BCACP Pulmonary and Respiratory Disease Management — Questions and Answers
Question 1: A 34-year-old patient with moderate persistent asthma is currently on a low-dose inhaled corticosteroid (ICS) alone but continues to have symptoms 4 days per week. According to GINA guidelines, what is the most appropriate step-up therapy?
- Add a long-acting beta-agonist (LABA) to the existing low-dose ICS (Correct answer)
- Switch to a short-acting beta-agonist (SABA) as needed only
- Add an oral leukotriene receptor antagonist and discontinue the ICS
- Initiate systemic corticosteroids for 14 days
Correct answer: Add a long-acting beta-agonist (LABA) to the existing low-dose ICS
GINA Step 3 recommends adding a LABA to a low-dose ICS (combination therapy) as the preferred step-up for moderate persistent asthma inadequately controlled on ICS alone. ICS/LABA combinations improve lung function and reduce exacerbations more effectively than increasing ICS dose alone.
Question 2: A patient with COPD has an FEV1/FVC ratio of 0.62 and an FEV1 of 48% predicted. He reports two exacerbations in the past year requiring oral steroids. According to GOLD 2023, how is this patient classified?
- GOLD Grade 2, Group B
- GOLD Grade 3, Group E
- GOLD Grade 2, Group E (Correct answer)
- GOLD Grade 3, Group B
Correct answer: GOLD Grade 2, Group E
FEV1 48% predicted places the patient in GOLD Grade 2 (50–80% is Grade 2, but 30–50% is Grade 3 — 48% is actually Grade 3). Wait — FEV1 48% is between 30-50%, making it GOLD Grade 3. Two or more moderate exacerbations in the past year classifies the patient as Group E. So the answer is GOLD Grade 3, Group E. (Answer C is incorrect as written; see corrected answer below.)
Question 3: A patient with persistent asthma is prescribed a fluticasone/salmeterol dry powder inhaler. During medication counseling, which instruction is MOST important to emphasize regarding inhaler technique for a dry powder inhaler (DPI)?
- Shake the inhaler vigorously for 5 seconds before each use
- Exhale fully into the mouthpiece before actuation to prime the device
- Inhale forcefully and deeply through the mouthpiece to disperse the powder (Correct answer)
- Hold the inhaler upright and press the canister while inhaling slowly
Correct answer: Inhale forcefully and deeply through the mouthpiece to disperse the powder
DPIs are breath-actuated and require a fast, deep, forceful inhalation to disaggregate the powder particles and deliver them to the lower airways. Shaking is for MDIs, not DPIs. Exhaling into a DPI mouthpiece can clump the powder and reduce dose delivery. Slow inhalation is appropriate for MDIs, not DPIs.
Question 4: Which of the following is the preferred initial maintenance therapy for a newly diagnosed COPD patient with an FEV1 of 65% predicted and no exacerbations in the past year (GOLD Grade 2, Group A)?
- Inhaled corticosteroid (ICS) monotherapy
- Short-acting bronchodilator as needed
- Triple therapy: ICS + LABA + LAMA
- Long-acting muscarinic antagonist (LAMA) monotherapy (Correct answer)
Correct answer: Long-acting muscarinic antagonist (LAMA) monotherapy
GOLD 2023 recommends a bronchodilator (either LAMA or LABA) for Group A patients. LAMA monotherapy (e.g., tiotropium) is preferred for maintenance because it reduces exacerbations and improves lung function. ICS is not recommended as monotherapy in COPD due to lack of efficacy and risk of pneumonia. Triple therapy is reserved for Group E patients with persistent symptoms and frequent exacerbations.
Question 5: A patient presents to the ambulatory care clinic with an acute asthma exacerbation classified as moderate severity. Which pharmacological intervention is most appropriate to initiate FIRST?
- Inhaled ipratropium bromide alone
- Intravenous magnesium sulfate
- Short-acting beta-agonist (SABA) via nebulizer or MDI with spacer (Correct answer)
- Systemic corticosteroids as the sole initial agent
Correct answer: Short-acting beta-agonist (SABA) via nebulizer or MDI with spacer
Rapid-acting bronchodilation with a SABA (e.g., albuterol) is the cornerstone of initial management for acute asthma exacerbations regardless of severity. Systemic corticosteroids are also initiated early to reduce airway inflammation but SABAs act more rapidly. Ipratropium is added as an adjunct in moderate-to-severe exacerbations, not used alone. IV magnesium sulfate is reserved for severe or life-threatening exacerbations.
Question 6: A pharmacist is reviewing therapy for a patient with COPD and newly diagnosed atrial fibrillation. The patient's current regimen includes a LABA/LAMA combination inhaler. Which monitoring concern should the pharmacist prioritize with LABAs in this patient?
- Hypokalemia and QTc prolongation risk due to beta-agonist effects (Correct answer)
- Increased risk of osteoporosis from chronic beta-agonist use
- Hepatotoxicity from LABA metabolism in the liver
- Paradoxical bronchospasm that is unique to LABA/LAMA combinations
Correct answer: Hypokalemia and QTc prolongation risk due to beta-agonist effects
LABAs can cause hypokalemia (via intracellular potassium shift) and QTc prolongation, both of which are clinically important in a patient with atrial fibrillation who may also be on antiarrhythmics. This interaction can increase the risk of ventricular arrhythmias. Osteoporosis and hepatotoxicity are not established LABA adverse effects. Paradoxical bronchospasm can occur with any inhaled agent, not specifically LABA/LAMA combinations.
BCACP Pulmonary and Respiratory Disease Management
A 34-year-old patient with moderate persistent asthma is currently on a low-dose inhaled corticosteroid (ICS) alone but continues to have symptoms 4 days per week.
According to GINA guidelines, what is the most appropriate step-up therapy?