Kasus 1

Bapak bambang (65 tahun) dengan berat badan 60 kg datang ke apotek untuk membeli
obat berdasarkan resep.
Diagnosa dokter :
- DM tipe II sejak 2 tahun yang lalu, dan selama 6 bulan terakhir sudah terkontrol
menggunakan pengobatan Amaryl M 1 x sehari.
- Hipertensi sejak 1 tahun yang lalu, telah menggunakan valsartan 80 mg 1 x sehari akan
tetapi hipertensi pasien tidak terkontrol (TD 180/90 mmHg).
- Asma sejak 10 tahun yang lalu dan sudah terkontrol. Tetapi akhir-akhir ini sering kambuh
karena cuaca dingin dan debu dan pasien menggunakan ventolin inhaler bila perlu.
Kondisi pasien yang lain :
Gejala flu meliputi hidung tersumbat, demam dan pusing, disebabkan karena cuaca dingin.
Pasien merokok sejak umur 45 tahun, rata-rata½ bungkus per hari, memiliki kebiasaan minum
kopi 2 x sehari. Dan sering mengkonsumsi antasida apabila pasien mengalami keluhan di
lambung.
Pemeriksaan Fisik :

Pemeriksaan Hasil pengukuran Normal

Tekanan Darah 180/90 mmHg 120/80 mmHg
BMI 160 cm/60 kg = 23,49 normal
Respiration Rate 12 x/menit 8-12 x / menit
Heart Rate 80 x/menit 60 – 100 x /menit

Data Laboratorium

Pemeriksaan Hasil Pengukuran Nilai Normal

GDP 85 mg/dl 70 – 110 mg/dl
GD2PP 120 mg/dl <140mg/dl
Hb A1c 7% <8%
GFR 118 ml/menit 120 + 25 ml/menit
BUN 20 mg/dl 8,0 – 20,0 mg/dl
TG 140 mg/dl s/d 190 mg/dl
HDL 60. mg/dl >55 mg/dl
LDL 110 mg/dl <150 mg/dl
Resep :

dr. Darmawan
SIP : 7678/SP/98
Jalan Sunaryo 8 Yogyakarta

Yogyakarta, 12 Desember 2011

 C
H
R/ Amaryl M. No. XXX S. AP
s. d. d. 1 a.c
R/ Valsartan
TE
S. s. d.d. 1 p.c R
R/ Adalat OROS No. XXX (Nifedipin) S. 24
s. d. d. 1 p.c
R/ Ventolin Inhaler I (Salbutamol) S Ch
prn ro
nic
Pro : Bp Bambang As
th
Umur : 65 tahun m
Alamat : Kompleks Colombo No 325 Yk a
79
SH

24 No alcohol or tobacco use. Married, sexually active.

Lives with husband (cabinetmaker; non-smoker) and
two cats.

