Case Study: Pharmacist Management of Inappropriate Prednisone Dosing Triggered By Asthma
Holistic and compassionate counseling by a pharmacist and pharmacy-interns on-duty over weekends could positively impact patient lives, especially for older adults and economically disadvantaged patients.
Asthma is one of the most prevalent long-term health conditions affecting about 8% of the US adult population and 1 in every 10 school-aged children, and it costs several billion dollars annually as a national health care burden.1,2 The prevalence of asthma is 1.5 to 2 times higher in females and economically disadvantaged patients,3 as highlighted in the following case study.
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AB is a 77-year-old female patient who presented to the pharmacy on a Sunday afternoon with multiple complications 2 days after initiation of oral steroid treatment for her asthma flair-up. The patient had called her primary care physician (PCP) on Friday evening after experiencing breathing difficulties. A mid-level practitioner who was on duty prescribed prednisone 20 mg tablets (2 tablets twice daily for a total daily dose of 80 mg). The patient told the pharmacy intern and pharmacist on duty that by Saturday evening she began experiencing significantly elevated blood pressure (200+/120 mmHg), blood sugar (300+ mg/dL), headache, insomnia, restlessness, malaise, and anxiety. The pharmacy intern, under the supervision of the preceptor-pharmacist, asked several open-ended questions to this patient and also examined the patient’s medication history to identify possible causes for the adverse events. Examples of the open-ended questions include the following:
- In addition to asthma, what other health problems are you having?
- What other medications are you taking?
- When was the last time you took or were prescribed this medication?
- What was the dose you were prescribed for this medication in the past?
- Who prescribed this medication in the past? Was it the same prescriber or someone else?
Based on the patient’s answers to these questions, the pharmacy intern and pharmacist realized that she is a long-term asthma patient with comorbid hypertension and type 2 diabetes. She is currently taking lisinopril 40 mg tablets once daily, amlodipine 10 mg tablets once daily, metformin extended-release tablets 500 mg twice daily, and sitagliptin 50 mg tablets once daily. The patient also had a history of smoking and was treated in the past for smoking cessation. Later, the patient was also diagnosed with smoking-triggered chronic obstructive pulmonary disease (COPD). She was also using a short-acting beta-agonist (SABA) rescue oral inhaler (albuterol HFA 90 mcg), along with an oral inhaler for fluticasone/salmeterol (250/50) with fluticasone as a steroid component and maintenance medication for asthma.
In the past, she had a prescription for prednisone 2.5 mg tablets twice daily, or a maximum of 5 mg tablets twice daily for asthma flair-ups. This was prescribed by a different physician before she relocated to a new town about 6 months ago. She said she has never been prescribed prednisone 20 mg tablets, 2 tablets twice daily. She added that she is scared to take the next dose of prednisone 20 mg tablets because her blood pressure and blood glucose levels were still high, and she cannot afford to seek medical treatment from the emergency department.
After careful consideration, the patient was counseled by the pharmacist and pharmacy intern to cut her 20 mg tablet in half and take this dose only if her blood glucose and blood pressure fall within a normal range and seek immediate medical attention from her PCP the following morning (Monday). In the event of exacerbation of her symptoms, the patient was instructed to call 911 to seek immediate medical attention to minimize the risk of a stroke.
The pharmacy intern and pharmacist also realized that the patient is self-medicating with OTC ibuprofen 200 mg tablets (4 tablets 3 times daily) as needed for headache and unspecified body pain. Because non-steroidal anti-inflammatory drugs (NSAIDs) are known to aggravate asthma and increase blood pressure, this patient was advised to discontinue OTC ibuprofen.
The pharmacy intern also reported the adverse events experienced by this patient to the FDA’s Medwatch online portal and, on the following Monday morning, the pharmacy intern updated the patient’s PCP about these adverse events. The patient’s new PCP had listed prednisone 2.5 mg and 5 mg twice daily in her medication history, but because of multitasking and multiple patients’ phone calls on a Friday evening before the physician’s office closed, the mid-level practitioner on duty overlooked it before prescribing prednisone 20 mg tablets twice daily.
This case highlights the need to incorporate and update specific guidelines to prescribe oral steroids for patients with asthma and/or COPD patients.1 Based on available asthma treatment guidelines and after consultation with the preceptor-pharmacist, the pharmacy intern also recommended that the PCP add a long-acting muscarinic antagonist (tiotropium) to manage the patient’s asthma, and the PCP agreed to do so.4 The case study presented here is a classic example of collaborative health care, emphasizing the critical role of pharmacy interns and pharmacists in serving patients, and particularly economically disadvantaged populations after hours and over weekends.
References
Asthma Statistics. Allergy & Asthma Network. Updated January 12, 2023. Accessed September 23, 2024. https://allergyasthmanetwork.org/what-is-asthma/asthma-statistics/
Data, Statistics, and Surveillance. CDC. Updated July 24, 2024. Accessed September 23, 2024. https://www.cdc.gov/asthma/asthmadata.htm
Mauer Y, Taliercio RM. Managing adult asthma: The 2019 GINA guidelines. Cleveland Clinic Journal of Medicine. 2020;87(9):569-575. doi:10.3949/ccjm.87a.19136
Ishiura Y, Fujimura M, Ohkura N, et al. Effect of triple therapy in patients with asthma-COPD overlap. Int J Clin Pharmacol and Therap. 2019;57(8):384–392. doi:10.5414/CP203382
