Page 379 - Basic _ Clinical Pharmacology ( PDFDrive )

CHAPTER 20 Drugs Used in Asthma 365

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for Diagnosis, Management, and Prevention of COPD. http://www Niewoehner DE: Clinical practice. Outpatient management of severe COPD.
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Huisman EL et al: Comparative efficacy of combination bronchodilator therapies Vogelmeier C et al: Tiotropium versus salmeterol for the prevention of exacerba-
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C ASE STUD Y ANSWER

This patient demonstrates the destabilizing effects of a patient and her parents need instruction on the importance
respiratory infection on asthma, and her mother’s comments of regular adherence to therapy, with reassurance that it can
demonstrate the common (and dangerous) phobia about be “stepped down” to a lower dose of inhaled corticosteroid
“overuse” of bronchodilator or steroid inhalers. The patient (although still in combination with a long-acting β agonist)
has signs of imminent respiratory failure, including her once her condition stabilizes. They also need instruction
refusal to lie down, her fear, and her tachycardia, which can- on an action plan for managing severe symptoms. This
not be attributed to her minimal treatment with albuterol. can be as simple as advising that if the patient has a severe,
Critically important immediate steps are to administer high- frightening attack, she can take up to four puffs of albuterol
flow oxygen and to start albuterol by nebulization. Adding every 15 minutes, but if the first treatment does not bring
ipratropium (Atrovent) to the nebulized solution is recom- significant relief, she should take the next four puffs while on
mended. A corticosteroid (0.5–1.0 mg/kg of methylpred- her way to an emergency department or urgent care clinic.
nisolone) should be administered intravenously. It is also She should also be given a prescription for prednisone, with
advisable to alert the intensive care unit, because a patient instructions to take 40–60 mg orally for severe attacks, but
with severe bronchospasm who tires can slip into respiratory not to wait for it to take effect if she remains severely short of
failure quickly, and intubation can be difficult. breath even after albuterol inhalations. Asthma is a chronic
Fortunately, most patients treated in hospital emergency disease, and good care requires close follow-up and creation
departments do well. Asthma mortality is rare (fewer than of a provider-patient partnership for optimal management.
4000 deaths per year among a population of more than If she has had several previous exacerbations, she should be
20 million asthmatics in the USA), and when it occurs, it considered a candidate for monoclonal anti-IgE antibody
is often out of hospital. Presuming this patient recovers, therapy with omalizumab, which effectively reduces the
she needs adjustments to her therapy before discharge. The rate of asthma exacerbations—even those associated with
strongest predictor of severe attacks of asthma is their occur- viral respiratory infection—in patients with allergic asthma.
rence in the past. Thus, this patient’s therapy needs to be Alternatively, if the patient is found to have blood eosino-
stepped up to a higher level, like a high-dose inhaled cortico- philia, treatment with an anti-IL-5 monoclonal antibody (eg,
steroid in combination with a long-acting β agonist. Both the mepolizumab) should be considered as well.