Kasus_ppok.pdf

80 ! Assessment

SECTION 3

29 yo woman with moderate to severe exacerbation of asthma; uncontrolled chronic asthma ! Clinical Course

Respiratory Disorders

The patient is admitted overnight for treatment with oxygen, inhaled bronchodilators, and oral prednisone 60 mg daily. She is discharged home with her previous regimen plus nebulized albuterol 2.5 mg every 8 hours for 5 days and prednisone 60 mg orally once daily to complete a 10-day burst. She was also given nystatin swish and swallow for treatment of her oral thrush infection. On follow-up at day 4 in the clinic, her lungs are clear without wheezing; her respiratory rate is 16 breaths per minute; and her pulse oximetry is 97% on room air. Her peak flow readings have improved to 300 L/min.

QUESTIONS Problem Identification 1.a. Create a list of the patient’s drug therapy problems. 1.b. What information indicates the presence of uncontrolled chronic asthma and an acute asthma exacerbation? 1.c. What factors may have contributed to this patient’s poorly controlled asthma and acute exacerbation? 1.d. How would you classify this patient’s level of asthma control (well controlled, not well controlled, or very poorly controlled), according to NIH guidelines?

Desired Outcome 2. What are the goals of pharmacotherapy in this case?

Therapeutic Alternatives 3.a. What nonpharmacologic therapies might be useful for this patient? 3.b. What feasible pharmacotherapeutic alternatives are available for treatment of this patient’s chronic asthma?

Optimal Plan 4.a. Outline an optimal plan of treatment for this patient’s chronic asthma.

write a two-page 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 anti-inflammatory 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, Full Report 2007. Available at http://www.nhlbi.nih.gov/guidelines/asthma/index.htm. 2. Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention (updated 2006). Available at http://www. ginasthma.org; 2006. 3. Greening AP, Ind PW, Northfield M, et al. Added salmeterol versus high-dose corticosteroid in asthma patients with symptoms on existing inhaled corticosteroid. Lancet 1994;344:219–224. 4. Busse W, Raphael GD, Galant S, et al. Fluticasone Propionate Clinical Research Study Group. Low-dose fluticasone propionate compared with montelukast for first-line treatment of persistent asthma: a randomized clinical trial. J Allergy Clin Immunol 2001;107:461–468. 5. Busse W, Nelson H, Wolfe J, et al. Comparison of inhaled salmeterol and oral zafirlukast in patients with asthma. J Allergy Clin Immunol 1999;103:1075–1080. 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. 7. Food and Drug Administration (FDA) 2007. FDA alert: Omalizumab (marketed as Xolair) information 2/2007. Available at: http:// www.fda.gov/cder/drug/infopage/omalizumab/default.htm.

4.b. What alternatives would be appropriate if the initial therapy fails?

Outcome Evaluation 5. What clinical parameters are necessary to evaluate the therapy for achievement of the desired therapeutic effect and to detect or prevent adverse effects?

Patient Education 6. What information should be provided to the patient regarding the use of her asthma medications and how she can use her peakflow readings to better manage her disease?

25 CHRONIC OBSTRUCTIVE PULMONARY DISEASE Quick Fix, Lifetime Risk . . . . . . . . . . . . . . . . . . . Level II Joel C. Marrs, PharmD, BCPS

■ SELF-STUDY ASSIGNMENTS 1. Review the NIH 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.

LEARNING OBJECTIVES

2. Review the literature on the impact of chronic inhaled corticosteroid use on the risk for development of osteoporosis, and

• Recognize modifiable and nonmodifiable risk factors for the development of COPD.

After completing this case study, the reader should be able to:

81 •

• Identify the importance of nonpharmacologic therapy in patients with COPD. •

Develop an appropriate medication regimen for a patient with COPD based on disease severity.

• Evaluate the role of inhaled and/or oral corticosteroids in the management of COPD.

•

Educate patients on the proper use of inhaled medications and determine which patients may benefit from spacers and/or holding chambers. Describe the relationship between α1-antitrypsin deficiency and the development of emphysema.

