QuestionPrescription
QuestionComment
on the bnf it says montelukast is for prophylaxis of asthma, not mentioned in treatment summaries 
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CT Kawasaki
QuestionComment
the guidelines have changed so if not controlled by moderate MART it says tiotropium?

60942
QuestionComment
this is what BNF says: If asthma is still uncontrolled in patients on a moderate-dose of ICS as maintenance with a LABA (either as a MART or a fixed-dose regimen), with or without a LTRA, consider the following options:

Increasing the ICS dose to a high-dose as maintenance (this should only be offered as part of a fixed-dose regimen with a short-acting beta2 agonist used as reliever therapy), or
A trial of an additional drug, for example, a long-acting muscarinic receptor antagonist (such as tiotropium) or modified-release theophylline, or
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Schistosomiasis
QuestionComment
https://www.asthmaandlung.org.uk/healthcare-professionals/adult-asthma/managing 

This link provides a photo of the new NICE/ BTS/ SIGN guidelines. If not controlled on moderate MART, you can start a LTRA or LAMA as you mentioned
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DJnR
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Schistosomiasis
Concept
Chapter
Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.

**Symptoms and Signs**

- Generally asymptomatic until a fragility fracture occurs
- Back pain
- Kyphosis (stooped posture)
- Fragility fractures

**Risk factors**

- Female sex
- Increasing age
- Smoking
- Corticosteroid use
- Low BMI (< 20-25kg/m<sup>2</sup>)
- Low body weight (<58kg)
- Vitamin D deficiency

**Protective factors**

- Higher BMI
- Exercise - mechanical loading stimulates bone formation

**Diagnosis**
Osteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.
A T score of < -2.5 indicates osteoporosis

**Management**

- Fall prevention
- Vitamin D and calcium supplementation
- Hormone replacement therapy (postmenopausal women)
- Oral bisphosphonates
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Prescribing a LABA in an asthmatic patient
Topic
92
General Practice
## Drug choice feedback

This patient's asthma isn't controlled. She is already taking moderate-dose MART. The next step in her treatment would be trial of LAMA or a leukotriene receptor antagonist, in accordance with NICE guidelines. However, because the patient is keen to avoid additional inhalers, montelukast would be the most appropriate option.

## Dose/Route/Frequency/Duration feedback

The options available to treat this patients uncontrolled asthma are as follows:

- Montelukast 10mg PO OD
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1 tablet
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montelukast 10 mg tablets
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To be reviewed
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nightly
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oral (PO)
PrescriptionAnswer
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10 mg
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montelukast 10 mg tablets
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To be reviewed
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nightly
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oral (PO)
Case Presentation: A 23-year-old woman attends her GP to shortness of breath and wheeze. She experiences this intermittently, her symptoms are most likely to occur at night and after exercising. Her FeNO level is re-checked and it is not raised. She is keen to avoid using any more inhalers.


She has good inhaler technique and is taking her prescribed medications as recommended.

## PMH
Asthma

## DH
Moderate-dose MART.

NKDA.

## On examination

Temperature 36.6°C, HR 68, RR 16, BP 115/78, O<sub>2</sub> 98% RA, GCS 15, Weight 55kg

A polyphonic wheeze is heard on auscultation of her chest, no other abnormalities found.

## Investigations

FEV1/FVC ratio: 56%. FeNO level and blood eosinophils are normal.

## Prescribing Request

Write a prescription for one drug that is most appropriate to treat her asthma based on NICE guidelines.