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 as the corticosteroid). The other unique thing about the Advair is that we are using the lowest dose in a patient with “severe” asthma. Digging into this would be a top concern for sure.
The scheduled 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 patient’s 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. Remember that propranolol can be used for esophageal varices prophylaxis.
What else would you want to know more about?
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the use of singular ( prophylaxis, maintenance ) and claritin ( antihistamine ) is there a duration limit of use ?
Why 2 beta blockers? Why on 2 inhaled steroids? Why around the clock albuterol with a LABA. Why not on a LAMA or short acting antimuscarinic instead ? i.e Spiriva or iptatropium
Nicely done. I recall reading on Aspirin and patients with COPD/Asthma. Anything significant there we should be aware of? Thanks Eric
A different question is WHY any BB rather than why 2. In someone with severe persistent asthma, I have sometimes given two ICS as a trial. Would use ICS/LABA + second high potency ICS. Data are not great. Either neutral or positive. I would use two high potency ICS. Reasonable to find out if has aspirin hypersensitivity. Might not need “aggressive” asthma therapy if stop BB. Agree about asking if has hepatic encephalopathy with lactulose. COULD BE a reason for propranolol.
ANOTHER THOUGHT is persistence/adherence. I am working with a severe, persistent asthmatic now. Taking a CLOSE look, he is not refilling ICS/LABA on time, and ends up in ED on regular basis. NO DRUG WORKS if they do not have it or take it.
Thanks Eric. I know NSAIDS is a trigger for asthma, but if low dose then there has to be an indication. Also BB, especially Propanolol. If the patient is equally hypertensive, then other safer alternatives can b used. I suggest You write Generic names of drugs or at least put them in bracket, to allow people of other countries to follow easily for such drug brands not commonly used in their states. Thanks