Annette N. Pellegrino, PharmD, BCPS

Dr. Pellegrino is a clinical assistant professor at the University of Illinois at Chicago College of Pharmacy.

Asthma is a chronic inflammatorydisease of the lungs, leadingto airway constriction and ultimately,remodeling of the bronchialmucosa.

 It is estimated that >17million Americans are currently diagnosedwith the disease. In 2004, itwas estimated that the indirect costsassociated with missed school dayswas $1.5 billion, and missed workdays related to asthma mortality was$1.7 billion.

 The need for better controlof the clinical manifestations ofthis disease is dire. Pharmacists inall settings are in a unique positionto help in this process.

Control recently has been clarified toencompass the minimization of asthmamanifestations through therapeuticintervention along with the attainmentof treatment goals.

 Pharmacologictherapeutic interventions are aimedat reducing airway inflammation anddecreasing bronchospasm.

 Six mainmedication classes are involved in thecontrol of asthma: beta adrenergicreceptor agonists, chromones, glucocorticoids,immunoglobulin E inhibitors,leukotriene inhibitors, and methylxanthines.The National AsthmaEducation and Prevention Program(NAEPP) identifies patient educationand patient self-management as a cornerstonein asthma control.

Many triggers contribute to asthma exacerbations.Patient education shouldfocus on identifying them and developingtrigger-avoidance plans. Environmentaltriggers include tobaccosmoke, dust mites, pollen, mold (indoorand outdoor), and animal dander Avoidance is the best method for minimizingexacerbations; however, it is notalways practical. Educating patients toclean their sheets in hot water (>130°F)once a week and to use protective pillowand mattress covers are optionsfor dust mite avoidance. Patients alsomay be encouraged to wear protectiveface masks while vacuuming or whenoutside on days with high mold or pollencounts.

Smoking cessation is a critical stepin asthma control for those patientswho smoke. For children with asthma,it is important to stress that keepingthe house smoke free will help in theirchild's disease management.

Some triggers can be found in foodproducts or medication classes used totreat comorbid conditions. Aspirin andnonsteroidal anti-inflammatory drugshave been shown to cause exacerbationsin up to 20% of adults and 5% ofchildren.

 Nonselective beta-blockersdo not potentiate an exacerbation butprevent the reversal with short-acting&#946;

Certain food products containing sulfitestrigger exacerbations, such as beer,dried fruit, open salad bars, and wine.

Providing education on these potentialtriggers is an important part of diseasestate management. It also is importantto note that these are potential triggers,and not all of them will affect everypatient.

Although avoiding triggers is 1 step inthe management of asthma, medicationadherence plays another important role.Some patients, although equipped withthe correct medication, lack the skillsto correctly use their medication as aresult of physical inability or a lack ofproper education.

Valved holding chambers (spacers)are delivery aids that fit between theinhaler and the patient's mouth, allowingfor better aerosolized drug transportto the lungs and potentially decreasingsystemic side effects. For proper use,the patient should fit the inhaler into 1end of the spacer, actuate the inhaler,take a slow deep breath, and hold for5 to 10 seconds. If a dose of a particularmedication calls for >1 actuation,this process should be repeated; only1 actuation should be administered ata time.

The use of spacers is recommendedfor young children (>4 years old),adolescents, and adults to aid in thedelivery of aerosolized medication tothe lungs. Spacers are an importanttool in drug administration, as it hasbeen shown that more than half ofpatients do not use proper technique inthe inhaler administration and deliveran inadequate amount of drugs to thelungs.

 In children <4 years old, spacerswith face masks are recommended.The face masks should fit snugly onthe face and fully cover the nose andmouth. Parents and health care professionalsshould never use face masksunless they are placed securely againstthe patient's face, as it has been shownthat a space as little as 2 cm reducesthe delivery of aerosol medication by asmuch as 80%.

