Case Studies: January 2024

CASE 1

A patient aged 24 years with newly diagnosed mild persistent asthma was recently started on fluticasone hydrofluoroalkane (HFA) 44 μg (1 puff) twice daily in addition to albuterol HFA 1 to 2 puffs every 4 to 6 hours as needed for shortness of breath. At the follow-up visit 6 weeks later, the pharmacist wishes to assess the patient’s level of asthma control to determine whether to recommend continuing treatment, stepping up treatment, or stepping down treatment.

Illustration by Kirstie Belle Medina

What approach should the pharmacist take to determine the care plan?

The pharmacist should holistically assess 4 key elements before making any treatment recommendations. First, proper adherence should be assessed to determine whether the patient is using the medications as prescribed. The pharmacist should then verify the patient’s inhaler technique and correct any errors if necessary. Next, the pharmacist can inquire whether environmental factors and/or triggers are being adequately mitigated. These may include but are not limited to engaging in smoking cessation; avoidance of dust mites, pollen, and mold; and managing comorbid conditions known to negatively affect asthma, such as sleep apnea and gastroesophageal reflux disease. Finally, the pharmacist can assess symptom control via a peak flow meter, validated questionnaire, and/or asking the patient about symptoms, impairments to activities of daily living, frequency of rescue inhaler use, and nighttime awakenings.^1,2

CASE 2

A patient with chronic obstructive pulmonary disorder (COPD) had an exacerbation in the past month. Today, he is presenting to his primary care physician (PCP) for adjustments to his COPD medications. His medical history includes hypertension and type 2 diabetes. His current medications include amlodipine (Norvasc;Viatris), olodaterol/tiotropium (Stiolto Respimat;Boehringer Ingelheim), and metformin. Upon review of his chart, the PCP learns that the patient’s current eosinophil level is 75 cells/μL and his forced expiratory volume in the first second (FEV1) is 55% predicted. The PCP confirms that the patient does not smoke, does not drink, and does not use illicit drugs. They also verify that the patient is taking his medications as prescribed and has good inhaler technique.

According to contemporary guidelines, what drug therapy recommendation would you make to the PCP?

Per the 2023 Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines, patients who have had an exacerbation should be managed according to the exacerbation pathway. Because the patient is on dual bronchodilator therapy already, options to intensify would include escalating to triple therapy (eg, adding an inhaled corticosteroid [ICS]), adding roflumilast (Daliresp; AstraZeneca), or adding azithromycin (Zithromax; Pfizer). Based on the patient’s eosinophil count, he would likely not benefit from triple therapy with ICS. Because his FEV1 is greater than 50% and it’s not clear whether the patient has bronchitis, roflumilast is not recommended at this time. Azithromycin could be added. Macrolide antibiotics have both antimicrobial and anti-inflammatory properties. Per the GOLD guidelines, azithromycin treatment for 1 year reduces exacerbations compared with usual care. The dose to recommend is 250 mg/d or 500 mg 3 times per week.¹

About the Author

Stefanie C. Nigro, PHARMD, BCACP, CDCES, is an associate clinical professor in the Department of Pharmacy Practice at the University of Connecticut School of Pharmacy in Storrs.

References

Case 1

1. Rubin LG, Levin MJ, Ljungman P, et al. 2013 IDSA clinical practice guideline for vaccination of the immunocompromised host. Clin Infect Dis. 2014;58(3):e44-e100. doi:10.1093/cid/cit684
2. Stelara. Prescribing information. Janssen Biotech Inc; 2022. Accessed October 20, 2022. https://www.janssenlabels.com/package-insert/product-monograph/prescribing-information/STELARA-pi.pdf

Case 2
Camacho PM, Petak SM, Binkley N, et al. American Association of Clinical Endocrinologists/American College of Endocrinology clinical practice guidelines for the diagnosis and treatment of postmenopausal osteoporosis-2020 update. Endocr Pract. 2020;26(auppl 1):1-46. doi:10.4158/GL-2020-0524SUPPL