Interactive Case Studies: October 2023

CASE 1

AM is a 30-year-old woman coming to the pharmacy to start smoking cessation therapy. After collecting some information, you learn that AM has a medical history of atopic dermatitis, asthma, and allergic rhinitis (ie, the atopic triad), for which she uses guideline-recommended therapies. She informs you that her time to first cigarette (TTFC) is within 20 minutes of waking and she has smoked approximately 15 cigarettes per day for the past 10 years. Previously, she tried varenicline (Chantix; Pfizer) but needed to halt therapy because of intolerable nausea. This time, she is interested in nicotine replacement products, specifically a patch, lozenge, or nasal spray. She wants to know which you think is best for her.

What do you advise?

The pharmacist should first verify that AM is not pregnant, because these options would be contraindicated if she were.¹ Because the patient has dermatitis, using the patch is not advisable because it can increase local skin irritation.² Similarly, the nasal spray should be avoided or used with caution in patients with reactive airways—like those with asthma— because it can increase the risk of bronchoconstriction.² The best available option to recommend based on AM’s history and preferences is the nicotine lozenge. Because her TTFC is within 20 minutes, she should be advised to purchase the 4-mg strength. Regarding use, she should use 1 lozenge every 1 to 2 hours, not to exceed 20 lozenges per day. AM should also be counseled to let the lozenge fully dissolve in the mouth without chewing or biting, to avoid gastrointestinal upset like nausea and dyspepsia.³

CASE 2

HP is a 36-year-old man presenting to the primary care clinic with complaints of shortness of breath and chest tightness. During this past week, HP states he has not been able to play recreational baseball for more than 10 to 15 minutes without having to stop and catch his breath. Because of this, he has had to use his teammate’s rescue inhaler multiple times throughout the day. Additionally, he had to sit out of a recent tournament, which was upsetting to him. HP also states he has had several nighttime awakenings this past week due to his symptoms. As a result of these symptoms, he has been diagnosed with asthma. You review the results of his pulmonary function tests and see that his current forced expiratory volume in 1 second (FEV₁) is 80% predicted.

How would you classify HP’s asthma severity, and what treatment should be recommended?

Per the National Heart, Lung, and Blood Institute guidelines, severity of asthma is determined by evaluating evidence of impairment and risk. Because HP is symptomatic throughout the day and uses his rescue inhaler multiple times per day, he is classified as having severe persistent asthma.¹ Patients in this category can be started on a daily and as-needed combination medium-dose inhaled corticosteroid (ICS) plus formoterol.² If that treatment is unavailable to HP, an alternative regimen may include a medium-dose ICS and a long-acting β-agonist plus a short-acting β-agonist to be used as needed. HP should be reassessed 2 to 6 weeks after therapy is initiated to see if his regimen requires further modification.

About the Author

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

References

Case 1:

1. Krist AH, Davidson KW, Mangione CM, et al. Interventions for tobacco smoking cessation in adults, including pregnant persons: US Preventive Services Task Force recommendation statement. JAMA. 2021;325(3):265-279. doi:10.1001/jama.2020.25019
2. US Department of Health and Human Services Tobacco Use and Dependence Guideline Panel. Treating tobacco use and dependence: 2008 update. May 2008. Accessed September 8, 2023. https://www.ncbi.nlm.nih.gov/books/NBK63952/
3. Leone FT, Zhang Y, Evers-Casey S, et al. Initiating pharmacologic treatment in tobacco-dependent adults. An official American Thoracic Society clinical practice guideline. Am J Respir Crit Care Med. 2020;202(2):e5-e31. doi:10.1164/rccm.202005-1982ST

Case 2:

1. National Asthma Education and Prevention Program. Expert Panel Report 3 (EPR-3): Guidelines for the diagnosis and management of asthma-summary report 2007. J Allergy Clin Immunol. 2007;120(suppl 5):S94-S138. doi:10.1016/j.jaci.2007.09.043
2. Cloutier MM, Baptist AP, Blake KV, et al. 2020 focused updates to the asthma management guidelines: a report from the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group. J Allergy Clin Immunol. 2020;146(6):1217-1270. doi:10.1016/j.jaci.2020.10.003