Metoprolol tartrate 50 mg po BID Salmeterol (Serevent Diskus) 1 inhalation (50 mcg) BID Tiotropium (Spiriva) 1 capsule (18 mcg) inhaled once daily Lisinopril 20 mg po once daily Esomeprazole (Nexium) 20 mg po once daily Albuterol MDI 1–2 puffs Q 6 h PRN Aspirin 81 mg po once daily ! All NKDA ! ROS (+) Shortness of breath with chronic nonproductive cough; (+) fatigue; (+) exercise intolerance ! Physical Examination

PATIENT PRESENTATION

Gen

! Chief Complaint

WDWN man appearing in mild respiratory distress after walking to the end of the hall to reach the exam room

“Why can’t I just take prednisone every day? It always works when I get admitted to the hospital.”

VS

! HPI Thomas Jones is a 66-year-old man with COPD who is presenting to the family medicine clinic today to have a 1-month follow-up appointment from his last hospital admission for an acute exacerbation of COPD. This last COPD exacerbation is the second hospital admission in the last 6 months related to TJ’s COPD instability. After TJ’s hospitalization, his discharge COPD regimen was changed to include tiotropium, 1 inhalation daily in addition to salmeterol 50 mcg, 1 inhalation Q 12 h, and an albuterol MDI as needed. TJ had pulmonary function tests (PFTs) while he was in the hospital 1 month ago but has yet to have them reassessed after the change in his COPD regimen. He wants to start taking prednisone every day because he believes this would prevent him from being readmitted to the hospital. The patient states that his respiratory symptoms are better than when he was admitted 1 month ago, but he still has shortness of breath every day and a decreased exercise capacity (e.g., he becomes very short of breath after walking a couple of blocks). He states that he is adherent to the new medication regimen that was changed on discharge from the hospital. No other medications were changed at that time that he can recall. His daughter, who is at the appointment today, states that she makes sure he uses his inhalers but often wonders if he is using them correctly because he still has daily symptoms.

BP 138/88, P 85, RR 26, T 37.5°C; Wt 95 kg, Ht 5'11'' Skin Warm, dry; no rashes HEENT Normocephalic; PERRLA, EOMI; normal sclerae; mucous membranes are moist; TMs intact; oropharynx clear Neck/Lymph Nodes Supple without lymphadenopathy Lungs Tachypnea with prolonged expiration; decreased breath sounds; no rales, rhonchi, or crackles CV RRR without murmur; normal S1 and S2 Abd Soft, NT/ND; (+) bowel sounds; no organomegaly Genit/Rect No back or flank tenderness; normal male genitalia

! PMH

MS/Ext

COPD × 12 years GERD × 5 years HTN × 20 years CAD (MI 5 years ago)

No clubbing, cyanosis, or edema; pulses 2+ throughout

! FH

! Labs

Mother died from emphysema 4 years ago at the age of 82. Father has a history of coronary artery disease. ! SH He lives with his daughter and her family. His wife died 10 years ago from breast cancer. He has a 35 pack-year history of smoking. He quit smoking approximately 3 months ago but has had occasional relapses. He states he has not smoked for approximately a week. He drinks one to two beers every evening.

Neuro A & O × 3; CN II–XII intact; DTRs 2+; normal mood and affect

Na 135 mEq/L K 4.2 mEq/L Cl 108 mEq/L CO2 26 mEq/L BUN 19 mg/dL SCr 1.1 mg/dL Glu 109 mg/dL

Hgb 12.1 g/dL Hct 38.5% Plt 195 × 103/mm3 WBC 6.4 × 103/mm3

AST 40 IU/L ALT 19 IU/L T. bili 1.1 mg/dL Alb 3.1 g/dL Pulse Ox 93% (RA)

Ca 8.9 mg/L Mg 3.6 mg/L Phos 2.9 mg/dL

! Pulmonary Function Tests (during Hospital Admission 1 Month Ago) Prebronchodilator FEV1 = 1.1 L (predicted is 3.1 L)

Chronic Obstructive Pulmonary Disease

•

! Meds

CHAPTER 25

Interpret spirometry readings to evaluate and appropriately stage the severity of COPD for an individual patient.

