Read case presentation: Chronic Asthma: Dust in the Wind Level IIAnswer questions # 3a, 3b, and 3c 3a. What are the goals of pharmacotherapy in this case?
3b. What non-drug therapies might be useful for this patient?3c. What feasible pharmacotherapeutic alternatives are available for treating this patient’s chronic asthma?
– Answer questions # 3d, 3e, and 4a and post to discussion board 3d. Create an individualized, patient­-centered, team­-based care plan to optimize medication therapy for this patient’s asthma and other drug therapy
problems. Include specific drugs, dosage forms, doses, schedules, and durations of therapy.
3e. What alternatives would be appropriate if the initial care plan fails?
4a. What information should be provided to the patient to enhance adherence, ensure successful therapy, and minimize adverse effects?
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Chapter 30: Chronic Asthma: Dust in the Wind Level II
Julia M. Koehler; Meghan M. Bodenberg; Jennifer R. Guthrie
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LEARNING OBJECTIVES
After completing this case study, the reader should be able to:
Recognize signs and symptoms of uncontrolled asthma.
Identify potential causes of uncontrolled asthma, and recommend preventive measures.
Formulate a patient­specific therapeutic plan (including drugs, route of administration, and appropriate monitoring parameters) for management
of a patient with chronic asthma.
Develop a self­management action plan for improving control of asthma.
PATIENT PRESENTATION
Chief Complaint
“I think the dust is getting to me!”
HPI
Lilly Madison is a 17­year­old Caucasian girl who presents to her primary care provider for follow­up and evaluation regarding her asthma. During her
visit, she reports having had to use her albuterol MDI approximately 3–4 days per week over the past 2 months, but over the past week she admits to
using albuterol once daily. She reports being awakened by a cough at night once a week during the past month. She states she especially becomes
short of breath when she visits her father’s workshop (“Madison Custom Cabinetry”) and when she exercises (although she admits that her shortness
of breath is not always brought on by exercise and sometimes occurs when she is not actively exercising). In addition to her albuterol MDI, which she
uses PRN, and she also has a fluticasone MDI, which she uses “most days of the week.” She indicates that her morning peak flows have been running
around 300 L/min (personal best = 400 L/min) over the past several weeks.
PMH
Asthma (previously documented as “mild persistent”) diagnosed at age 7; no prior history of intubations; hospitalized once in the past year for asthma
exacerbation; one visit to the ED in the past 6 months; treated with oral systemic corticosteroids during last hospitalization and at ED visit.
Migraine headache disorder (without aura; diagnosed at age 15); currently taking prophylactic medication; has had only one migraine attack in the last
year.
FH
Mother 49 years old with HTN, migraine HA disorder, and asthma; (nonsmoker); father 50 years old (smoker) with HTN and type 2 DM; brother, age 21,
healthy
(smoker);
twin sister,
17, healthy
(nonsmoker)
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Chapter 30: Chronic Asthma: Dust in the Wind Level II, Julia M. Koehler? Meghan M. Bodenberg? Jennifer R. Guthrie
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No alcohol or tobacco use. Single, not sexually active. Lives at home with parents (father is a cabinet maker), twin sister, and two cats. Brother is
year.
FH
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Mother 49 years old with HTN, migraine HA disorder, and asthma; (nonsmoker); father 50 years old (smoker) with HTN and type 2 DM; brother, age 21,
healthy (smoker); twin sister, age 17, healthy (nonsmoker)
SH
No alcohol or tobacco use. Single, not sexually active. Lives at home with parents (father is a cabinet maker), twin sister, and two cats. Brother is
currently away at college.
Meds
Flovent HFA 44 mcg, two puffs BID
Proventil HFA two puffs Q 4–6 H PRN shortness of breath, cough, wheezing
Propranolol 80 mg PO BID
Maxalt­MLT 5 mg PO PRN acute migraine
All
PCN (rash)
ROS
Denies fever, chills, headache, eye discharge or redness, rhinorrhea, sneezing, sputum production, chest pain, palpitations, dizziness, or confusion
Physical Examination
Gen
Well­developed, well­nourished white female appearing stated age in NAD
VS
BP 110/68, HR 78, RR 16, T 37°C; Wt 58 kg, Ht 5?5?