CHRONIC ASTHMA Meds

Fluticasone HFA 110 mcg, 2 puffs BID
Cat Got Your Tongue? . . . . . . . . . . . . . . . . . . . .
Albuterol HFA 2 puffs Q 4–6 h PRN shortness of breath
.Level I Ortho-Tri-Cyclen 1 po daily
Julia M. Koehler, PharmD Propranolol 80 mg po BID
Maxalt-MLT 5 mg po PRN acute migraine
Carrie Maffeo, PharmD, BCPS, CDE
All
Sulfa (rash)
this morning. She states that she has been using her albuterol
LEARNING every hour for the past 6 hours and that it doesn’t seem to be
OBJECTIVES helping. Her peak flows have been running between 180 L/min
After completing this case study, the reader should be and 200 L/min today (personal best = 400 L/ min). In addition to
able to: her albuterol MDI, which she uses PRN, she also has a fluticasone
MDI, which she uses “most days of the week.” She reports having
• Recognize signs and symptoms of uncontrolled
to use her albuterol inhaler approximately 3–4 times per week
asthma.
over the past 2 months, but over the past week she admits to
• Identify potential causes of uncontrolled using albuterol almost daily. She reports being awakened by a
asthma. cough three times over the past month. She states she especially
• Formulate a patient-specific therapeutic plan becomes short of breath when she exercises; although she admits
(including drugs, route of administration, and that her shortness of breath is not always brought on by
appropriate monitoring parame- ters) for exercise and sometimes occurs when she is not actively exercising.
management of a patient with chronic asthma. She indicates that her morning peak flows have been running
around 300 L/min (personal best = 400 L/min) over the past
• Develop a self-management action plan for several weeks.
improving control of asthma.
PM
H
PATIENT
Asthma (previously documented as “mild persistent”) since
PRESENTATION child- hood; no prior history of intubations; hospitalized
twice in the past year for poorly controlled asthma; three visits
Chief
to the ED in the past 6 months; treated with oral systemic
Complai
corticosteroids during both hospitalizations and at each ED
nt
visit.
“I can’t…breathe…and my albuterol…doesn’t seem to be Migraine headache disorder (diagnosed at age 21); currently
helping!” taking prophylactic medication; has had only one migraine
attack in the past year.
H F
P H
I
Both parents living; mother 52-years-old with HTN,
Madison Bradley is a 29-year-old woman who presents to osteoporosis; father 54-years-old with COPD (33 pack-year
the ED for an acute visit due to shortness of breath. She smoking history) and Type 2 DM; brother, age 34 (smoker);
reports feeling especially short of breath since awakening sister, age 32 (non-smoker)
 ra
x
Phy
High-pitched, diffuse expiratory wheezes bilaterally,
sica
two-thirds of the way up
l
Exa B
min r
atio e
n a
G s
e t
n s
Anxious-appearing Caucasian female; moderate Nontender
respiratory distress with audible wheezing without masses
noted; unable to speak in complete sen- tences;
C
suprasternal muscle retractions noted; hunched
V
forward
Tachycardia; Regular
V rhythm; no MRG
S
A
BP 134/78, HR 110, RR 22, T 37°C; Wt 68 kg, Ht b
5'5''; Pulse Ox 88% d
o
n Soft,
NTND;
R (+) BS
A G
H e
E n
E i
N t
T /
R
PERRLA; mild oral e
thrush; TMs intact c
t
N
e D
c e
k f
/ e
L r
y r
m e
p d
h
E
N x
t
o
d Normal ROM; peripheral pulses
e 3+; no CCE
s
N
Supple; no
e
lymphadenopathy or
u
thyromegaly
r
L o
u No motor deficits; CN II–XII grossly intact;
n A&O×3
g
s
/ L
T a
h b
o s

Na 134 mEq/L Hgb 12 g/dL WBC 8.0 × 103/mm3

SE
CT K 3.0 mEq/L Hct 36% Ca 9.3 mg/dL
IO PMNs 56% Cl 99 mEq/L
RBC 5.0 × 106/mm3 Bands
N 1%
3 CO2 28 mEq/L MCH 28 pg Che
Eosinophils 3% BUN 22 mg/dL st
MCHC 34 g/dL Basophils
2%
X-
SCr 0.7 mg/dL MCV 90 μm3 Ray
Re Lymphocytes 33% Glu 117 mg/dL Hyperinflated lungs; no
spi Plts 192 × 103/mm3 Monocytes
rat infiltrates
5%
or 80 Therapeutic
y
Di Alternative
so
rd
As s
ses
ers sm 3.a. What nonpharmacologic therapies might
ent be useful for this patient?
29 yo woman with moderate to severe exacerbation 3.b. What feasible pharmacotherapeutic
of asthma; alternatives are available for treatment of
uncontrolled this patient’s chronic asthma?
chronic asthma
O
Cli
nical p
Cours t
e i
The patient is admitted overnight for treatment with m
oxygen, inhaled bronchodilators, and oral prednisone 60
mg daily. She is discharged home with her previous
a
regimen plus nebulized albuterol 2.5 mg every 8 hours l
for 5 days and prednisone 60 mg orally once daily to P
complete a 10-day burst. She was also given nystatin l
swish and swallow for treatment of her oral thrush
infection. On follow-up at day 4 in the clinic, her lungs a
are clear without wheezing; her respira- tory rate is 16 n
breaths per minute; and her pulse oximetry is 97% on 4.a. Outline an optimal plan of treatment for
room air. Her peak flow readings have improved to 300 this patient’s chronic asthma.
L/min.
4.b. What alternatives would be appropriate if
the initial therapy fails?

