What is the treatment for leg cramps and an asthma flare-up?

Treatment of Leg Cramps and Asthma Flare-Up

For the asthma flare-up, immediately administer nebulized salbutamol 5 mg or terbutaline 10 mg with oxygen, followed by oral prednisolone 30-60 mg, and assess response within 15-30 minutes to determine if hospital admission is needed; for leg cramps, initiate stretching exercises of the affected muscle group as the primary intervention. 1, 2

Immediate Asthma Management

Assessment of Severity

First, rapidly assess the severity of the asthma exacerbation by evaluating these specific parameters 1:

• Ability to speak in complete sentences (inability indicates severe asthma)
• Respiratory rate (>25 breaths/min indicates severe asthma)
• Heart rate (>110 beats/min indicates severe asthma)
• Peak expiratory flow (PEF) (<50% of predicted or best indicates severe asthma)

Initial Treatment Protocol

For moderate asthma (can complete sentences, pulse <110, respirations <25, PEF >50%): 1

• Administer nebulized salbutamol 5 mg or terbutaline 10 mg immediately
• Give oral prednisolone 30-60 mg as a single dose
• Monitor response 15-30 minutes after nebulizer treatment
• If PEF improves to >50-75% predicted, continue home treatment with close follow-up within 48 hours

For severe asthma (cannot complete sentences, pulse >110, respirations >25, or PEF <50%): 1

• Administer oxygen 40-60% if available
• Give nebulized salbutamol 5 mg or terbutaline 10 mg via oxygen-driven nebulizer
• Administer oral prednisolone 30-60 mg OR intravenous hydrocortisone 200 mg
• Add ipratropium bromide 0.5 mg to nebulizer if response is inadequate 1
• Strongly consider hospital admission if more than one severe feature is present 1

Monitoring and Reassessment

Reassess 15-30 minutes after initial nebulizer treatment 1:

• If severe features persist, arrange immediate hospital admission
• If improving but PEF remains <75%, repeat nebulized treatment and continue oral steroids
• Continue nebulized β-agonist every 4 hours if symptoms partially relieved 3

Steroid Dosing

The evidence strongly supports oral corticosteroids for asthma exacerbations 1:

• Adults: 40-60 mg prednisolone daily for 5-10 days (no taper needed for short courses)
• IV route preferred only if patient cannot tolerate oral medication or has life-threatening features
• Early administration is critical as anti-inflammatory effects take 6-12 hours to manifest 1

Common Pitfall

Do not delay corticosteroid administration - they are the only treatment proven effective for the inflammatory component of asthma and should be given early in any moderate-to-severe exacerbation 1. The British Thoracic Society guidelines emphasize that underuse of corticosteroids is a major factor in preventable asthma deaths 1.

Leg Cramp Management

Primary Treatment: Stretching

Initiate immediate passive stretching of the affected muscle during acute cramp 4, 2:

• For calf cramps: dorsiflex the foot and straighten the knee
• Hold stretch until cramp resolves (typically 30-60 seconds)
• Follow with gentle massage of the affected muscle 4

Preventive Stretching Program

For recurrent leg cramps, implement a daily stretching regimen 2:

• Perform calf and hamstring stretches daily for at least 6 weeks
• This may reduce cramp severity (reduction of approximately 1.3 cm on a 10 cm pain scale), though the effect on frequency is uncertain 2
• Stretching should be done before bedtime if cramps are nocturnal 5

What NOT to Do

Avoid quinine sulfate - it is no longer recommended due to potential serious adverse effects including thrombocytopenia, cardiac arrhythmias, and hypersensitivity reactions, with only modest efficacy 6, 5.

Alternative Considerations

If stretching alone is insufficient after 6 weeks 4, 6:

• Consider magnesium supplementation (though evidence is limited)
• Ensure adequate hydration with water or electrolyte drinks
• Rule out medication-induced cramps (diuretics, statins, β-agonists can cause cramps) 5

Important Caveat

Beta-agonists used for asthma (like albuterol/salbutamol) can potentially worsen leg cramps through hypokalemia 7. Monitor for this connection, though treating the asthma exacerbation takes priority. The hypokalemia is usually transient and asymptomatic 7.

Follow-Up Requirements

For asthma: 1, 3

• Schedule follow-up within 24-48 hours if treated at home
• Monitor PEF twice daily and record on chart
• Continue prednisolone for full 5-10 day course
• Step up maintenance inhaled corticosteroid therapy
• Provide written asthma action plan 8

For leg cramps: 2

• Reassess after 6 weeks of stretching intervention
• If severe or associated with abnormal neurological examination, consider ENMG and metabolic workup to exclude neuropathy, radiculopathy, or metabolic disorders 9

Red Flags Requiring Immediate Hospital Transfer

Any of these features mandate immediate hospital admission for asthma: 1

• Life-threatening features: silent chest, cyanosis, feeble respiratory effort, bradycardia, hypotension, confusion, exhaustion, or coma
• PEF <33% predicted after initial treatment
• Persistent severe features 15-30 minutes after nebulizer treatment
• Afternoon/evening presentation with recent worsening
• Previous severe attacks or ICU admissions

1, 8, 3, 7, 4, 9, 6, 2, 5