82

SECTION 3

Prebronchodilator FVC = 3.2 L Postbronchodilator FEV1 = 1.6 L ! Pulmonary Function Tests (during Clinic Visit Today) Prebronchodilator FEV1 = 1.3 L (predicted is 3.1 L) Prebronchodilator FVC = 3.2 L Postbronchodilator FEV1 = 1.47 L ! Assessment

Respiratory Disorders

This is a normal-appearing 66 yo man presenting to the clinic with mild respiratory distress for follow-up on his COPD medication regimen that was changed 1 month ago on hospital discharge. He also has a history of GERD, HTN, CAD, and a chronic cough.

QUESTIONS Problem Identification 1.a. Create a list of this patient’s drug-related problems. 1.b. What signs, symptoms, and laboratory data provide evidence that this patient is not yet optimally managed to reach a stable COPD status? Based on the evidence, is his history more consistent with emphysema or chronic bronchitis?

Desired Outcome 2. What are the desired goals for the treatment of COPD?

Therapeutic Alternatives 3.a. What nonpharmacologic therapies would be useful to improve this patient’s COPD symptoms? 3.b. What feasible pharmacotherapeutic alternatives are available for the treatment of COPD in this patient based on his response to the current medication regimen and the most recent GOLD guideline recommendations? 3.c. Should home oxygen therapy be considered for the patient at this time? 3.d. Is this patient a candidate for α1-antitrypsin (Prolastin) therapy?

Optimal Plan 4. Evaluate the patient’s current COPD regimen and develop recommendations to continue or change the current COPD medications at his clinic visit today. Make sure to include specific doses, route, frequency, and duration of therapy.

Outcome Evaluation 5.a. What clinical parameters will you monitor to assess the COPD pharmacotherapy regimen in this patient? 5.b. What will need to be monitored to assess any possible medication side effects? 5.c. What laboratory tests can be performed and how often should they be performed to assess the efficacy of the current COPD regimen as well as progression of the patient’s lung disease?

Patient Education 6. What information should be provided to the patient to enhance adherence, ensure successful therapy, and minimize adverse effects?

■ SELF-STUDY ASSIGNMENTS 1. Describe and compare the expectations for deterioration in pulmonary function in normal healthy adults and smokers with emphysema. In particular, emphasis should be placed on expected patterns of change in DLco, FEV1, and FVC, and general health over time in years. 2. Why would additional phenotyping be necessary if this patient were to have an abnormally low serum α1-antitrypsin level? What are the implications of the results if the patient were designated as homozygous ZZ, heterozygous MZ, or heterozygous SZ at the α1-antitrypsin allele? 3. Research and describe the evidence-based medicine approach to the management of an acute exacerbation of COPD and discuss the process of how to transition a COPD patient back to his or her chronic COPD regimen and/or adjust this regimen after an acute exacerbation of COPD.

CLINICAL PEARL A pulmonary rehabilitation program including mandatory exercise training of the muscles used in respiration is recommended for patients with COPD because of the established benefit related to improvements seen in dyspnea symptoms, health-related quality of life, and reduced number of hospital days secondary to exacerbations.

REFERENCES 1. Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: executive summary. Updated 2006. Available at http://www.goldcopd.com. Accessed March 28, 2007. 2. American Thoracic Society/European Respiratory Society Task Force. Standards for the diagnosis and management of patients with COPD [Internet]. Version 1.2. New York, American Thoracic Society, 2004. Updated Sept. 8, 2005. Available at http://www.thoracic.org/go/copd. 3. Callahan CM, Dittus RS, Katz BP. Oral corticosteroid therapy for patients with stable chronic obstructive pulmonary disease: a metaanalysis. Ann Intern Med 1991;114:216–223. 4. Anzueto A. Clinical course of chronic obstructive pulmonary disease: review of therapeutic interventions. Am J Med 2006;119:546–553. 5. MacDonald JL, Johnson CE. Pathophysiology and treatment of alpha 1-anti-trypsin deficiency. Am J Health Syst Pharm 1995;52:481–489. 6. Nichols J. Combination inhaled bronchodilator therapy in the management of chronic obstructive pulmonary disease. Pharmacotherapy 2007;27:447–454. 7. Toogood JH. Helping your patients make better use of MDIs and spacers. J Respir Dis 1994;15:151–166. 8. Package insert. Spiriva (tiotropium bromide). New York, Boehringer Ingelheim Pharmaceuticals Inc., October 2006. 9. Package insert. Advair (fluticasone propionate/salmeterol). Research Triangle Park, NC, GlaxoSmithKline, February 2007. 10. Ries AL, Bauldoff GS, Carlin BW, et al. Pulmonary rehabilitation: joint ACCP/AACVPR evidence-based clinical practice guidelines. Chest 2007;131:4S–42S.