Patients also should be counseledabout proper spacer maintenance. Staticcan accumulate along the sides andcause a decrease in the delivery of aerosolizedmedications to the lungs. It isrecommended that spacers be washedin a dilute solution of water and dishsoap (1:10) once a week, and allowedto drip dry.

One of the last steps in patient self-managementis recognition and monitoringof symptoms. Two key componentsin this area are the peak flow meter(PFM) and asthma action plan. Routinemonitoring with the use of PFMs alonedoes not improve patient outcomes,but it can be a useful tool for patientswho are not able to recognize airwayobstruction.

 Currently, the NAEPP recommendsthe use of PFMs for patientswith severe asthma who are not able torecognize airway obstruction; this couldbe a patient with multiple emergencydepartment (ED) visits for asthma exacerbationsin a given year.

In addition to the use of PFMs, theNAEPP has developed an asthma actionplan system using a traffic light approachto the self-management of manifestations.

 The following percentages arebased on the patient's individual bestvalue: the green zone is 80% to 100%,the yellow zone is 50% to 79%, and thered zone is <50%. The red zone usuallyrequires a call to the patient's primarycare provider or 911 if unable to walk ortalk due to shortness of breath. The yellowzone is a caution zone that requiresan oral corticosteroid with steps to takeif a green zone value is not achievedwithin 1 hour.

Although the use of PFMs and asthmaaction plans are important steps in monitoringand controlling symptoms, theyare completely useless if the patientdoes not understand how they workor how to use them correctly. As pharmacists,it is important to recognize thepatient just discharged from the ED andto ensure understanding of these tools.Refilling of short-acting &#946;-agonists toosoon signals that the patient may nothave his or her asthma symptoms undercontrol, and warrants a call to the primarycare provider for further evaluation.

Too often, patients have the propertools for disease state management, butdo not know how to use them appropriately.Pharmacists can empower asthmapatients to get more involved in theirhealth care, help them to better understandtheir disease state, and ultimatelyachieve better management.

Kaminsky DA. Asthma. In: Hanley M, Welsh C: 

Current Diagnosis & Treatment in Pulmonary Medicine

. New York: McGraw-Hill Medical. 2003; 67-78.

Sorkness CA. Asthma. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, eds. 

Pharmacotherapy: A Pathophysiologic Approach

National Institutes of Health, National Heart, Lung, and Blood Institute. National Asthma Education and Prevention Program. Guidelines for the diagnosis and management of asthma (EPR-3) 2007. 

Undem BJ. Pharmacotherapy of Asthma. In: Brunton LL, Lazo JS, Parker KL, eds. 

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Articles

Too often, asthma patients have the proper tools to manage their disease but do not know how to use them properly; the pharmacist is uniquely positioned to help.

Home Management for the Asthma Patient

Annette N. Pellegrino is a clinical assistant professor at the University of Illinois at Chicago College of Pharmacy.

Urinary tract infections (UTIs) are a common and often recurring complaint, especially among sexually active women. 

 is the causative agent in 85% of community-acquired UTIs occurring in the United States each year; it is estimated that 6 million to 8 million episodes of UTIs in this patient population cause $1 billion in direct health care costs and >8 million physician visits per year.

 UTIs can be broken down into a number of categories, depending on site of infection and whether they are considered complicated or uncomplicated. For the purpose of this article, UTI will be synonymous with acute, uncomplicated cystitis.

The majority of UTIs occur in sexually active women. Risk increases at least 3-fold in this patient population when diaphragms are used for contraception. Failure to void the bladder shortly after sexual intercourse, as well as the use of spermicides, also increase the risk for acquiring a UTI.

The most common presenting symptoms of a UTI are dysuria, along with urgency or polyuria. These characteristic symptoms can predict the diagnosis of a UTI in 70% to 80% of all cases.

