Epidemiology• Asthma is classiﬁed as inﬂammation of the airways leading to narrow passages and trouble breathing. Patients usually have symptoms of coughing and wheezing.• 20 million Americans affected (1 in 15 americans)• 50% of asthma cases are “allergic asthma”• Asthma is the most common chronic childhood disease and is also more common in children than adults. Asthma Facts and Figures. Asthma and Allergy Foundation of America. http:// www.aafa.org/display.cfm?id=9&sub=42#prev
Patient Summary• KB is a 25 y/o female that is presenting with uncontrolled asthma and exacerbations. She wakes up at least once a night with coughing a wheezing. She ﬁnds it difﬁcult to do errands after an attack because she feels so out of breath. She is wheezing daily and has 2-3 exacerbations per week.• KB has recently moved from Florida and now lives in an old apartment. She says that her asthma has gotten worse after the move.• Her personal best peak ﬂow was 485L/min but her
Exams and History• KB has had asthma since 1992. She has been hospitalized once and has never been intubated.• KB suffers from seasonal allergies (pollen and ragaweed). Also has allergies to dried fruit, aspirin and peanuts• Physical exam is normal expect she has a high respiratory rate of 20. KB is unable to get air out of her lungs because of the asthma. Her lungs also have bilateral wheezing.• Family history is unimpressive• In social history it should be noted that she lives an active lifestyle (so the exacerbations may be exercise induced) and her asthma has worsened upon moving.
Goals of Therapy• Control KBs asthma• Decrease frequency of exacerbations• Decrease dependence on SABA• Increase awareness of environmental and behavioral factors• Get KBs PEF in the green zone• Streamline KBs medication regimen to better control
Medications• Ventolin HFA 2puffs q4-6h prn• Flovent HFA 110mcg 2puffs BID (last ﬁlled in 2009)• Ibuprofen 200mg prn for headache• Tums 2tablets qid prn for heartburn• Ehinacea extract prn for onset of cold/ﬂu
Classifying KBs Asthma Days with Nights w/ FEV1 or Class sx/ SABA sx PEF use Severe Continual Frequent <60% Persistent Moderate >60%, Daly >1x/wk Persistent <80% Mild >2x/ >2x/wk >80% Persistent month Mild <2x/ <2x/wk >80% Intermittent month• “GINA Classiﬁcation of Asthma” http://www.medicalcriteria.com/site/index.php? option=com_content&view=article&id=68%3Apulgina&catid=77%3Apulmonary&Itemid=80&lang=en
Classifying KB’s Asthma• KB would be classiﬁed as having moderate persistent asthma because she has daily symptoms and she wakes up once a week from coughing and wheezing.• KBs PEF cannot be determined because she lost her peak ﬂow meter• We can help control KBs asthma by revamping her medication regimen and suggesting some environmental changes.
Environmental/Behavioral Changes• KBs asthma worsened when she moved into an old apartment. Mold and dust from the apartment may be aggravating her asthma. KB should dust frequently and clean her pillows and blankets. KB should even consider getting plastic allergen covers for her furniture.• Don’t go out on high pollen days.• Take the Ventolin before exercise
Management of KBs Allergies• KB is allergic to aspirin and is also taking ibuprofen. Ibuprofen and aspirin come from the same derivative so there may be cross reactivity.• KB is also allergic to peanuts so we must take note of the propellants used in some of the HFA inhalers. Some of the propellants (in Combivent for example) have are based in lecithin. Kelly H. W, Sorkness Christine A, "Chapter 33. Asthma" (Chapter). Joseph T. DiPiro, Robert L. Talbert, Gary C. Yee, Gary R. Matzke, Barbara G. Wells, L. Michael Posey: Pharmacotherapy: A Pathophysiologic Approach, 8e: http:// www.accesspharmacy.com/content.aspx?aID=7975293.
Medications• KB has not been compliant with her ICS (Flovent) which is used for long term chronic asthma.• We suggest counseling KB on the importance of using the ICS every day for chronic symptoms and using the Ventolin for acute attacks only.• Explain that the ICS must be taken daily even when symptoms are clearing. Effects won’t be seen for 1-2 weeks with full effects in 4-8 weeks.• Also cousel KB on the importance of not overusing the Ventolin because it can lead to serious side effects.
Therapy Alternatives• If KB still presents with uncontrolled asthma at follow up consider the following:• Oral corticosteroid burst therapy if exacerbations persist• Increase the dose of ICS (Flovent 88mcg -> 220mcg)• Long Acting Beta Agonists in conjunction with ICS• Leukotrine modiﬁers (salmeterol) because they are good for exercise and allergy induced asthma.
Echinacea • Echinacea is believed to be an immuno-stimulant. • Asthma is a disease cause by an over-reactive immune system. • Additionally, asthma is treated by inhaled cortico- steroids, which are immuno-suppressants. • These factors all make the use of Echinacea illogical during the treatment of asthma. • Bottom line, strongly advise KB to discontinue echinacea.Arch Intern Med. 1998 Nov 9;158(20):2200-11.Herbal medicinals: selected clinical considerations focusing on known or potential drug-herb interactions.Miller LG. http://0-www.ncbi.nlm.nih.gov.helin.uri.edu/pubmed/9818800
Counseling Points• KB may not be getting the most beneﬁt from her inhaler. Counsel KB on how to use the inhaler and encourage the use of a spacer Kelly H. W, Sorkness Christine A, "Chapter 33. Asthma" (Chapter). Joseph T. DiPiro, Robert L. Talbert, Gary C. Yee, Gary R. Matzke, Barbara G. Wells, L. Michael Posey: Pharmacotherapy: A Pathophysiologic Approach, 8e: http://www.accesspharmacy.com/content.aspx?aID=7975293.
How to Use the InhalerKelly H. W, Sorkness Christine A, "Chapter 33. Asthma" (Chapter). Joseph T. DiPiro, Robert L. Talbert, Gary C. Yee, Gary R.Matzke, Barbara G. Wells, L. Michael Posey: Pharmacotherapy: A Pathophysiologic Approach, 8e: http://www.accesspharmacy.com/content.aspx?aID=7975293.
Summary• Recommend thorough cleaning of KB’s new living environment.• Strongly advise discontinuing echinacea.• Stress the importance of using the ICS everyday, even when symptoms are clearing.• Discontinue ibuprofen.• Counsel patient on importance of compliance and how to use an inhaler correctly