Advanced Pharmacology Respiratory Disorders Discussion

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Advanced Pharmacology Respiratory Disorders Discussion

JR is a 56 yo man with h/o asthma, HTN and hyperlipidemia. He presents to the ER today with h/o shortness of breath for 45 minutes at rest. He reports that he was feeling well and in his usual state of health until about an hour ago, when he smelled something burning. 20 minutes later, he began to feel short of breath and was wheezing. He tried using his albuterol inhaler without success, so he proceeded to the ER. Upon arrival, he was tachycardic, tachypneic, wheezing, using accessory muscles and hypertensive. His last admission for an asthma attack was 2 months ago. He denies a recent cold or URI and says the albuterol usually helps him when he feels an attack coming on and tends to use it on a daily basis. He generally has wheezing and shortness of breath on a daily basis. JR reports poor sleep due to waking about 2 times a week for shortness of breath. He has 2 cats, which sleep next to him on his pillow and he lives in an apartment complex. JR does not smoke, but his neighbor smokes. JR is a carpenter by occupation. He monitors his peak flow once a week at home. He reports that his peak flow generally runs about 325 L/min and his personal best is 480 L/min. His current peak flow is 175 L/min. Advanced Pharmacology Respiratory Disorders Discussion

 

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Medication Prior to Admission:

Albuterol MDI 2 puffs BID-QID PRN

Salmeterol Diskus 1 inhalation QID

Ipratropium bromide MDI 2 puffs QID

Lovastatin 20 mg po HS

Lisinopril 10 mg po QD

Questions:

  1. Classify JR’s asthma severity and control based on signs and symptoms prior to this most recent exacerbation and visit to the ED.
  2. Classify JR’s exacerbation severity based on PEF and symptoms.
  3. Identify the various triggers in JR’s life that may exacerbate asthma and prevent control.
  4. Which step should JR have been on prior to ER based on severity and current medications?
  5. Which medications are dosed incorrectly and/or inappropriate for JR’s asthma severity?
  6. Would a short-burst of oral corticosteroid be indicated at this time? If so, what dose and duration?
  7. How would you assess that JR is well-controlled?
  8. If JR is well-controlled, how would you step down in therapy?

 

Post your initial response by Wednesday at midnight. Respond to one student by Sunday at midnight.  Both responses should be a minimum of 150 words, scholarly written, APA formatted, and referenced.  A minimum of 2 references are required (other than your text). Refer to the Grading Rubric for Online Discussion in the Course Resource section. Advanced Pharmacology Respiratory Disorders Discussion

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1) Classify JR’s asthma severity and control based on signs and symptoms prior to this most recent exacerbation and visit to the ED.

Level of asthma control should be described in terms of symptom control and future risk of adverse outcomes. According to the GINA Symptom Control Tool, JR’s level of asthma symptom control is “uncontrolled”: he experiences daytime asthma symptoms on a daily basis, he wakes about twice per week due to shortness of breath, and  he uses his albuterol rescue inhaler on a daily basis (GINA Science Committee, 2019). Additionally, he is at increased risk for future exacerbations due to frequency of severe exacerbations in the last 12 months (we know that just 2 months ago he had a hospital admission related to asthma), exposure to cigarette smoke (from his apartment neighbors), and high SABA use (daily use of PRN albuterol inhaler) (GINA Science Committee, 2019). According to the Gina science committee (2019), asthma severity is determined by the level of treatment required to control symptoms and exacerbations. JR’s asthma symptom severity could be categorized as “severe” since his asthma remains uncontrolled despite daily therapy with salmeterol diskus (1 inhalation QID) and ipratropium bromide MDI (2 puffs QID), however, the Gina science committee (2019) indicates that it is important to differentiate between severe and uncontrolled asthma. Before determining that JR’s asthma is definitely “severe,” his inhaler technique should be observed, his medication adherence reviewed, comorbidities ruled out, and sensitizing or irritant agents in the home or work environment evaluated (such as cigarette smoke from his neighbors and assessing for a cat allergy). Advanced Pharmacology Respiratory Disorders Discussion

2) Classify JR’s exacerbation severity based on PEF and symptoms.

JR was in obvious distress upon his admission to the ER: he was tachycardic, tachypneic, wheezing, using accessory muscles, and hypertensive. JR’s PEF before going into the ER was 175 L/min which is approximately 34% of his personal best, 480 L/min, and approximately 54% of his norm, 325 L/min. According to Chisholm-burns (2019), a PEF under 50% of personal best indicates the patient is in the “red zone” which is a medical emergency; the patient should immediately use their SABA, take an oral corticosteroid, and proceed to the ER (GINA Science Committee, 2019).