Kasus 2 Keluhan Utama : Tenggorokan saya sakit, dan saya tidak ingin bangun dari tempat tidur. Saya juga merasakan demam, sesak nafas dan peningkatan batuk cokelat yang berlendir serta mengi sudah 5 hari belakangan. Riwayat kondisi dahulu : James Hershey adalah laki-laki berusia 50 tahun datang ke bagian gawat darurat mengeluh sakit tenggorokan, sakit kepala, demam, dan malaise sekitar 5 hari sebelumnya, dia menolak makan sesuatu yang padat karena dia mengeluh itu terlalu menyakitkan. Pasien memiliki riwayat PPOK 10 tahun yang lalu dan belakangan ini juga mengeluhkan sesak nafas nya bertambah parah, mulai mengalami nyeri dada dan batuk produktif selama 5 hari terakhir, dan merasa bahwa dia demam dengan menggigil, meskipun dia tidak mengukur suhu tubuhnya. Dia menyatakan bahwa gejala awal sesak nafasnya dimulai sekitar 1 minggu yang lalu setelah pada awal hari musim dingin. 1 minggu yang lalu dia pergi ke klinik dan menerima resep levofloxacin 750 mg po selama 5 hari, yang tidak pernah dia tebus karena alasan keuangan. Dia mengonsumsi acetaminophen dan obat batuk dan pilek yang dijual bebas untuk mengurangi gejala. Pasien juga memiliki riwayat hipertensi sudah sejak 15 tahun yang lalu dan alergi terhadap penisilin. Riwayat Sosial : Tinggal bersama istri dan empat anak. Pasien merokok aktif 2 bungkus/hari selama 30 tahun terakhir. Pasien tidak mengkonsumsi alkohol dan narkotika. Tanda Vital : Tekanan darah 150/90 mmHg, RR 31 x, T 39,1 derajat celcius, BB : 65 kg, TB : 170 cm Hasil laboratorium : BUN = 31 mg/dl HCt = 35% SrCr = 1,4 mg/dl Hb = 12,1 mg/dl Na = 141 mEq Ca = 2 mEq K = 3,8 mEq Glukosa puasa= 101 mg/dl MCV = 91 mikro meter pangkat 3 Sel darah merah = 3,8 x 10 pangkat 6 / mm pangkat 3 MCHC = 35 g/dL Sel darah putih = 17,2 x 10 pangkat 3 / mm pangkat (normal 4500-10000 sel/mm) Tes fungsi paru (dengan spirometri) : FEV1 = 1,39 L (normal 3.1 L) (45%)
 Strain gram dahak : 25 WBC / hpf, <10 sel epitel / hpf, banyak Gram (+) streptococci berpasangan Obat yang sekarang digunakan : Lisinopril 10 mg po 1 x sehari; Hidroklortiazid 12,5 mg po 1 x sehari; Ipratropium/Albuterol MDI 2 semprot 4 x sehari; Albuterol MDI 2 semprot jika diperlukan pada saat sesak nafas; Asetaminofen 650 mg po setiap 6 jam jika demam; Guaiafenesin/dekstrometorfan (100 mg/10 mg per 5 mL) 2 sendoh teh setiap 4 jam jika batuk; Amoksisilin 500 mg 3 x sehari 10 tablet