Therapeutics Cases Answers ASTHMA

Q1 :- H.T., a 45-year-old, 91-kg man with a long history of severe persistent asthma, presents to the ED with severe dyspnea and wheezing. He is able to say only two or three words without taking a breath. He has been taking four inhalations of beclomethasone HFA (80 mcg/puff) BID and two inhalations of albuterol MDI QID PRN on a chronic basis. H.T. ran out of beclomethasone a week ago; since then, he has been using his albuterol MDI with increasing frequency up to Q 3 hr on the day before admission. He is a lifelong nonsmoker. What adverse effects experienced by H.T. are consistent with systemic 2-agonist administration? Ans:- H.T. experienced palpitations, Albuterol, terbutaline, and all other agonists are cardiac stimulants that may cause tachycardia and, arrhythmias. Because they are relatively 2-specific, the cardiac effects are more prominent with systemic administration (as opposed to inhalation) and at higher dosages. The decrease in the serum potassium concentration could be attributed to 2-adrenergic activation of the Na+-K+ pump and subsequent transport of potassium intracellularly (albuterol and terbutaline cause relatively little effect on serum potassium.) Q2 :- H.T. was given one dose of 60 mg methylprednisolone IV and three doses of albuterol 5 mg/ipratropium 0.5 mg by nebulizer Q 20 minutes in the ED (after the two initial doses of SC terbutaline). H.T. claimed slight subjective improvement after this therapy; yet, expiratory wheezes still were audible, and he still was using his accessory muscles for ventilatory efforts. His PEF improved only to 35% of predicted, and a repeat ABG measurement showed a PaCO 2 of 40 mmHg. What should be done at this time? Ans:- H.T. still is significantly obstructed despite intensive therapy in the ED. As a result, he should be admitted to the intensive care unit (ICU), where he can be monitored closely Q3 :- H.T. has been taking corticosteroids for a total of 6 days. Long-term corticosteroid use is associated with many adverse effects (e.g., adrenal suppression, osteoporosis, cataracts). What adverse effects are related to short-term corticosteroid use?

Ans:- Short courses of daily corticosteroids are usually associated with minor side effects. Facial flushing, appetite stimulation, gastrointestinal irritation, headache, and mood changes ranging from a mere sense of well-being to overt toxic psychosis are the most commonly encountered adverse effects of short-term corticosteroid therapy. Q4 :- H.T.'s history of increased use of his short acting beta 2 agonist (SABA) inhaler during the early stages of this asthma attack and the cardiac irregularities noted during admission suggest improper use of this medication. What are the risks from overuse of 2-agonists? Ans:- The overuse of SABAs as a possible risk factor for asthma death Q5 :- S.T., a 12-year-old girl with severe persistent asthma, has not been well controlled on steroid (mometasone) one inhalation daily (she admits to using it only when she feels Las if she needs it) and uses as-needed inhaled albuterol MDI five or six times every day. When her symptoms worsen, she uses her nebulizer at home. S.T. awakens most nights with wheezing. She has been hospitalized four times in the last 2 years and has required bursts of prednisone with increasing frequency. Her parents are concerned about her increased use of prednisone now that she is approaching puberty. S.T. is just finishing a 2-week course of prednisone 20 mg/day and has a round facies appearance typical of chronic oral corticosteroid use. What actions are needed to improve S.T.'s care? Ans:- Because S.T. is suffering needlessly and requiring frequent systemic corticosteroids, all efforts must be made to optimize other therapies and to minimize systemic corticosteroid toxicities. Although S.T. is receiving an ICS, she admits to poor adherence. Therefore, with her severe persistent asthma, she initially needs higher-dose ICS therapy. Q6 :- S.T.'s parents recently discovered an article in a national newspaper that addressed concerns of using long acting beta 2 agonist (LABAs) due to an increased risk of death. Since S.T.'s parents have called and left a message for the clinician, What other side effects should S.T. and her family be aware of? Ans:- tachycardia, tremor

Q7:- P.W. is a 52-year-old man with mild persistent asthma. His asthma symptoms began when he was 2 years of age, and he has never smoked. P.W. has had numerous drug regimens for his asthma over the years, but he tells his physician that he wants the simplest regimen possible and that he prefers oral medication if at all possible. What is a good choice for controller therapy in P.W.? Ans:- oral agent such as montelukast with once-daily dosing at bedtimehas obvious advantages Q8:- E.G. is a 7-year-old boy with mild persistent asthma. E.G.'s new pediatrician notes that he has been previously managed only by as-needed inhaled albuterol. If the trial fails, she plans to switch to the lowest possible dosage of ICS. Should cromolyn be added to E.G.'s 2-agonist therapy? Is agent preferred over theophylline or a leukotriene modifier in E.G.? Ans:- In studies of childhood asthma, cromolyn has been found to reduce symptoms and the need for acute-care visits, and this drug has an excellent safety profile