Case approach in

Asthma and Allergic rhinitis

Assist.Prof.Sunee Lertsinudom
BSc.Grad.Diplo.BCP.
Department of Clinical pharmacy
Khonkaen University
Outlines
- Systematic approach
- Case approach in pediatric Asthma and allergic rhinitis
- Case approach in adult Asthma and allergic rhinitis
Systematic approach

(Adapted from Clinical Resource and Audit Group, 1996)

Step 1: Assess the patients drug therapy needs
and identify actual and potential drug therapy problems
Good communication
To collect, synthesize and interpret the relevant information.
Assess the risk of drug therapy problems
Pharmacists SOAP notes

S= Subjective data
O= Objective data
A= Assessment
P= Plan
 SOAP note
Data from patient
CC, PI

PMH, SH, FH

Medical history

All, SE

Etc.
 SOAP note

Physical examination
Vital signs
Laboratory data
Diagnostic tests
Etc.
 SOAP note

Critical thinking
Analyze subjective and objective data
Patients health status
DTPs
Patients health outcomes
Analyze goals and if met or not
Assessment
IESAC
I - indication
E - efficacy
S - safety
A - adherence
C cost
Step 2: Develop a care plan to
resolve and/or prevent drug therapy problems
Prioritize drug therapy problems
Identify desired therapeutic objectives and proposed actions
Develop a monitoring strategy
Document the care plan
 SOAP note

Action to resolve any identified problems.

Action should be goal oriented.
Action should be patient and medication specific.
Action should include follow up monitoring (when F/U)
 SOAP note
Therapeutic plan
Goal
Monitoring parameter:
Efficacy
Safety or toxicity or ADRs
Education
Future plan
 Systematic approach

Step 3: Implement the care plan

Step 4: Evaluate and review the care plan

 1

4 04/11/54
CC: - ()
HPI: known case asthma
/
1

1
1

PMH: asthma
15/08/51: Imp. Acute asthmatic attack with
respiratory failure, pneumonia on ET-tube 7
salbutamol syrup, amoxicillin/clavulanic acid

23/09/51: Lung: crepitation both lung, CXR: pulmonary

infiltration at RUL Imp: bacterial pneumonia with acute asthmatic
attack amoxicillin, paracetamol
salbutamol syrup loss of follow up
 1

23/05/53-4/06/53: refer
acute asthmatic attack with respiratory failure on ET-tube 7
days
seretideR evohaler (salmeterol 25 mcg/fluticasone 125 mcg) 1 puff bid
with spacer, salbutamol MDI 2 puff prn refer

26-29/06/54: admit Imp: bacterial pneumonia

with acute asthmatic attack seretideR evohaler
(salmeterol 25 mcg/fluticasone 125 mcg) 1 puff bid with spacer,
salbutamol MDI 1 puff prn, prednisolone (5) 1x3, amoxicillin syrup 1.5
tsp PO tid
 1
5/08/54: discharge
salbutamol MDI 2-3 salbutamol

31/08/54-02/09/54: admit Imp: viral pneumonia with
acute asthmatic attack salbutamol NB .

Med PTA
5/08/54 (asthma clinic)
Seretide evohaler (salmeterol 25 mcg/ fluticasone 125 mcg)1 puff bid
Salbutamol MDI 2 puff PRN
2/09/54 (home medication)
Oseltamivir 30 mg PO bid
Clarithromycin 4 ml PO bid
Salbutamol 3.5 ml PO tid, hs
 1

ALL: NKDA
SH:
FH:
PE: Alert, BW 15 kg, Ht 105 cm
V/S: BP 110/70 mmHg, RR 24 /min, HR 110 /min
Lung: clear
Clear discharge from nose
Imp: Uncontrolled asthma with Allergic rhinitis
 1

Interviewing data:
spacer
:

salbutamol MDI
Medication:
Seretide evohaler (salmeterol25 mcg/ fluticasone125 mcg)1puff bid# I
Salbutamol MDl 2 puff PRN # I
Montelukast (5 mg) 1xhs # 90 tab
F/U: 12 wk (27/01/55)
How to approach?
 SOAP note

Analyze subjective and objective data

Patients health status
DTPs
Patients health outcomes
Analyze goals and if met or not
Assessment
IESAC
I - indication
E - efficacy
S - safety
A - adherence
C cost
 Step approach

1.

2.
 Asthma predictive index
Wheezing 3 1 1
1 2


Atopic dermatitis

AR
Eo 5 %
wheezing
 Differentiating allergic rhinitis from other causes
Symptom suggestive of allergic rhinitis Symptom usually NOT
associated with allergic rhinitis

2 or more following symptoms for -unilateral symptoms

>1 hr on most day -nasal obstruction without other
symptoms
-watery anterior rhinorhea -mucopurulent rhinorhea
-sneezing,especially paroxysmal -posterior rhinorrhea (post nasal
-nasal obstruction drip) with thick mucous
-nasal pruritus and /or no anterior rhinorrhea
-pain
+/- conjunctivitis -recurrent epistaxis
-anosmia
Classify and assess severity
ARIA = Allergic Rhinitis and its Impact on Asthma. Refer the patient rapidly to a physician
Bousquet et al. J Allergy Clin Immunol. 2001;108 (5 suppl):S147.
Bousquet et al. Allergy. 2002;57:841.
Levels of Asthma Control: GINA 2010
 Classification of allergic rhinitis
Intermittent symptoms Persistent symptoms
l 4 days per week l >4 days per week
l Or 4 weeks l And >4 weeks
Mild Moderate/Severe
l Normal sleep One or more items
l Abnormal sleep
l Normal daily activities, sport, l Impairment of daily activities,
leisure sport, leisure
l Normal work and school l Problems caused at work
or school
l No troublesome symptoms l Troublesome symptoms

