Case 1

Mr Thomson, a 32 year old asthmatic who is well known to you comes into your pharmacy.
He is known to have a best peak flow of 640 L/min. He tells you that over the last few weeks
he has been wakening up once or twice a week coughing, and he is using his salbutamol
inhaler a couple of times a day. He has recorded his morning and night-time peak flows
these have averaged 580 L/min and 540L/min respectively. He has recently changed his job
and is now working in the open air rather than in an office.

His PMR shows that he has been maintained on

salbutamol MDI 2 puffs as required
beclometasone 100 MDI 2 puffs twice a day (recently changed to non CFC
(Clenil Modulite))

for the last four years. He also buys antihistamine tablets from you during the summer.
®
His prescription today is for a Seretide MDI 50 2 puffs twice a day.

Based on the information available construct a care plan for this patient. He is under
pharmacist care for his asthma.

Include in the plan the immediate management of the patient and the monitoring you
would carry out to ensure that the patient is benefiting from your plan.

The immediate management needs of this patient relate to the step up of his asthma
medication caused by the loss of control of his asthma. The patient has uncontrolled
asthma but his PEFR is between 84 and 90% of predicted. The other signs of
uncontrolled / poorly controlled asthma are the night-time wakening and cough.

The immediate care issues are

• To ensure that his beclomethasone inhalers is stopped to ensure that he does
not take too much inhaled steroid
• To ensure that he understands the step up in his medication by the inclusion of
a LABA
• To explain that the steroid in Seretide is twice as potent as beclometasone so
the dose has not been reduced by the introduction of the Seretide 50 inhaler
• To ensure that the patient can use the inhaler device and understands the
need to take it twice a day and rinse his mouth / brush his teeth after use of
the inhaler
• To investigate with the patient any precipitating factors for the loss of
control of his asthma
• To advise on a plan of action if his asthma continues to deteriorate – when to
contact the GP / NHS 24 or call an ambulance

The monitoring required for this patient should include

• Continuing to monitor his PEFR as previously
• To continue recording any night-time wakening and symptoms bymeans of a
symptom diary
• To record any limitation on his daily activities
One month later Mr Thomson returns with a repeat prescription for his Seretide® 50 inhaler.
He tells you that he feels a little better and is now sleeping but his peak flow still only
averages 600 L/min and is using his salbutamol inhaler 6 times a week.

At this consultation update your care plan for this patient.

Include in your plan any monitoring for the patient and any suggested changes in
therapy. What would you use as criteria for referral of this patient to the GP or
secondary care?

Update to the care plan

• Ask the patient the questions on the care plan to assess his control. Update
the asthma symptoms. Patient now sleeping, PEFR now approx 94% of best,
still using SABA 6 times weekly.
• Ask the patient when he is using his SABA – this may be before exercise.
• Patient compliance should be discussed to ensure that he is taking the inhaler
• Once you have answers to these questions that suggest that the patient’s
asthma is still only partially controlled you would follow the guidelines and again
step up his asthma medication to Seretide 125 2 puffs bd.
• If you are a prescriber you may be able to increase this without returning to
the GP

The patient should be given another review appointment in 1 month.

The criteria for referral would be deterioration in his asthma control rather than a
slight improvement. The same asthma question could be asked to decide when the
patient is referred

Six months later Mr Thomson is admitted to hospital with an exacerbation of asthma. On

admission his pulse is 120 beats per minute, his respiratory rate is 28 breaths per minute and
his PEFR is 390 L/min.

How would you define Mr Thomson’s asthma control now?

What would you include in his care plan now? Could Mr Thomson be managed in the
community or does he need to be admitted to hospital?

The patient is showing signs of acute severe asthma – PEFR is approx 60% of best. This
patient’s immediate symptoms could be managed in the community by using multiple puffs
of a MDI in a spacer. Each puff should be inhaled before the next puff is put into the
spacer. The patient could also be given prednisolone in the community. If the patient
requires oxygen it may be difficult to administer this in the community.

