Chapter 4 Respiratory Andrew Stanton SALBUTAMOL (in acute asthma) 5 in acute asthma Nebulised (driven by oxygen not air) 4 6 hourly In acute severe asthma not responding to initial treatment or in life-threatening asthma, can be given up to every 15 30 minutes. Once clinical stability/improvement obtained, 2.5 may be adequate (especially if side effects predominate). Repeated dosing, especially if more than 4 6 hourly, is associated with risk of lactic acidosis. ATROVENT (ipratropium bromide) 0.5 Nebulised (driven by oxygen not air) 4 6 hourly Unlike salbutamol additional clinical benefit is not seen with more frequent dosing. Not indicated in moderate acute asthma. PREDNISOLONE in asthma 40 50 PO Stat, then once daily for at least 5 days Tailing off steroid dosage is not necessary unless the patient is on regular maintenance oral steroid or if the patient has been on highdose steroid for 3 or more weeks (very rare) In life-threatening asthma, or if oral route not possible, give 100 hydrocortisone IV as equivalent. Essential Practical Prescribing, First Edition. Georgia Woodfield, Benedict Lyle Phillips, Victoria Taylor, Amy Hawkins and Andrew Stanton. 2016 by John Wiley & Sons, Ltd. Published 2016 by John Wiley & Sons, Ltd.
MAGNESIUM in asthma 1.2 2 g IV g Once only as IV infusion over 20 minutes in 100 ml 5% dextrose or normal saline Only give in life-threatening asthma, or in severe acute asthma not responding to initial therapy. No evidence of benefit of repeated administration. Reason for varying dose relates to fact different doses have been used in different studies (see Evidence). AMINOPHYLLINE in acute asthma 5 /kg loading dose then 0.5 /kg/h infusion IV As loading dose over 20 minutes then continuous IV infusion Loading dose must not be given if the patient is on maintenance theophylline preparation take blood level then commence maintenance infusion.
LABAs in asthma Salmeterol Eformoterol 50 micrograms 6 12 micrograms Inhaled Inhaled micrograms micrograms BD 1 2 puffs BD/ PRN Available in Accuhaler DPI (dry powder inhaler) (50 micrograms/puff), 1 puff BD and MDI (metered dose inhaler) (25 micrograms/puff, 2 puffs BD). Non-generic name: Serevent. Available in Turbohaler DPI. Maximum recommended total dose 96 micrograms/day. Non-generic names: Oxis, Atimos, Foradil. ICSs in asthma Beclomethasone Budesonide propionate Extrafine beclomethasone 100 400 micrograms 100 400 micrograms 100 500 micrograms 50 200 micrograms Inhaled Inhaled Inhaled Inhaled micrograms micrograms micrograms micrograms BD BD BD BD Maximum daily licensed dose is 800 micrograms BD. Non-generic names: Becotide, Becloforte, Asmabec, Clenil. Maximum daily licensed dose is 800 micrograms BD. Non-generic name: Pulmicort Maximum daily licensed dose is 1000 micrograms BD. Non-generic name: Flixotide Non-generic name: Qvar.
ICS/LABAs in asthma Product Symbicort Seretide Fostair Relvar Ellipta Flutiform Individual components Budesonide + eformoterol (propionate) + salmeterol Beclomethasone (extra-fine particle) + formoterol (furoate) + vilanterol (propionate) + formoterol (ICS/LABA) 100/6 or 200/6 See below 100/6 92/22 or 184/22 50/5 125/5 250/10 Inhaled Inhaled Inhaled Inhaled Inhaled micrograms micrograms micrograms micrograms micrograms 1 2 puffs BD +/- PRN 1 2 puffs BD depending on device 1 2 puffs BD 1 puff OD 2 puffs BD Not licensed for reliever therapy Turbohaler device. Also licensed for maintenance and reliever therapy (SMART Symbicort maintenance and reliever therapy). Generally with this 1 puff is taken BD with 1 puff for relief as needed (max. dose is 8 puffs of 200/6 strength/day). 3 different licensed doses each for the Accuhaler dry powder device (100, 250, 500 micrograms fluticasone, each containing the full 50 micrograms of salmeterol per actuation) and the Evohaler MDI (50, 125, 250 micrograms fluticasone, containing 25 micrograms salmeterol per actuation. Accuhaler devices are therefore 1 puff BD and Evohaler devices 2 puffs BD. Available in MDI and newer dry powder (NEXThaler) device. Also licensed for maintenance and reliever therapy (Fostair maintenance and reliever therapy, FMART) as 1 puff BD + 1 puff PRN, max. 4 puffs/day. furoate is a different molecule with much higher affinity for glucocorticoid receptor, hence lower dose required. It is a long-acting once-daily ICS. Not licensed as reliever therapy.