Bousquet J. Reid J. Weel C.V. et al. Allergic rhinitis management pocket reference 2008. Allergy 2008: 63: 990996
.
Step approach

3.
Stepwise approach to management of
allergic rhinitis
Short course of
corticosteroids added to INS,
INS added to non-sedating AH
non-sedating AH decongestant or LTRA
decongestant or
Non-sedating AH LTRA
decongestant or Inadequate response to
LTRA therapy, symptoms
Moderate persistent impact upon HRQoL,
symptoms, co-morbidities
Mild intermittent bothersome
symptoms Step-down
as symptoms improve:
Immunotherapy if symptoms: lReduce number of drugs
lShow inadequate response to therapy lReduce dose
lProlonged lChange therapy
lImpact upon HRQoL
lLead to co-morbid conditions

AH, antihistamine; HRQoL, health-related quality of life; Bousquet J et al. Allergy 2008;63(Suppl 86):8160.
Step approach

4.

Step approach

5.
 2

59 3/11/54
CC: 1
1 1
HPI: known case asthma
( 5 ) salbutamol MDI
prn controller allergic
rhinitis
24/02/2553 . acute asthmatic
attack
28/02/53 admit . acute asthmatic attack
 2

11/03/53 easy asthma clinic .

lung function
30/09/53 . Seretide accuhaler
(salmeterol 50 mcg/ fluticasone 250 mcg) 1 puff bid
Salbutamol MDI 2 puff prn loss of follow up

28/09/54 -01/10/54 admit . Dx. Acute asthmatic attack

asthma clinic 3/11/54
PMH: asthma, AR, OA knee
 2

Med PTA (1/10/54):

Prednisolone (5 mg) 2 tab tid # 30
Salbutamol MDI 2 puff prn # I
Seretide accuhaler(salmeterol 50 mcg/fluticasone 250 mcg)1 puff bid # I
Ranitidine (150 mg) 1 tab BID # 20
Bromhexine 1x3 # 1 tab TID # 20
ALL: penicillin
amoxycilin
PE: Thai female good conscious
BW 64.6, Ht 153 cm, BP 130/70 mmHg, PEFR 150 L/min (46% predicted)
HEENT: no oral candidiasis
 2

Interviewing data:
1

seretide
accuhaler 3

:

Accuhaler:
MDI:
F/U: 4 wk (1/12/54)
How to approach?
 Step approach

1.

2.
 Asthma Diagnosis

History and patterns of symptoms

Physical examination
Measurements of lung function
 Is it Asthma?

Recurrent episodes of wheezing

Troublesome cough at night
Cough or wheeze after exercise
Cough, wheeze or chest tightness after exposure to airborne
allergens or pollutants
Colds go to the chest or take more than 10 days to clear
Symptoms respond to anti-asthma therapy
 Differentiating allergic rhinitis from other causes
Symptom suggestive of allergic rhinitis Symptom usually NOT
associated with allergic rhinitis

2 or more following symptoms for -unilateral symptoms

>1 hr on most day -nasal obstruction without other
symptoms
-watery anterior rhinorhea -mucopurulent rhinorhea
-sneezing,especially paroxysmal -posterior rhinorrhea (post nasal
-nasal obstruction drip) with thick mucous
-nasal pruritus and /or no anterior rhinorrhea
-pain
+/- conjunctivitis -recurrent epistaxis
-anosmia
Classify and assess severity
ARIA = Allergic Rhinitis and its Impact on Asthma. Refer the patient rapidly to a physician
Bousquet et al. J Allergy Clin Immunol. 2001;108 (5 suppl):S147.
Bousquet et al. Allergy. 2002;57:841.
Levels of Asthma Control: GINA 2010
 Classification of allergic rhinitis
Intermittent symptoms Persistent symptoms
l 4 days per week l >4 days per week
l Or 4 weeks l And >4 weeks
Mild Moderate/Severe
l Normal sleep One or more items
l Abnormal sleep
l Normal daily activities, sport, l Impairment of daily activities,
leisure sport, leisure
l Normal work and school l Problems caused at work
or school
l No troublesome symptoms l Troublesome symptoms

Bousquet J. Reid J. Weel C.V. et al. Allergic rhinitis management pocket reference 2008. Allergy 2008: 63: 990996
.
Step approach

3.
Stepwise approach to management of
allergic rhinitis
Short course of
corticosteroids added to INS,
INS added to non-sedating AH
non-sedating AH decongestant or LTRA
decongestant or
Non-sedating AH LTRA
decongestant or Inadequate response to
LTRA therapy, symptoms
Moderate persistent impact upon HRQoL,
symptoms, co-morbidities
Mild intermittent bothersome
symptoms Step-down
as symptoms improve:
Immunotherapy if symptoms: lReduce number of drugs
lShow inadequate response to therapy lReduce dose
lProlonged lChange therapy
lImpact upon HRQoL
lLead to co-morbid conditions

AH, antihistamine; HRQoL, health-related quality of life; Bousquet J et al. Allergy 2008;63(Suppl 86):8160.
Step approach

4.

Step approach

5.
Any questions ?
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