If the patient does not respond to the initial SABA and prednisolone in the community
they should be admitted to hospital.

For his admission to hospital his care plan should include

• Ensure that the patient is prescribed the correct medication – SABA,
anticholinergics, steroid and oxygen. And that the doses are correct.
Salbutamol nebulised 5mg four times a day and as required, ipratropium
nebulised 500mcg four times a day, prednisolone 50mg and oxygen via a
venture mask at 60 – 80%
• Ensure that the patient is continued on their inhaled steroid – this has no
advantage to therapy except ensuring that the patient is not stopped this
therapy and that they are discharged on the appropriate dose of ICS.
• Monitor the patients PEFR for improvement which will indicate when the
patient may be changed back to their inhaled therapy and the nebulisers
stopped.
• Ensure that the patient’s prednisolone is not continued for too long. The
guideline recommendation is that this therapy is continued for at least 5 days
or 2 days after the resolution of symptoms
• Ensure that the patient can use their inhalers – this may mean changing the
device
• Ensure that the patient knows to comply with therapy.
• Ensure that the patient has follow-up on discharge from hospital – this may be
with the community pharmacist
• Ensure that any changes in therapy are communicated to the primary care
team
Case 2

You are asked to dispense a prescription for Angela, age 10 years, for

salbutamol MDI 2 puffs when required

Seretide® 50 Evohaler 2 puffs twice daily

Angela has been a patient of your pharmacy since she was a small child and has suffered
from eczema and hay fever since she was 3 years old. Two years ago she was diagnosed
with asthma and her GP has commenced this prescription. You know that she has been
referred to the local hospital to see the respiratory paediatrician as her asthma was not
controlled on Seretide 50, 2 puffs twice a day. She saw the hospital paediatric respiratory
consultant last week.

Construct a care plan for this child.

In the care plan you should include prescribing, monitoring and follow-up for Angela.
Indicate when you would expect to see her again and how often she should attend for
follow-up. What other health-care professionals would you involve in the care of this
patient?

The aims of asthma management are the same for children as they are for adults. In
this case the care plan should take into consideration Angela’s other problems of eczema
and hayfever. These are atopic conditions and may be associated with asthma in
children.

The care plan for this child should contain

• Ensure that the prescription is appropriate for a child of this age. The dose of
Seretide of 50mcg fluticasone 2 puffs twice a day is equivalent to 400mcg of
beclometasone. This is at the upper limit of the dosage guidance for a child. It
is safe.
• Monitor the child’s growth to ensure that she is growing appropriately. This
should not be based on a single measurement but on a trend in growth. There is
no need to monitor adrenal function.
• Ensure that the inhaler is being used in the most appropriate manner. For a child
this age the most appropriate delivery method may be using a spacer – there may
be compliance problems with this as the child may not like this. The choice of
inhaler may change as the child grows up and becomes a teenager. The patient
choice needs to be taken into consideration to ensure that compliance is
optimised.
• Investigate if any changes have been recommended for the child at the
respiratory clinic.
• Monitor the outcome of treatment. In children the RCP questions can be used
rather than monitoring PEFR. Also asking about how the child is participating in
exercise and play – a child with asthma should be able to take part in the same
sports as any other child and should not be limited by the condition
• The care of this patient will also involve the child’s GP, the school nurse, teacher
as well as the parents to ensure that she complies with therapy and is able to
lead an active life.
• Follow up for Angela should be in 6 – 8 months as she is well and showing no signs
of any exacerbation

Angela is discharged from hospital following an acute exacerbation she is now prescribed
 salbutamol MDI 2 puffs as required
Seretide® 125 Evohaler 2 puffs twice daily
prednisolone 50mg 3 days to complete a 5 day course

How would you alter the care plan for Angela following her hospital admission? Does
this change the monitoring and follow-up for the child?

