Case Studies: Respiratory Illnesses

JANUARY 08, 2019
Mary Barna Bridgeman, PharmD, BCPS, BCGP, and Rupal Patel Mansukhani, PharmD
Case 1: Mild Asthma Symtpoms 

Q: TR, a 23-year-old man, is seeking advice. Although he is generally in good health, he has recently been developing a mild wheezing and tightness in his chest after exercising and playing soccer. TR does not smoke and has not had any respiratory illnesses recently. However, he does recall using an inhaler as a child for asthma but was told that he had outgrown the condition. TR does not take any medications. He says he does not want to follow up with a physician, if possible, because he is between jobs and does not have health care insurance. What information can you provide regarding nonpharmacologic approaches to managing this condition and self-care?

A: TR may be suffering from intermittent, exercise-induced asthma symptoms, given his history and symptoms. As far as self-care options, it is important to recognize that the FDA recently approved a new formulation of the OTC epinephrine inhaler Primatene Mist to treat mild, intermittent asthma symptoms. This chlorofluorocarbon-, propellant-free formulation is likely to be available in early 2019 on pharmacy shelves and will replace the original formulation withdrawn from the market in 2011. Approved for use in patients 12 years and older, unlike the original preparation, the new formulation will include a different inhaler device accompanying the active ingredient, epinephrine. Patients should be educated about proper use, including the need for priming and shaking before use and cleaning the device afterward. Although  this is a reasonable option for alleviating TR’s infrequent symptoms, it is nonetheless worth educating him about the chronic and inflammatory nature of asthma. If TR does not respond within 20 minutes of using a dose, experiences more than 2 attacks in a week, notices worsening symptoms, or is using more than 8 doses in a 24-hour period, he should be urged to seek medical evaluation. This medication is an effective bronchodilator but will ultimately not address more moderate-to-severe asthma symptoms and treat the underlying disease.1

Case 2: Cold Symptoms 

Q: AI, a 60-year-old woman, wants to know what OTC remedy is best for treating her cold symptoms. Her medical history includes hypertension and hyperthyroidism, and she is taking several medications, including lisinopril and methimazole. AI is suffering from significant nasal congestion, which is preventing her from sleeping well at night, and she would like to take a nonprescription decongestant, but the label on the medication she selected says to check with a doctor or a pharmacist if individuals have high blood pressure or thyroid disease. What recommendations can you provide? 

A: There are an estimated 62 million occurrences of the common cold in the United States each year. Symptoms include congestion, cough, headache, malaise, pain, postnasal drip, rhinorrhea, sinus pressure, and/or sneezing. Given AI’s medical and medication history, she should avoid systemic decongestants containing pseudoephedrine or other active ingredients that cause vasoconstriction to provide symptom relief. These agents can cause increases in blood pressure and may exacerbate symptoms of hyperthyroidism. To err on the side of caution, it is prudent to recommend forms of nonpharmacologic relief of congestion in this case, including nasal decongestant strips, saline or a teapot, or topical camphor- or menthol-containing preparations that may help clear inflamed nasal passages. 

Case 3: Pearls for Patients with COPD 

Q: HW, a 74-year-old man, is looking for advice. His wife encouraged him to speak with a pharmacist, as he recently received a diagnosis of chronic obstructive pulmonary disease (COPD) and wants to make sure he is doing everything he can to reduce his chances of complicating or exacerbating his condition. HW has a significant medical history, including coronary artery disease post stent placement, heart failure, hypertension, and high cholesterol, along with his new diagnosis of COPD. He has an extensive medication list, which includes various pharmacologic agents for managing these conditions. HW started smoking as a teenager and quit cold turkey several years ago at the uArging of his cardiologist. What information can you provide regarding self-management of HW’s COPD?