HEENT
PERRLA; mild oral thrush present on tongue and buccal mucosa
Neck/Lymph Nodes
Supple; no lymphadenopathy or thyromegaly
Lungs/Thorax
No intercostal retractions or accessory muscle use with respirations; good air movement; mild expiratory wheezes bilaterally
CV
RRR; no MRG
Abd
Soft, NTND; (+) BS
Ext
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Chapter 30: Chronic Asthma: Dust in the Wind Level II, Julia M. Koehler? Meghan M. Bodenberg? Jennifer R. Guthrie
Normal ROM; peripheral pulses 3+; no CCE
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RRR; no MRG
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Soft, NTND; (+) BS
Ext
Normal ROM; peripheral pulses 3+; no CCE
Neuro
A&O × 3. Cranial nerves II–XII grossly intact. No focal weakness or loss of sensation.
Labs
Na 136 mEq/L
Hgb 14 g/dL
WBC 6.0 × 103/mm3
K 3.6 mEq/L
Hct 42%
PMNs 56%
Cl 99 mEq/L
RBC 5.0 × 106/mm3
Bands 1%
CO2 27 mEq/L
Plts 192 × 103/mm3
Eosinophils 3%
BUN 18 mg/dL
Basophils 2%
SCr 0.6 mg/dL
Lymphocytes 33%
Glu 98 mg/dL
Monocytes 5%
Ca 9.3 mg/dL
Assessment
A 17­year­old girl with uncontrolled chronic asthma and mild oral thrush
QUESTIONS
Collect Information
1.a. What subjective and objective information indicates the presence of uncontrolled chronic asthma?
1.b. What additional information do you need to assess this patient? (Consider factors that may have contributed to this patient’s uncontrolled
asthma.)
Assess the Information
2.a. Assess this patient’s level of asthma control based on the subjective and objective information available.
2.b. Create a list of the patient’s drug therapy problems and prioritize them. Include assessment of medication appropriateness, effectiveness, safety,
and patient adherence.
Develop a Care Plan
3.a. What are the goals of pharmacotherapy in this case?
3.b. What nondrug therapies might be useful for this patient?
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Chapter
Chronic
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Wind Levelare
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M. Koehler?
Meghan
M. Bodenberg?
3.c. What30:
feasible
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chronicJennifer
asthma?R. Guthrie
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3.d. Create an individualized, patient­centered, team­based care plan to optimize medication therapy for this patient’s asthma and other drug therapy
problems. Include specific drugs, dosage forms, doses, schedules, and durations of therapy.
and patient adherence.
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Develop a Care Plan
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3.a. What are the goals of pharmacotherapy in this case?
3.b. What nondrug therapies might be useful for this patient?
3.c. What feasible pharmacotherapeutic alternatives are available for treating this patient’s chronic asthma?
3.d. Create an individualized, patient­centered, team­based care plan to optimize medication therapy for this patient’s asthma and other drug therapy
problems. Include specific drugs, dosage forms, doses, schedules, and durations of therapy.
3.e. What alternatives would be appropriate if the initial care plan fails?
Implement the Care Plan
4.a. What information should be provided to the patient to enhance adherence, ensure successful therapy, and minimize adverse effects?
4.b. Describe how care should be coordinated with other healthcare providers.
Follow­up: Monitor and Evaluate
5.a. What clinical parameters should be used to evaluate the therapy for achievement of the desired therapeutic outcome and to detect or prevent
adverse effects?
5.b. Develop a plan for follow­up that includes appropriate time frames to assess progress toward achievement of the goals of therapy.
SELF­STUDY ASSIGNMENTS
1 . Review the GINA guidelines on the management of asthma during pregnancy, and develop a pharmacotherapeutic treatment plan for this patient’s
asthma if she were to become pregnant.
2 . Review the literature on the impact of chronic inhaled corticosteroid use on the risk for development of osteoporosis, and write a two­page paper
summarizing the available published literature on this topic.