• The basic care plan remains the same in terms of monitoring growth and
compliance.
• Ensure that the Seretide Evohaler is prescribed correctly – this dose is above
the recommended dose for a child and should only be used on the advice of a
specialist in paediatric respiratory medicine. Just being in hospital does not
ensure this. A plan for monitoring and ensuring that the dose is reduced when
appropriate needs to be pt in place
• Ensure that the prednisolone is stopped after the short course and that it does
not get repeated.
• Ensure that a steroid warning card is issued to the child’s parents and that they
are aware of the need to point out to other heath care professionals that Angela
is on steroids. This is appropriate for the higher dose steroid inhaler as well as
the oral prednisolone
• Ensure that Angela is followed up about a week after discharge and the
prescription reviewed.
Case 3

Mrs White, a 35 year old woman who is 28 weeks pregnant, comes in to your pharmacy on a
Saturday afternoon with a repeat prescription for a terbutaline turbohaler. She last received a
prescription for terbutaline 10 days ago and on that occasion received 2 turbohalers.

From your PMR you note that at the same time she was also prescribed
Symbicort® 100/6 Turbohaler 2 doses twice daily

On questioning Mrs White regarding her symptoms she says her asthma is usually worse at
this time of year. She has used her last two terbutaline turbohalers and that although you
dispensed the Symbicort® she has not been using these for the last six months as she was
concerned about the effect that the corticosteroids may have on her unborn child. She has
been using up all the terbutaline inhalers that she had at home and is now wheezy

Mrs White is breathless.

What is the immediate care that Mrs White requires? How can this be delivered?

Construct a care plan for Mrs White to deal with her breathlessness. Include in this
recommendations for prescribing and monitoring

The immediate care for the patient does not involve drawing up a care plan but dealing
with the medical emergency that you have in front of you. The patient has used two
turbohalers in the last 10 days well over the recommended dose and shows that she has
uncontrolled asthma. She is using about 20 doses of SABA a day.

The options that you have are

a. To dispense her prescription and send her on her way
b. To counsel the patient on the need to take her Symbicort inhaler, dispense
her prescription and send her on her way
c. To send her to hospital to get her asthma sorted out

The third is the only sensible option

Over the past months the care plan for this patient should have contained

• Ensure that the patient is still taking her ICS and LABA. The risk to the unborn
child of uncontrolled asthma is greater than the risk of the ICS and LABA.
• Ensure that the patient understands the need for her asthma to be well
controlled to ensure that the baby is healthy.
• Monitor the patient in the same way as any other asthma patient by using the 5
questions on the care plan to ensure that she is well controlled.
• The high use of the SABA inhaler should have prompted a review of this patient
and an early discussion about her asthma

Mrs White returns to your pharmacy with a prescription for

prednisolone 50 mg each morning for 7 days

Symbicort® 100/6 Turbohaler 2 doses twice daily
terbutaline turbohaler as required

Mrs White requests that only the terbutaline is dispensed.

Update your care plan for Mrs White. Include in this the counselling that you would
need to undertake to ensure that Mrs White has an effective prescription.

• The most important part of this patients care plan is the counselling
• Ensure that the patient understands the need to take the oral steroid and the
ICS to ensure asthma control. This counselling may take some time to
o explain the nature of asthma and the need for the inhaled and oral
steroids,
o the nature of drug delivery to the lungs and the small amounts absorbed
from here into the systemic circulation
o the problems associated with poor oxygen supply to the unborn baby
o there is no evidence that the ICS and LABA have any effect on the
unborn baby
o the use of the OCS for short term use is not known to have any effect
on the unborn baby
o the risks of the asthma are greater than the risks of the medication
• Ensure that the OCS is a short course only and that it is not repeated
• Ensure that the patient is given a steroid warning card but explain that the risks
of the side effects are small
• Monitor the patients improvement by giving her a diary card to record her PEFR,
use of SABA and other symptoms