3) Identify the various triggers in JR’s life that may exacerbate asthma and prevent control.

According to the Asthma and Allergy Foundation of America (AAFA) common asthma triggers include dust mites, cockroaches, pollen, molds, pet dander, smoke from cigarettes, air pollution, wood fires, charcoal grills, strong fumes/ odors, dust, and chemicals (2019). JR indicated that he does not smoke but that he lives in an apartment and that his neighbors smoke, so it is possible he is reacting to second-hand smoke. Additionally, JR sleeps in bed with his two cats; he should be tested for a cat allergy as this could be impacting his asthma control. It is also mentioned that JR is a carpenter; this should be investigated further to determine if there is any risk of occupational asthma, for example if he is at risk for inhaling wood particles, chemicals, etc. What seems to have sparked JR’s most recent asthma attack was the smell of something burning, which could have been an irritating scent or even smoke inhalation.  Removing himself from these potential irritants may have diminished his response and possibly prevented his asthma attack.

4) Which step should JR have been on prior to ER based on severity and current medications? Advanced Pharmacology Respiratory Disorders Discussion

According to Box 3-5A (GINA Science Committee, 2019) JR would have been on step 4 based on his current medication regimen and symptom severity.

Due to the current state of JR’s asthma and his recent hospitalization, he should have a written action plan on what he should do in the event of an attack/exacerbation. The scenario indicates that after JR tried his albuterol inhaler and had no success, he went to the ER, but does not indicate how much or how frequently he used his inhaler. When JR noticed his symptoms worsening, he should have started treatment with his albuterol inhaler (SABA), 4-10 puffs every 20 minutes for the first hour as this is an effective way to achieve quick reversal of airflow limitation (GINA Science Committee, 2019, Box 4-3). If he began to improve, he could continue PRN use of his albuterol, though the recommendation varies between 4-10 puffs every 3-4 hours and up 6-10 puffs every 1-2 hours (GINA Science Committee, 2019). Chisholm-burns (2019) indicate that the addition of ipratropium bromide to SABAs during a moderate to severe asthma exacerbation improves pulmonary function and can decrease hospitalization rates. Since JR is prescribed ipratropium bromide, he should also have used this medication.  He also should have removed himself from any possible irritants, such as the smoke, odor, and possibly cat dander.

5) Which medications are dosed incorrectly and/or inappropriate for JR’s asthma severity? Advanced Pharmacology Respiratory Disorders Discussion

The prescribed dosing for JR’s albuterol is okay for intermittent use, however, the dosing mentioned above should be prescribed as part of his action plan for future exacerbations. JR is currently prescribed salmeterol diskus 1 inhalation QID, however, the recommended dose for adults is 1 inhalation every 12 hours (Chisholm-burns et al., 2019, Tables 14-3). JR is prescribed ipratropium bromide MDI 2 puffs QID; this medication is not prescribed accurately. Ipratropium bromide has a duration of action of 4-8 hours and is used primarily for asthma exacerbations, not as maintenance (Chisholm-burns et al., 2019). Tiotropium bromide, which has a duration of longer than 24 hours is better used as a long-term maintenance medication in addition to an ICS, however, anti-cholinergic medications may have undesirable side-effects such as dry mouth (Chisholm-burns et al., 2019).

6) Would a short-burst of oral corticosteroid be indicated at this time? If so, what dose and duration?

The GINA Science Committee (2019) indicates that for management of worsening asthma exacerbations, oral corticosteroids (OCS) be given promptly if the patient continues to deteriorate and has already used their rescue reliever and controller medications, so JR would have benefitted from an OCS.  The recommended dose for adults is 1 mg prednisone/kg/day up to a maximum of 50 mg/day for 5-7 days (GINA Science Committee, 2019). This should be part of JR’s action plan for his next attack. Advanced Pharmacology Respiratory Disorders Discussion

7) How would you assess that JR is well-controlled?

In the ER setting, clinical progress should be assessed frequently, and lung function should be measured one hour after initial treatment (GINA Science Committee, 2019). When symptoms improve and JR’s PEF is 60-80% of his personal best he can be considered for discharge planning. Prior to discharge, a medication reconciliation should be completed including an ICS, and since JR already has one prescribed, the dose should be increased for 2-4 weeks, as well as 5-7 days of OCS (prednisone 40-50 mg/day), and an as-needed reliever medication, such as the albuterol inhaler JR is already prescribed (GINA Science Committee, 2019).