CLINICAL PEARL
Patients with asthma who report that taking aspirin makes their asthma symptoms worse may respond well to leukotriene modifiers. Aspirin inhibits
prostaglandin synthesis from arachidonic acid through inhibition of cyclooxygenase. The leukotriene pathway may play a role in the development of
asthma symptoms in such patients, as inhibition of cyclooxygenase by aspirin may shunt the arachidonic acid pathway away from prostaglandin
synthesis and toward leukotriene production. Although inhaled corticosteroids are still the preferred anti­inflammatory medications for patients with
asthma and known aspirin sensitivity, leukotriene modifiers may also be useful in such patients based on this theoretical mechanism.
REFERENCES
1. National Asthma Education and Prevention Program. Executive Summary of the NAEPP Expert Panel Report 3: Guidelines for the Diagnosis and
Management of Asthma. Bethesda, MD, U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health, National
Heart, Lung, and Blood Institute, 2007. Full report. Available at:
http://www.nhlbi.nih.gov.ezproxylocal.library.nova.edu/guidelines/asthma/index.htm. Accessed April 19, 2019.
2. Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention (updated 2018). Available at:
http://www.ginasthma.com ; 2018. Accessed April 19, 2019.
3. Lemanske RF, Mauger DT, Sorkness CA, et al. Step­up therapy for children with uncontrolled asthma while receiving inhaled corticosteroids. N Engl
J Med 2010;362:975–985. [PubMed: 20197425]
4. Busse W, Raphael GD, Galant S, et al. Fluticasone Propionate Clinical Research Study Group. Low­dose fluticasone propionate compared with
montelukast for first­line treatment of persistent asthma: a randomized clinical trial. J Allergy Clin Immunol 2001;107:461–468. [PubMed: 11240946]
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Chapter
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Julia M.KA.
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Comparison
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Allergy Clin Immunol 1999;103:1075–1080. [PubMed: 10359889]
6. Humbert M, Beasley R, Ayres J, et al. Benefits of omalizumab as add­on therapy in patients with severe persistent asthma who are inadequately
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University
3. Lemanske RF, Mauger DT, Sorkness CA, et al. Step­up therapy for children with uncontrolled asthma while receiving inhaled
corticosteroids.
N Engl
Access Provided by:
J Med 2010;362:975–985. [PubMed: 20197425]
4. Busse W, Raphael GD, Galant S, et al. Fluticasone Propionate Clinical Research Study Group. Low­dose fluticasone propionate compared with
montelukast for first­line treatment of persistent asthma: a randomized clinical trial. J Allergy Clin Immunol 2001;107:461–468. [PubMed: 11240946]
5. Busse W, Nelson H, Wolfe J, Kalberg C, Yancey SW, Rickard KA. Comparison of inhaled salmeterol and oral zafirlukast in patients with asthma. J
Allergy Clin Immunol 1999;103:1075–1080. [PubMed: 10359889]
6. Humbert M, Beasley R, Ayres J, et al. Benefits of omalizumab as add­on therapy in patients with severe persistent asthma who are inadequately
controlled despite best available therapy (GINA 2002 step 4 treatment): INNOVATE. Allergy 2005;60:309–316. [PubMed: 15679715]
7. Ortega HG, Liu MC, Pavord ID, et al. Mepolizumab treatment in patients with severe eosinophilic asthma. N Engl J Med 2014;371:1198–1207.
[PubMed: 25199059]
8. Bleecker ER, FitzGerald JM, Chanez P, et al. Efficacy and safety of benralizumab for patients with severe asthma uncontrolled with high­dosage
inhaled corticosteroids and long­acting ?–agonists (SIROCCO): a randomized, mulitcentre, placebo­controlled phase 3 trial. Lancet 2016; 388:2115–
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9. FitzGerald JM, Bleecker ER, Nair P, et al. Benralizumab, an anti­interleukin­5 receptor monoclonal antibody, as add­on treatment for patients with
uncontrolled, eosinophilic asthma (CALIMA): a randomized, double­blind, placebo­controlled phase 3 trial. Lancet 2016; 388:2128–2141. [PubMed:
27609406]
10. Rabe KF, Nair P, Brusselle G, et al. Efficacy and safety of dupilumab in glucocorticoid­dependent severe asthma. N Engl J Med 2018;378:2475–
2485. [PubMed: 29782224]
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