Case: Salient Features

■ Age: 52 years old

■ Gender: Female
Patient M ■ Allergies: None
■ College professor

No 2 Weeks
Obese
Dyspnea and
Significant (BMI 36) Wheezing
History
 at the Emergency Department

O2 sat. of 92% PEF rate: 250 L/min

in mild respiratory nebulized albuterol

distress with audible & corticosteroid
wheezing injection

Discharged home – 5 day prednisone taper

Referred to Pulmonologist for further management
Case: Salient Features

At the clinic:
• (+) mild expiratory wheezing
• (+) respiratory symptoms at
night
• entered menopause about a
year prior and recently started
Hormone Replacement
Therapy (HRT)
 LABS / DIAGNOSTICS

SPIROMETRY
baseline Forced Expiratory A
Volume in 1 sec (FEV1) of
1.8L (61%)

which improved to 2.76 L P.E.

(94%) after bronchodilator use B Expiratory wheezing
Dyspnea
Diagnosis:
late-onset
asthma
PATHOPHYSIOLOGY
■ Chronic inflammation
associated with upper
airway hyper
responsiveness
■ Recurrent episodes of
wheezing, breathlessness,
chest tightness &
coughing, particularly at
night or early morning
■ Airflow obstruction
within the lung; often
reversible
GOAL: reduce the burden to the patient
and their risk of exacerbations and airway
damage

MANAGEMENT
 Management

Weight Management
01
Non-
Pharmacologic Relaxation & Breathing
02 techniques
Pharmacologic Treatment

Step 1 - done
Short Acting Beta-Antagonist
(SABA) - Albuterol

Step 2 - next
Low Dose Inhaled
Corticosteroid (ICS)

Global Initiative for Asthma (GINA)

Guidelines, 2017
 ESSA

Efficacy Safety Suitability Affordability Total

Fluticasone +++ ++ ++ +++ 10

Beclomethasone ++ ++ +++ + 8

Budesonide ++ ++ +++ + 8

Mometasone ++ ++ +++ ++ 9
FLUTICASONE
Drug Class: Corticosteroid
acts by their broad anti-inflammatory efficacy;
inhibition of production of inflammatory cytokines

Pharmacologic Action/Effects
It utilizes a fluorocarbothioate ester linkage at the 17-
carbon position. It has potent vasoconstrictive and anti-
inflammatory activity

reduces the symptoms, improves lung

function and prevents asthma exacerbation
 Pharmacokinetic Properties

Absorption
systemically primarily via lungs.
Bioavailability: 13.9%. Time to peak
plasma concentration: 0.5-1 hr.
D M
Distribution
Extensively distributed in the body.
Volume of distribution: 4.2 L/kg.
Plasma protein binding:
Approximately 91%.
A Metabolism
extensive hepatic first-pass
metabolism, converted to
17β-carboxylic acid by
CYP3A4 isoenzyme.
E Excretion
Mainly via feces; Terminal
elimination half-life:
approximately 8 hrs.
 Toxicity / Side Effects

01 02 03
Oropharyngeal Hoarseness Osteoporosis
candidiasis direct local effect of ICS and cataracts
Instruct the patient to on the vocal cords Increased risk with chronic
gargle after inhalation of use
ICS

Adrenocortical suppression, headache, nausea,

Over Dosage: vomiting, hypotension, temporary suppression of
the hypothalamic-pituitary-adrenal axis
 Dosage Adverse Drug Drug
Reaction Interaction
Adults and children
Mouth and throat Increased fluticasone levels
over 16 years of age:
candidiasis, throat with CYP 3A4 inhibitors e.g
100 to 1000
irritation, ritonavir, ketoconazole,
micrograms twice
hoarseness/dysphonia, itraconazole. Additive
daily
nasopharyngitis effects with other β-agonist.
Therapeutic Dose
1– 2 puffs twice a day,
125mcg/actuation
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REFERENCES
■ Case Study: Management of a Middle-Aged Patient with Multiple Comorbidities.
(2018, April 16). Retrieved from https://www.medpagetoday.com/resource-
centers/advances-severe-uncontrolled-asthma/case-study-management-middle-aged-
patient-multiple-comorbidities/1938
■ Global Initiative for Asthma, 2017
■ KATZUNG, B. G. (2020). BASIC AND CLINICAL PHARMACOLOGY. S.l.:
MCGRAW-HILL EDUCATION.
■ MIMS, Fluticasone. (n.d.). Retrieved from
https://www.mims.com/philippines/drug/info/fluticasone formoterol?mtype=generic
■ Non-drug interventions for asthma. (2017, November 30). Retrieved from
https://www.ncbi.nlm.nih.gov/books/NBK279518/