You can’t tell everything from a medication list, but you can certainly begin to formulate questions and identify possible areas of concern.  What do you notice that seems a little wacky? Here’s a patient with severe asthma, on multiple medications:

• Advair 100/50 BID
• Albuterol inhaler 2 puffs four times daily and as needed
• Singulair 10 mg daily
• Pulmicort nebulizer 0.5 mg twice daily
• Claritin 10 mg daily
• Lactulose 30 mls twice daily
• Propranolol 20 mg BID
• Diovan 80 mg daily
• Coreg 6.25 mg BID
• Aspirin 81 mg daily

If we address the known “severe asthma” first, the duplication of two inhaled corticosteroids is a little bizarre.  The patient has orders for both Pulmicort nebulizer (and why are they doing a nebulizer?) and Advair (which contains a long acting beta agonist as well).  The other unique thing about the Advair is that we are using the lowest dose in a patient with “severe” asthma.    I have had situations where the patient will use nebulized medications most of the time and a non-nebulized form for when they may be traveling or out of their home for a while and don’t want to carry the nebulizer. Digging into this would be a top concern for sure.

The schedule use of albuterol and assessment of how much prn albuterol is being used would also be an important aspect in this case.

Next I would look at the duplicate beta-blockers.  This patient is on both Coreg (carvedilol) and Propranolol.  Also remember that propranolol is non-selective and has a higher risk of exacerbating this patients asthma than other beta-blockers.  With that stated, and noticing the lactulose order, I would assess if this patient has a history of liver issues.

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