QUES Outcom
TIONS e
Evaluat
Problem ion
Identification 5. What clinical parameters are necessary to
1.a. Create a list of the patient’s drug therapy evaluate the therapy for achievement of the
problems. desired therapeutic effect and to detect or
1.b. What information indicates the presence of prevent adverse effects?
uncontrolled chronic asthma and an acute asthma
exacerbation? Patie
1.c. What factors may have contributed to this patient’s nt
poorly controlled asthma and acute exacerbation? Educ
1.d. How would you classify this patient’s level of ation
asthma control (well controlled, not well
6. What information should be provided to the
controlled, or very poorly con- trolled),
patient regarding the use of her asthma
according to NIH guidelines?
medications and how she can use her peak-
flow readings to better manage her disease?
Desired
Outcome ■ SELF-STUDY
2. What are the goals of pharmacotherapy ASSIGNMENTS
in this case?
1. Review the NIH guidelines on the management of
asthma during pregnancy, and develop a
pharmacotherapeutic treatment plan for this
patient’s asthma if she were to become pregnant.
2. Review the literature on the impact of chronic
inhaled cortico- steroid use on the risk for
development of osteoporosis, and
write a two-page paper summarizing the available
published literature on this topic.
CLINICAL
PEARL
Patients with asthma who report that taking aspirin
makes their asthma symptoms worse may respond well to
leukotriene modifiers. Aspirin inhibits prostaglandin
synthesis from arachidonic acid through inhibition of
cyclooxygenase. The leukotriene pathway may play a role
in the development of asthma symptoms in such patients,
as inhibition of cyclooxygenase by aspirin may shunt the
arachidonic acid pathway away from prostaglandin
synthesis and toward leuko- triene production. Although
inhaled corticosteroids are still the pre- ferred anti-
inflammatory medications for patients with asthma and
known aspirin sensitivity, leukotriene modifiers may also
be useful in such patients based on this theoretical
mechanism.
REFER
ENCES
1. National Asthma Education and Prevention Program.
Executive sum- mary of the NAEPP expert panel report 3:
guidelines for the diagnosis and management of asthma.
Bethesda, MD: U.S. Department of Health and Human
Services, Public Health Service, National Institutes of
Health, National Heart, Lung, and Blood Institute, Full
Report 2007. Available at
http://www.nhlbi.nih.gov/guidelines/asthma/index.htm.
2. Global Initiative for Asthma (GINA). Global strategy for
asthma man- agement and prevention (updated 2006).
Available at http://www. ginasthma.org; 2006.
3. Greening AP, Ind PW, Northfield M, et al. Added
salmeterol versus high-dose corticosteroid in asthma
patients with symptoms on existing inhaled corticosteroid.
Lancet 1994;344:219–224.
4. Busse W, Raphael GD, Galant S, et al. Fluticasone
Propionate Clinical Research Study Group. Low-dose
fluticasone propionate compared with montelukast for
first-line treatment of persistent asthma: a randomized
clinical trial. J Allergy Clin Immunol 2001;107:461–468.
5. Busse W, Nelson H, Wolfe J, et al. Comparison of inhaled
salmeterol and oral zafirlukast in patients with asthma. J
Allergy Clin Immunol
1999;103:1
075–1080.
6. Humbert M, Beasley R, Ayres J, et al. Benefits of
omalizumab as add- on therapy in patients with severe
persistent asthma who are inade- quately controlled
despite best available therapy (GINA 2002 step 4
treatment): INNOVATE. Allergy 2005;60:309–316.
7. Food and Drug Administration (FDA) 2007. FDA alert:
Omalizumab (marketed as Xolair) information 2/2007.
Available at: http://
www.fda.gov/cder/drug/infopage/omalizumab/default.htm.
2
5
CHRONIC
OBSTRUCTIVE
PULMONARY DISEASE
Quick Fix, Lifetime Risk . . . . . . . . . . . . . . . . . . .Level
II
Joel C. Marrs, PharmD,
BCPS

LEARNING
OBJECTIVES
After completing this case study, the reader should be able
to:
• Recognize modifiable and nonmodifiable risk factors for
the development of COPD.