OXYGEN Most units ask you to prescribe according to target saturations, either 88 92% or 94 98% depending on whether the patient has, or is at risk of, ventilatory failure Often you will be required to select an initial delivery device only, e.g. Venturi 24% Inhaled Specify device (e.g. venture mask/ non-rebreathe) and oxygen flow rate Continuously See text. Be very careful of using nasal cannulae in patients with low respiratory rates who are at risk of ventilatory failure can result in unexpectedly high inspired oxygen concentrations. SALBUTAMOL (in COPD) 5 Nebulised (driven by air not oxygen) ATROVENT (ipratropium bromide) in COPD 0.5 Nebulised (driven by air not oxygen) 4 6 hourly Unlike salbutamol, additional clinical benefit is not seen with more frequent dosing. Stop any LAMA (e.g. tiotropium) while on nebulised Atrovent. PREDNISOLONE in COPD 30 PO Stat, then once daily for 7 14 days (although 5 days 40 probably adequate) Tailing off steroid dosage is not necessary unless patient is on regular maintenance oral steroid (a strategy not favoured in COPD) or if patient has been on highdose steroid for 3 or more weeks 4 6 hourly As with asthma dosage can be repeated within 15 30 minutes if poor clinical response. Use of the IV route is rarely justified. If significant desaturation occurs while using air-driven nebuliser, supplement with oxygen via nasal cannulae (but exercise care as per Section Long-acting Beta Agonists).
LABAs in COPD Salmeterol Eformoterol Indacaterol Olodaterol 50 micrograms 12 micrograms 150 micrograms 2.5 micrograms Inhaled Inhaled Inhaled Inhaled micrograms micrograms micrograms micrograms BD 1 puff BD 1 puff OD 2 puffs OD Available in Accuhaler (DPI, 50 micrograms/ puff), 1 puff BD and MDI (25 micrograms/ puff), 2 puffs BD. Available in Turbohaler DPI. Administered via Breezhaler, fast onset of action similar to eformoterol. Administered via Respimat device. LAMAs in COPD Tiotropium (Handihaler device) Tiotropium (Respimat device) Aclidinium Glycopyrronium Umeclidinium 18 micrograms/ puff 2.5 micrograms/ puff 400 micrograms 44 micrograms 55 micrograms Inhaled Inhaled Inhaled Inhaled Inhaled micrograms micrograms micrograms micrograms micrograms OD 2 puffs OD 1 puff BD 1 puff OD 1 puff OD Administered via Genuair device. Administered via Breezhaler. Administered via Ellipta device.
ICS/LABAs in COPD Product Symbicort Seretide Fostair Relvar Ellipta Individual components Budesonide + Eformoterol (propionate) + salmeterol Beclomethasone (extra fine particle) + formoterol (furoate) + vilanterol (ICS/LABA) 400/12 1 puff BD or 200/6 2 puffs Inhaled 500/50 100/6 92/22 micrograms micrograms micrograms micrograms BD 1 puff BD 2 puffs BD 1 puff OD Turbohaler device. Other seretide formulations are not licensed in COPD and should not be used. is a different molecule with much higher affinity for glucocorticoid receptor, hence lower dose. CAP Amoxicillin/ ampicillin Co-amoxiclav Clarithromycin 500 1.2 g (IV) 625 (PO) 500 PO (amoxicillin) IV (ampicillin) IV PO TDS TDS BD Some units use IV benzylpenicillin 1 g QDS instead in severe CAP. Although can be given IV there is minimal difference in bioavailability and oral route should be used unless patient unable to swallow. IV also carries risk of local thrombophlebitis.
bronchiectasis mild/ moderate exacerbations where oral therapy appropriate Amoxicillin/ ampicillin Co-amoxiclav Ciprofloxacin Doxycycline 500 625 500 750 200 stat then 100 PO PO PO PO TDS TDS BD OD Should cover: H. influenzae S. pneumoniae M. catarrhalis. 1 g TDS sometimes used if failure to improve with lower doses. Should cover: H. influenzae M. catarrhalis S. aureus. Use lower dose in milder exacerbations only. Should cover Pseudomonas and coliforms (more unusual), although risk of resistance with recurrent use. Should cover H. influenzae S. pneumoniae M. catarrhalis bronchiectasis moderate/ severe exacerbations/ failure of oral therapy where IV therapy required Ceftazidime Tazocin Meropenem 2 g 4.5 g 2 g IV IV IV g g G TDS TDS TDS Give 1 g TDS if egfr <50 ml/min, or if age >80 years. BD dosing if egfr <20 ml/min also reduced in renal impairment as follows: egfr 26 50 dose 2 g BD egfr 10 25 dose 1 g BD egfr < 10 dose 1 g OD