Medicine Issues/ Tips:

  • Inhaled corticosteroids should be used regularly to achieve maximum benefit.
  • Corticosteroids have an anti-inflammatory effect. A patient who uses an inhaled corticosteroid for three to four weeks and experiences an improvement in symptoms is likely to have a reversible asthma, rather than COPD, although some have mixed aetiology. Benefits are usually felt within three to four days.

Side-effects:

  • Corticosteroids can cause adrenal suppression and glaucoma.
  • If the patient experiences hoarseness or candidiasis, advise them to rinse the mouth with water after use or to use a spacer (action)
  • If a patient reports coughing immediately after using theICS, recommend they use their bronchodilator inhaler immediately beforehand.
  • If patients taking corticosteroids develop paradoxical bronchospasm they should immediately stop taking the drug and contact their doctor.

Lifestyle Tips:

  • Ensure the patient knows what an asthma attack or COPD exacerbation is likely to feel like, and the appropriate course of action – AsthmaAction/ Care Plan should be in place for each patient.
  • Asthma: Check peak flow once a week and record in the diary – to alert worsening symptoms.
  • Children on long-term inhaled corticosteroids should have their height monitored.
  • Encourage asthma sufferers to eat more fruit and vegetables as these help build up the immune system.
  • COPD: Encourage the patient to lose or increase weight (depending on the situation).
  • Encourage patient to be more physically active as this can improve exercise tolerance - Weight bearing exercise – e.g. walking 20mins every day would be optimum (30mins three times a week) - maintains bone density – steroids have negative effect on bone. Gentle swimming encourages deeper breathing.
  • Stress can cause an attack: advise the patient to try relaxation techniques such as yoga, and meditation.
  • Asthma can be triggered by certain allergens. Encourage the patient to try and identify any that affect them (for example, animal dander, pollen, fungal spores, food, royal jelly) and avoid them if possible. Vacuum house and curtains regularly. Once daily antihistamines should be considered where appropriate.
  • Reduce alcohol intake to safe limits – i.e. 1-2 units per day (3-4 units per - negative effect on bone – affected by steroids). Encourage a 48 hour period without alcohol in the system.
  • If a smoker – encourage or offer a plan to quit (cause and trigger to bronchospasm and negative effect on bone).
  • Adequate water - helps to thin mucous, and reduces fatigue.

Consider other meds:

  • Patients on methylxanthines should be advised to not smoke at all – causes variations in plasma-theophylline concentrations. Methylxanthines have an anti-inflammatory and dilatory effect. They may be used if inhalers not suitable but requiring long-term treatment, or added to inhaled therapy where still symptomatic. Taken 12 hourly.
  • ICS may be used in combination with a long-acting beta2 agonist for patients with moderate to severe COPD. Check whether patient is on the SMART programme – variable dose according to response with Symbicort. A short course of oral steroids should be given if the increased breathlessness of an exacerbation interferes with daily activities.
  • Asthma/COPD - Inhaled short-acting beta2 agonists (salbutamol, terbutaline) – SABA - reduce breathlessness, and asthma symptoms respond rapidly to such treatment - taken when required. If needed more than once a day, check ICS compliance or refer to asthma nurse. Oral beta2 agonists may be used at night where nocturnal asthma is an issue.
  • Inhaled long-acting beta2 agonists (salmeterol, formeterol) - LABA - are taken twice a day. Not for relieving acute exacerbations.
  • Inhaled short-acting anticholinergics (ipratropium) are taken three or four times a day reduce breathlessness, bronchoconstriction and mucus secretion. Tiotropium is taken ONCE daily.
  • Cromoglicate and nedocromil may be used for patients who have allergy-associated asthma. Their mechanism of action is unclear. Does not work for everyone.
  • Leukotriene receptor antagonists are used in patients who suffer from allergy/ exercise-induced asthma, or may be added to inhaled corticosteroids where an additive effect is required. Does not work for everyone.
  • Mucolytics (carbocisteine, erdosteine, mecysteine) are taken in divided doses throughout the day in chronic cough COPD

Further reading & Signposting: NICEBNF Chapter 3; RPS practice guidance; BLF

INHALED CORTICOSTEROIDS

KEY REVIEW QUESTIONS TO ASSIST WITH MUR

WHY ARE YOU TAKING THEM:The inhaled corticosteroids beclometasone, budesonide, fluticasone, mometasone and ciclosonide are commonly used in chronic asthma and, less commonly, in chronic obstructive pulmonary disease (COPD) to reduce the inflammation in the airways/ breathing tubes caused by the condition, and which reduces your ability to breathe normally.
Ask these Qs – if YES, refer back to GP/ Nurse for a review:
Q: Have you had regular daytime asthma symptoms (cough, breathlessness, wheeze, tight chest)?
Q: Asthma: Are you having to use your reliever more than 3 days a week?
Q: Have you had difficulty sleeping or are you woken up by your asthma symptoms?
Q: Are your symptoms interfering with your usual activities (shopping, sports, work, stairs)?
Additional notes:consider allergies/ pets – induced asthma
HOW DO YOU TAKE THEM:
  • Check inhaler technique (correct device for patient? Haleraid indicated? Knows when nearly empty?)
  • Check switch from generic to brand: QVAR (extra fine particles – double potency) vs Clenil Modulite. Record brand on PMR. Check for compliance from dispensing frequency.
  • Using a spacer (if no – action: recommend -where indicated)? Replace device 6-12 monthly.
  • Rinse out mouth after useweekly - allow .ites.PC website.hol awareness, exercise, long term conditions, sexual health, cancer prevention
  • Take preventer regularly regardless of symptoms
  • Peak Flow – once a week or more often
  • Inhaler and Spacer care – wash out weekly/monthly as recommended, dry naturally (avoid static)
  • Care Plan in place for dealing with worsening symptoms (if no – action: refer to asthma nurse).

Additional notes:
SIDE EFFECTS:
  • Corticosteroids can cause adrenal suppression (steroid card needed?) and glaucoma – eye check? Hoarseness or candidiasis – advise to rinse the mouth with water (or brush teeth) after use or to use a spacer.
  • Dose associated problems? Check dose – higher than recommended? Action: Consider step down.

Additional notes:
OTHER DRUGS:
  • ACE-I/ A2As can cause cough – cross check.
  • Beta2 agonists commonly cause cramp, tachycardia, nervousness and tremor.
  • Anticholinergics commonly cause a cough and a dry mouth, nausea and constipation – advise here.
  • Methylxanthines commonly cause gastrointestinal reflux, headache and nausea.
  • Cromoglicate and nedocromil commonly cause throat irritation, transient bronchospasm, and cough.
  • Leukotriene receptor antagonists commonly causes thirst, shooting abdominal pain and a headache.
  • Mucolytics very rarely cause rashes and gastrointestinal bleeds.
Discuss waste management (re-ordering/ safe disposal) & synchronisation.
Additional notes:check OTC meds ie NSAIDS and Aspirin for allergy
HEALTH TIPS:
Consider triggers (see over) – reduce stress/ allergens. Flu and Pneumo vaccination recommended (COPD)
Follow healthy diet (extra fruit and veg – increases immunity) to reduce weight (COPD) and increase calcium intake (helps with bone health).Reduce alcohol to safe limits. Offer stop smoking advice/ service/ referral. Increase exercise.Drinkwater – helps reduce mucous viscosity and drowsiness- (see overleaf). Pass recorded BP/ weight/ BMI/ life style monitoring info to GP.

USEFUL PATIENT INFORMATION:Any leaflets to support?

Asthma UK: NHS Choices: Eat Well: Stop Smoking: Metoffice.gov.uk