In the outpatient setting, after discharge from the ER, JR should follow-up with his PCP or pulmonologist within 2 days of discharge to ensure asthma symptoms are well-controlled (GINA Science Committee, 2019). Frequency of continued follow-up should be dependent upon urgency and changes to treatment plan. In order to determine if JR is well-controlled, his symptom frequency, reliever use, night waking due to asthma, activity limitations, lung function, medication side-effects, inhaler technique, medication adherence, and exacerbations and management since previous visit should be evaluated (GINA Science Committee, 2019). JR would be considered well-controlled when he does not display any of the following symptoms for 4 weeks: daytime asthma symptoms more than twice per week, nighttime awakening due to asthma, reliever needed for symptoms more than twice per week, and activity limitations due to asthma (Chisholm-burns et al., 2019, Tables 14-7). Step down therapy should be considered if symptoms are controlled for 3 months and the patient displays low risk for exacerbations. Advanced Pharmacology Respiratory Disorders Discussion

8) If JR is well-controlled, how would you step down in therapy?

The goal of step down therapy is to find the lowest treatment that controls the patient’s symptoms and exacerbations. Box 3-7 of the Global Initiative for Asthma (GINA) (2019), provides an algorithm for assisting with step down therapy by determining the current step that the patient is in based on their current medication and dose and options for stepping down. Depending on JR’s medication alterations after he leaves the hospital, he would most likely fall into Step 4: “moderate to high dose ICS- LABA maintenance treatment or medium dose ICS-formoterol as maintenance and reliever or high dose ICS plus second controller” (GINA Science Committee, 2019, Box 3-7). Options for stepping down start with 50% reduction of ICS and continuing rescue inhaler PRN. When starting step down therapy, the patient should have a written action plan created with their provider in the case of an attack and enough medication to resume their previous dose if necessary (GINA Science Committee, 2019).

 

References

AAFA Medical Scientific Council. (2019). What triggers or causes asthma? Asthma and Allergy Foundation of America (AAFA). https://www.aafa.org/asthma-triggers-causes/?gclid=Cj0KCQjwxNT8BRD9ARIsAJ8S5xaumMcexjEcPpDMh58R4TSlB8E88-S5EAUrNwe5DiBiwOWfHoFGSEEaAvNdEALw_wcB

Chisholm-burns, M., Schwinghammer, T., Malone, P., Kolesar, J., Lee, K. C., & Bookstaver, P. B. (2019). Pharmacotherapy principles and practice, fifth edition (5th ed.). Mcgraw-hill Education / Medical.

GINA Science Committee. (2019). Global strategy for asthma management and prevention (2019 update) [PDF]. Global Initiative for Asthma (GINA). https://ginasthma.org/wp-content/uploads/2019/06/GINA-2019-main-report-June-2019-wms.pdf  Advanced Pharmacology Respiratory Disorders Discussion

  • Module 9: Respiratory

     

    Module IX:  Asthma

                Asthma is a heterogenous disease characterized by airway inflammation that primarily affects the lower respiratory tract.  Common characteristics are wheezing, cough, and difficulty breathing. This disease affects adults and children alike and can be mild to severe. Treatment goals for asthma include reduction of symptoms, minimization of adverse risks, and maintenance of normal activity levels.

    JR’s presentation is consistent with moderately severe persistent asthma as evidenced by daily wheezing and shortness of breath, in addition to waking twice a week at night for shortness of breath (O’Byrne et al., 2017).  JR’s asthma is clearly not well controlled as he endorses using his short acting beta agonist (SABA) inhaler, albuterol, daily (McCracken et al., 2017).  Beta agonists relax airway muscles and increase mucociliary clearance.  JR’s current exacerbation is severe based upon JR being tachypneic, tachycardic, and the ineffectiveness of the SABA (Fergeson et al., 2017).   Further analysis of his peak expiratory flow (PEF) shows that his current PEF is 54% of his average PEF and 37% of his personal best.  According to the Guidelines from the National Asthma Education and Prevention Program, a division of the U.S. Department of Health and Human Services, this indicates the need for immediate medical care (U.S. Department of Health and Human Services, 2012).  Values less than 35% indicate a possibly life-threatening episode, and JR is remarkably close to these numbers.  Unfortunately, JR’s asthma is further exacerbated by environmental triggers in his life.  JR works as a carpenter, meaning that he is often exposed to dust and wood particles.  He also sleeps next to 2 cats who produce dander and is exposed to second-hand smoke via his neighbor.  These environmental factors, while modifiable, contribute to JR’s poorly controlled asthma (Fergeson et al., 2017).