 The gold standard for diagnosis is a urine analysis, preferably captured mid-stream to avoid contaminants. OTC dipstick tests are available; however, unless the infecting bacteria are gram-negative, this test could lead to a false negative. Given the high percentage of diagnoses from symptomatic presentations, further questioning of patients about symptoms is warranted for potential referral to their primary care provider.

The Table provides a summary of the most common agents and typical dosing used in the treatment of UTIs.

 One important factor to consider in the choice of agents for UTIs is drug inter-actions. Sulfonamides' main interactions include oral anticoagulants, sulfonylurea hypoglycemic agents, and hydantoin anticonvulsants. The mechanism for these interactions is believed to be inhibition of metabolism, thus potentiating the effect of the other agent.

Dosage adjustment most likely will be necessary when a sulfonamide is given concomitantly with these agents.

Interactions with the fluoroquinolone class and oral anticoagulants also exist, but to a lesser extent than the sulfonamides. For the majority of the antibiotic agents, gastrointestinal (GI) upset is the main set of adverse drug reactions that occur with therapy.

Phenazopyridine hydrochloride displays an analgesic action on the urinary tract and alleviates the common presentation symptoms of UTIs: dysuria, polyuria, burning, and urgency. This agent can be found in a variety of OTC products in dosages <100 mg. The usual prescription dose is 200 mg, 3 times daily. An important patient counseling point for this medication is that it can dye the urine an orange/red color. The most common adverse effect is GI upset, which can be avoided if administered with food. Some clinical controversy does exist with the use of this medication, as it can mask the symptoms of a UTI in an infection that may not be responding to antibiotic therapy.

Cranberry products have been debated in current literature without much consensus on their utility. One proposed mechanism for their use in preventing UTIs is by decreasing the ability of the infecting pathogen to adhere to the bladder.

probiotics also have been theorized to help reduce the risk of acquiring UTIs. The theory is that the 

 lowers the vaginal pH, thus decreasing the chance of bowel flora (

More than 20% of women who initially were diagnosed with a UTI will develop frequent recurrences.

 can be defined as a symptomatic episode that occurs at least 3 times in a year. Women who fall into this category can be classified as candidates for long-term administration of low-dose prophylactic antibiotic therapy.

These women should receive proper education to avoid spermicide use and to void their bladder shortly after intercourse to help decrease the risk of a UTI. Medications of choice for prophylactic therapy include daily or 3-times-a-week low-dose administration of the following agents: trimethoprim-sulfamethoxazole (single strength), trimethoprim, or nitrofurantoin.

Patient education in minimizing behaviors associated with an increased risk of acquiring UTIs plays an important role in reducing the occurrence of these community-acquired infections. When dispensing antibiotic prescriptions for the treatment of UTIs, pharmacists can use the opportunity to remind patients of risk factors for recurrence. Pharmacists also are well-positioned to help identify patients needing referral to their primary health care provider for assessment, as well as those who might benefit from prophylactic therapy.

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Harrison's Principles of Internal Medicine.

 17th ed. New York,  NY: McGraw-Hill; 2008:937.

2. Warren JW, Abrutyn E, Hebel JR, et al. Guidelines for antimicrobial treatment of uncomplicated acute bacterial cystitis and acute pyelonephritis in women. 

CURRENT Practice Guidelines in Primary Care 2009. 

4. Coyle EA, Prince RA.      Urinary Tract Infections and Prostatitis. In: DiPiro JT, Talbert RL, Yee      GC, Matzke GR, Wells BG, Posey LM, eds. 

Pharmacotherapy: A Pathophysiologic Approach.

 7th ed. New York, NY:      McGraw-Hill; 2008:1899. 

5. Petri WA.      Sulfonamides, Trimethoprim-Sulfamethoxazole, Quinolones, and Agents for      Urinary Tract Infections. In: Brunton LL, Lazo JS, Parker KL, eds. 

Goodman & Gilman's The Pharmacological      Basis of Therapeutics.

 11th edition. New York, NY: McGraw-Hill; 2005:1111.