A: COPD is estimated to affect more than 16 million Americans, with older adults more likely to experience this condition than younger individuals.2 Although COPD necessitates medical evaluation and prescription drug treatment, self-care and self-management are critical to ensuring optimization of symptom control and quality of life through reduction in exacerbations and hospitalizations for complications. In HW’s case, there are several important educational opportunities for the pharmacist. These include asking him to demonstrate his inhaler technique and reviewing it with him; ensuring that he is up-to-date on all indicated vaccines, based on his age and medical comorbidities; inquiring about medical follow-up appointments; and underscoring the importance of using his maintenance medications, even if he is not having trouble breathing. In addition, social support is critical to ensuring optimal health outcomes, particularly with a chronic lung disease such as COPD. Living with a chronic disease is difficult, and the risk of comorbid depression is high. Encourage HW to include his wife, other family members, or caregivers to help him manage his condition and troubleshoot with him if questions arise. 

Case 4: Influenza

Q:
AT, a 38-year-old woman, calls the pharmacy inquiring about self-care for influenzalike symptoms. She works as an elementary school teacher and reports a sudden onset of chills, fatigue, general malaise, and muscle pains that caused her to be sent home out of fear that she had the flu, even though she had received her influenza vaccine. Upon arriving home, AT took her temperature and confirmed a fever of 101.6°F. She reports no significant medical history and says she takes no chronic medications other than occasional nonprescription medicines for mild conditions. AT has a cadre of cold and cough preparations at home, along with some pain relievers, but she wants to know what will best alleviate her symptoms and help her recover as quickly as possible. What recommendations or eAducation on self-care for managing flulike symptoms can you offer?

A: Symptoms associated with the influenza virus can vary and range from mild to severe. Given AT’s age and medical history, she is not considered high risk for developing influenza-associated complications. Nonetheless, it isimportant to educate her about proper self-care to promote recovery and reduce her chances of spreading the illness. First and foremost, encourage AT to stay home and avoid contact with others as much as possible, unless she needs medical care. She may consider seeking medical evaluation for confirmation of influenza and treatment with prescription medications to reduce symptom duration. For the 2018-2019 influenza season in the United States, 4 antiviral medications (oral baloxavir and oseltamivir, inhaled zanamivir, and intravenous peramivir) are approved and recommended to treat influenza.3 Regarding the efficacy of these medications, time is of the essence, as these agents should be initiated within 48 hours of the onset of symptoms. Beyond consideration for antiviral therapy, supportive care interventions should be used. These include controlling the fever with whatever analgesic or antipyretic AT has in her medicine cabinet; hydrating with water, soups, juices, or other noncaffeinated beverages; and washing her hands to avoid spreading the virus. Encourage her to stay home for at least 24 hours after the fever subsides, in accordance with CDC recommendations.4

REFERENCES
  1. CDER conversation: safely using the newly available OTC asthma inhaler Primatene Mist. FDA website. www.fda.gov/Drugs/NewsEvents/ucm624994.htm. Updated November 8, 2018. Accessed November 17, 2018.
  2. COPD national action plan. National Heart, Lung, and Blood Institute website. nhlbi.nih.gov/health-topics/education-and-awareness/COPD-national-action-plan. Accessed November 18, 2018.
  3. Influenza antiviral medications: summary for clinicians. CDC website. cdc.gov/flu/professionals/antivirals/summary-clinicians.htm. Updated November 28, 2018. Accessed December 13, 2018.
  4. The flu: what to do if you get sick. CDC website. cdc.gov/flu/takingcare.htm. Updated March 9, 2018. Accessed December 13, 2018.
 
Mary Barna Bridgeman, PharmD, BCPS, BCGP, is a clinical associate professor at the Ernest Mario School of Pharmacy at Rutgers University in Piscataway, New Jersey, and an internal medicine clinical pharmacist at Robert Wood Johnson University Hospital in New Brunswick, New Jersey.

Rupal Patel Mansukhani, PharmD,CTTS, FAPhA, is a clinical associate professor at the Ernest Mario School of Pharmacy at Rutgers University and a transitions-of-care clinical pharmacist at Morristown Medical Center in New Jersey.



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