced
– In this case to 0.61. Less than 0.7 is diagnostic.
– Spirometry is also used as one factor in assessing severity of
obstruction, taking the FEV1 as a % of predicted.
– In this example 58%, based on NICE, mild obstruction.
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Asthma case study 1
• An adult patient is visibly breathless, you ask them
how you can help they reply “I think………
I’m…….having….asthma.” and then are unable to
continue.
• You can see they are breathing rapidly and feel a
racing pulse
• How should this patient be managed?
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Asthma case study 1
• High-dose inhaled short-acting beta2 agonist
(salbutamol or terbutaline sulfate) given as soon as
possible.
• Salbutamol pMDI 2–10 puffs via a large volume
spacer (note each puff is to be inhaled separately).
• Nebulise if available.
• WHILST arranging immediate transfer to hospital.
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Asthma case study 1
• The BNF describes four levels of acute asthma attack
– Moderate acute asthma
– Severe acute asthma
– Life-threatening acute asthma
– Near-fatal acute asthma
• The parameters to differentiate are clearly listed in the BNF
– For this patient RR>25, HR>110BPM, unable to complete
sentences.
– What treatment is required?
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Asthma case study 1
• Oxygen - Maintain SpO2 level between 94–98%
• Bronchodilators
• Continue to give salbutamol, use a nebuliser, driven
by oxygen in life-threatening cases, consider
continuous nebulisers if poor response.
• IV is an option in some circumstances.
• Nebulised ipratropium may also be added to this.
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Asthma case study 1
• Steroids - In all cases of acute asthma, patients should be
prescribed an adequate dose of oral prednisolone once
daily for at least 5 days or until recovery.
• IV hydrocortisone or
intramuscular methylprednisolone are alternatives
in patients who are unable to take
oral prednisolone.
• Prednisolone oral 40-50mg or IV hydrocortisone
100mg every 6 hours until conversion to oral
prednisolone is possible
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Respiratory Therapeutics Seminar
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Asthma case study 1
• Magnesium sulfate (IV infusion over 20mins) –
• Weak evidence it has a bronchodilator effect.
• Single dose given to patients with acute severe asthma (PEF
<50% best or predicted) who have not had a good initial
response to inhaled bronchodilator therapy.
• IV aminophylline - Again, poor evidence
•
Not likely to result in any additional bronchodilation compared with
standard care
• Used only on advice of senior medical staff.
• In patients with life threatening asthma not responding to other
therapy.
• Those who will benefit are rare.
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Asthma case study 2
• Alexis is a 4 year-old girl, she has been diagnosed by
her GP with asthma.
• Her mother presents you with a prescription for the
following items:• Salbutamol 200mcg Accuhaler 1 or 2 puffs prn
• Beclometasone 200mcg pMDI 2 puffs bd
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Respiratory Therapeutics Seminar
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Asthma – case study 2
• Is this prescription appropriate?
• Consider:• Is the medication appropriate?
• Is the dose appropriate?
• Is the formulation appropriate?
• What counselling would you need to provide to
Alexis’s mother?
• What side-effects in relations to steroids in children
require monitoring?
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Asthma case study 2
• NICE: Offer a SABA as reliever therapy to children
under 5.
• This should be used for symptom relief alongside
all maintenance therapy.
• SIGN: Prescribe an inhaled short-acting β2 agonist as
short-term reliever therapy for all patients with
symptomatic asthma.
• Both NICE and BTS agree with the above.
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Asthma case study 2
• SIGN: consider regular ICS preventer therapy for children under
the age of 5 years when:
– Using inhaled β2 agonists three times a week or more
– Symptomatic three times a week or more
– Waking one night a week
• NICE: Consider an 8 week trial of a paediatric moderate dose of
an ICS in children under 5 with:
– There are symptoms at presentation that clearly indicate the
need for maintenance therapy (for example, asthma-related
symptoms 3 times a week or more, or causing waking at night) or
– Suspected asthma that is uncontrolled with a SABA alone.
– At the end of the 8 weeks, stop treatment and assess response
and subsequent progress.
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Asthma case study 2
• Both corticosteroids and bronchodilator therapy should
routinely delivered by Pressurised Metered Dose Inhaler
(pMDI) and spacer system, with a face mask where necessary.
• NICE [TA10] date: 23 August 2000
• If not clinically effective consider nebulised therapy
• Children aged 3 to 5 years, a dry powder inhaler (DPI) may also
be suitable but only if reason pMDI unsuitable.
• Choose any suitable device but consider cost.
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Asthma case study 2
• Counselling
– How to use the inhalers
– How to use a spacer / face mask
– How to keep the devices clean
– Clear indications for each of the inhalers
– How to recognise signs of an asthma attack
– What to do if Alexis has an asthma attack
– Signpost to asthma.org.uk
• Side-effects
– Growth restrictions
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Asthma – case study 2
15
• Is this prescription appropriate? NO
• Consider:• Is the medication appropriate? Yes
• Is the dose appropriate? Perhaps
• Is the formulation appropriate? Probably not, and the brand
must be specified for ICS
• Salbutamol pMDI 100mcg 1 or 2 puffs prn
• Clenil Modulite 100 micrograms/dose inhaler 2 puffs twice
daily
• To be given via a spacer device and face mask
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Asthma case study 3
• Miss R.B, 25 years old, was admitted to hospital with
an acute exacerbation of asthma.
• She has had asthma since the age of 8 years.
• In the last few months she had noticed her asthma
getting progressively worse and she has had 2
attendances to the hospital with attacks in the last 8
months.
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Asthma case study 3
• Current Medication
– Salbutamol pMDI 100mcg/dose, 2 puffs PRN
– Ipratropium bromide 20mcg/dose, 2 puffs QDS
– Clenil Modulite 200mcg/dose 2 puffs BD
– Prednisolone 5mg OM started last discharge from an
admissions ward.
• Following the last discharge she has attended for your
pharmacist respiratory specialist review. What will you
discuss / what interventions might you consider?
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Asthma case study 3
• Explore reasons for loss of control
•
•
•
•
Discuss and identify any lifestyle changes.
Triggers, what could they be and are they avoidable?
Inhaler technique
Adherence/compliance
• Draw up an asthma management plan
• Include how to identify an exacerbation and what to do, e.g. temporary
increase in ICS use.
• Suggest use of a Peak flow diary
• Consider using a validated questionnaire at reviews (for
example, the Asthma Control Questionnaire or Asthma Control
Test).
• Plan follow-up appointments - specialist nurse/pharmacist.
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Asthma case study 3
• Optimise pharmacological therapies:• Compare current regime against up to date
evidence/guidelines (both national and local), discuss
previous therapies tried before making changes.
• Potential interventions:• Stop ipratropium
• Consider a LTRA (Leukotriene receptor antagonist)
• Consider adding a LABA i.e. switch to a LABA/ICS
combination inhaler
• Review the oral prednisolone and establish a plan for
withdrawal.
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Asthma case study 3
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Asthma case study 3
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Exam Style MCQ’s
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You have been asked to advise on the most appropriate antibiotic for a 70-year- old patient with an
exacerbation of COPD. The patient has a penicillin allergy and a past medical history which
includes cardiovascular disease. Their current medication is:

Aspirin 75mg tablets; ONE to be taken daily

Bisoprolol 2.5mg tablets; ONE to be taken daily

Lisinopril 5mg tablets; ONE to be taken daily

Simvastatin 40mg tablets; ONE to be taken at night
Which of the following would be the MOST appropriate antibiotic choice for this patient?
A
Amoxicillin 500mg three times a day for 5 days
B
Doxycycline 200mg on first day and then 100mg daily to complete a 5-day course
C
Co-amoxiclav 500mg/125mg three times a day for 5 days
D
Clarithromycin 500mg twice daily for 5 days
E
Levofloxacin 500mg once daily for 5 days
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A 24-year-old man with a diagnosis of asthma attends your asthma review clinic.
He is currently prescribed:

Salbutamol 100microgram/puff metered dose inhaler, 1 – 2 puffs when needed

Clenil Modulite® 100microgram/puff metered dose inhaler, 2 puffs twice daily
He describes a worsening of asthma symptoms despite good adherence to his inhaler
regimen.
As per NICE guidance, what action WOULD you take to improve his symptom control?
A. Add in montelukast
B. Add in salmeterol
C. Add in theophylline
D. Increase the inhaled corticosteroid to a moderate maintenance dose
E. Increase the inhaled corticosteroid to a high maintenance dose
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Post-seminar Case Study
•
Following the seminar please ensure that you look at the
post-seminar case study and on-call queries.
•
You have been provided with the additional resources
need to complete this on Canvas.
•
Feedback will be provided once you have had sufficient
time to work though it.
• If you have any further questions after this please just let
us know.
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National Guidance
• Asthma
• British Guideline on the Management of Asthma. BTS/SIGN. July
2019.
• Asthma: diagnosis, monitoring and chronic asthma management.
NICE guideline [NG80]. November 2017. Last updated: 22 March
2021
• COPD
• Chronic obstructive pulmonary disease in over 16s: diagnosis and
management. NICE guideline [NG115] December 2018. Last
updated: 26 July 2019.
• COPD DIAGNOSIS, MANAGEMENT, AND PREVENTION . GOLD.
Yearly reports. 2020.
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Respiratory Therapeutics Seminar