    As JR has been endorsing the need to use his albuterol inhaler, a SABA, on a daily basis, in addition to endorsing shortness of breath and nighttime awakening from his asthma more than once a week, JR should have already been on Step 4. An asthma specialist should be consulted for patients requiring Step 4 care and higher (U.S. Department of Health and Human Services, 2012).   Step 4 recommendations include a medium to high dose inhaled corticosteroid in combination with a long acting beta agonist such as fluticasone propionate/salmeterol (Advair).  Research has demonstrated that SABA use can be decreased with the utilization of a long acting beta agonist (LABA), along with an inhaled corticosteroid (ICS) such as fluticasone (Flovent) or budesonide (Pulmicort)  (O’Byrne et al., 2017).  As JR has poorly controlled moderately severe asthma, the recommended starting dose would be Advair 230/21 twice daily or budesonide and formoterol (Symbicort) 160/4.5 twice daily. As Advair comes in 3 different strengths, this might be a better option for further step-down control in the future.

    JR presented to the ER on albuterol, salmeterol, and ipratropium bromide.  The recommendations for Step 4 from the Global Initiative for Asthma (GINA), include an inhaled corticosteroid, which JR is not currently taking.  Studies show that inhaled corticosteroids are the most effective long-term medication for asthma as they reduce symptom severity (Falk et al., 2016, p. 457).  Regardless, JR’s medications reveal some misguided dosing.  Salmeterol, a LABA, should be ordered as twice daily, not four times a day.  Additionally, the USDA approved a black box warning regarding LABAs.  These indicate the increased risk of adverse outcomes and death when not prescribed with an ICS (McCracken et al., 2017).   Albuterol MDI can be given as 2 puffs, but is generally ordered as every four hours and instructions include that a patient can take 4 puffs every 4 hours doing an acute exacerbation.   JR has also been prescribed ipratropium bromide 2 puffs four times a day.  This medication is a short acting muscarinic antagonist (SAMA) that relaxes smooth muscle in the larger airways.  While ipratropium bromide does have some demonstrated efficacy, due to JRs underling conditions such as hypertension and hyperlipidemia, JR would be better off taking tiotropium bromide, as ipratropium has an increased risk of cardiovascular events, but tiotropium does not (Fergeson et al., 2017).

    Finally, a short stint of oral corticosteroids from 3-10 days, would be highly effective for JR as their onset is in 4-12 hours. The dosage is recommended to continue until the PEF is 70% or more of his personal best (O’Byrne et al., 2017).  Once JR’s asthma has been well-controlled for 2-3 months, as evidenced by not needing to use the SABA as often and decreased episodes of asthma attacks (Fergeson et al., 2017),  step down therapy can begin.  Step down therapy involves reduction of medication intensity/dosage as control is achieved (Falk et al., 2016).  JR also needs to address environmental triggers.  As his cats are a trigger, perhaps not having them sleep on his pillow would be beneficial.  JR’s job exposes him to dust and he could consider wearing a respirator or anti-dusk mask.

     

    References

    Bernstein, J. A., & Mansfield, L. (2018). Step-up and step-down treatments for optimal asthma control in children and adolescents. Journal of Asthma, 56(7), 758–770. https://doi.org/10.1080/02770903.2018.1490752

    Falk, N., Hughes, S., & Rodgers, B. (2016). Medications for chronic asthma. American Family Physician, 94(6), 454–461.

    Fergeson, J. E., Patel, S. S., & Lockey, R. F. (2017). Acute asthma, prognosis, and treatment. Journal of Allergy and Clinical Immunology, 139(2), 438–447. https://doi.org/10.1016/j.jaci.2016.06.054

    McCracken, J. L., Veeranki, S. P., Ameredes, B. T., & Calhoun, W. J. (2017). Diagnosis and management of asthma in adults. JAMA, 318(3), 279. https://doi.org/10.1001/jama.2017.8372

    O’Byrne, P. M., Jenkins, C., & Bateman, E. D. (2017). The paradoxes of asthma management: Time for a new approach? European Respiratory Journal, 50(3), 1701103. https://doi.org/10.1183/13993003.01103-2017

    U.S. Department of Health and Human Services. (2012). Asthma care quick reference. http://www.nhlbi.nih.gov/files/docs/guidelines/asthma_qrg.pdf. Advanced Pharmacology Respiratory Disorders Discussion