USP Results In
USP Results In
A Case Study Challenge

We received a
great response
to the latest
U.S. Pharmacist
Case Study
Here is the
author's own
take as well as
selected feedback
from readers.


Call for papers
What Would You Do?

"My Breathing Is Getting Worse Over
the Last Month."

Click here for this case study, which was
emailed to you on September 13, 2012.

Author Answer

As in the management of many chronic disease states, the primary goal of COPD pharmacotherapy is to reduce the frequency and severity of exacerbations and decrease or eliminate symptoms and complications. Upon reviewing the patient's medication list, she is taking long-acting inhaled bronchodilators combined with inhaled corticosteroids, which help reduce exacerbations and related hospitalizations and improve lung function and health status in patients with moderate-to-very-severe COPD. During the hospital course, CiCi was continued on systemic tapered corticosteroids, which have been shown to be effective and shorten recovery time, improve FEV1, and improve hypoxemia.

In this case, it was decided to add the following medications upon discharge from the hospital: amoxicillin/clavulanate 875 mg bid x 7 more days to finish the 10-day course since she has bronchitis; prednisone taper dose; and theophylline 100 mg po bid. Theophylline was also added to help improve her symptoms. There is evidence that theophylline has a modest bronchodilator effect and some symptomatic benefit. Studies showed that theophylline added to salmeterol produces a greater increase in FEV1 and relief of breath shortness than salmeterol alone. CiCi's baseline heart rate is elevated, and she needs to be monitored closely since theophylline has the tendency to increase heart rate. The plan is to keep her on low-dose theophylline to prevent adverse events.

Also, we recommended evaluating the benefit of adding azithromycin to her drug regimen once she returns in 2 weeks for a follow-up visit. There is a new study that was published in The New England Journal of Medicine in August 2011 that showed the addition of azithromycin for 1 year to the current regimen was associated with prolonged time to first exacerbation, a significant decrease in the frequency of acute exacerbations of COPD, and an improvement in quality of life.

Amne Borghol, PharmD
Associate Professor of Clinical Pharmacy
Xavier University of Louisiana
New Orleans, Louisiana

Reader Response

One thing I would do is titrate her Coreg to help with CHF. I might try changing the Advair to Symbicort and get her off the oral steroids, as fluid retention will only aggravate the CHF. I would keep her on the Mucinex for a while to help decrease secretion viscosity (even after abx therapy is completed). Personally I think Albuterol HHN works as well as Xopenex in most patients. So changing that would decrease her expense.

Mark Lockard

Reader Response

Although carvedilol is a first-line agent to treat CHF, its nonselectivity for beta-receptor antagonism may worsen her COPD and SOB symptoms. It may be more beneficial to have this patient try Toprol XL instead of carvedilol.

We need to ask her if she's rinsing her mouth adequately after each Advair inhalation. With the amount of corticosteroids she is taking (orally and inhaled), the possibility of fungal and possibly bacterial colonization in her airway may contribute to COPD exacerbations and declining respiratory function and O2 saturation.

We will need to consider reducing her corticosteroid intake of prednisone to a lower daily dose and possibly her Advair 500/50 to 1 puff bid.

L. Poon, PharmD
San Francisco, California

Reader Response

I would consider adding a time-released theophylline product. Some dose titration will probably be needed considering her past smoking history. Theophylline should improve bronchodilation and have some added diuresis as a bonus.

Daliresp might also be a consideration, but theophylline is much less expensive and probably more effective if adequate levels are maintained.

Brien R. Woodson, RPh

Reader Response

To help control readmissions for this patient, I would suggest continuing the same medications but have her try to determine what triggers her COPD exacerbations (environmental, stress, etc.). The other problem may be how she is using her inhalers, and a review of her inhaler use may be needed. Check for compliance with her medication regimen.

N. Zaksek, PharmD
Mt. Pleasant, Pennsylvania