BL is an 18 yo female who presents to your clinic today with some concerns regarding her asthma. She says she was diagnosed with asthma as a child, but her symptoms seem to be worsening lately. She has experienced increased wheezing and shortness of breath as well as chest tightness and cough. She denies sputum in her cough and reports no recent fevers. She says that she recently moved to a new house and since then her allergies have been worse than ever before. In the past 4 weeks she has had symptoms most days of the week and has experienced nighttime awakenings with asthma at least once a week. She feels it has now started to limit her daily activity and she can’t exercise like she used to. The only medication she takes for her asthma is an albuterol inhaler which she says she relies on pretty much every day. She is not having an acute exacerbation at this time.
PMH: anxiety/depression, allergic rhinitis, asthma
SH: Denies tobacco use
Medications: Sertraline 100 mg PO QD, albuterol (90 mcg/actuation MDI) 2-4 puffs PO Q4-6H PRN, cetirizine 10 mg PO QD, fluticasone nasal spray 50 mcg/spray 2 sprays in each nostril QD
Weight: 140 lbs
FEV1 (% predicted)- baseline: 69%
FEV1 - after albuterol 400 mcg: 85%
Which of the following low-dose inhaled corticosteroid plus long acting beta agonist combination medications would be best to initiate for long-term control of her asthma?
A. Add Symbicort 80 mcg/4.5 mcg: 2 puffs QD
B. Add Advair Diskus 100 mcg/50 mcg: 1 puff BID
C. Add Breo Ellipta 160mcg/4.5 mcg: 2 puffs BID
D. Add Dulera 200 mcg/5 mcg: 2 puffs BID
E. Add Trelegy Ellipta 100 mcg/62.5 mcg/25 mcg: 1 inhalation QD
F. No addition is required at this time
Answer with rationale:
Correct Answer: B
Symbicort= budesonide + formoterol
Advair Diskus= fluticasone propionate + salmeterol
Dulera= mometasone + formoterol
Trelegy Ellipta= Fluticasone + Umeclidinium + Vilanterol
To start this case, it is important to first look at the patient as a whole and make sure that this is indeed an issue with the patient’s asthma. Her symptoms of wheezing, shortness of breath, chest tightness and cough are all consistent with worsening asthma. She also does not have sputum in her cough or fevers which could help rule out possible infective processes. Looking at her PMH, she also has seasonal allergies and recently moved where the allergies have worsened. Allergens can trigger worsening asthma. Her labs also show variable expiratory airflow limitation. This can be seen with her FEV1/FVC being just below the lower limit of normal (0.75- 0.8 in adults), and her post bronchodilator FEV1increasing by >12% (bronchodilator reversibility). With all of this in mind you can confidently determine that her problems are asthma related.
Next it is important to evaluate her level of symptom control. In the past 4 weeks she had daytime symptoms more than twice/week, nighttime awakenings at least once/week, nearly daily dependence on her SABA reliever (short acting beta agonist- albuterol), and limitation to her daily activity. These details would cause her to fall in the uncontrolled category. When looking at the GINA guidelines, this patient falls into Step 3 (symptoms most days or waking with asthma once a week or more). That means that she should be on a daily controller inhaler as well as a reliever. Her controller should be a low dose ICS-LABA (inhaled corticosteroid (Ex: budesonide, fluticasone, mometasone) + long-acting beta agonist (Ex: formoterol, salmeterol). She is not yet at Step 4 because she does not have low lung function (FEV1/FVC is not <0.7 and FEV1 not <68% predicted), and she is not having an acute exacerbation at this time.
Looking at the answer choices, the only low dose ICS- LABA with correct dose and frequency is answer choice B. The key is in reading the question: It specifically asked for a low-dose ICS plus LABA combination. Answer choice A is the correct inhaler (ICS-LABA) that is low dose, however it is written for QD and the directions for Symbicort should be 2 puffs BID. Answer choice C is Breo Ellipta which does have an ICS and LABA, but this is actually the dose for Symbicort with medium dose ICS. Answer choice D is Dulera which would be an acceptable choice because it is an ICS-LABA, however this is also the medium ICS dose. The low dose would be Dulera 100 mcg/5 mcg: 2 puffs BID. Answer choice E is for Trelegy Ellipta which is an inhaler typically used in COPD. It contains an ICS (fluticasone), LABA (vilanterol) and LAMA (long acting muscarinic agonist- umeclidinium), therefore it is not indicated for this patient. Finally, answer choice F is incorrect because it does not solve the problem of a missing controller inhaler. She needs a daily inhaler in addition to her PRN/rescue albuterol.
Familiarity with various asthma medications is really important as the components including brand/generic can definitely be confusing even for the seasoned pharmacist. Knowledge of dosing and potency is also important with corticosteroids as these are the mainstay for chronic treatment of asthma.
It would be reasonable as well to change the patient's PRN albuterol to PRN formoterol plus a low-dose ICS as this is a new recommendation from the guidelines to prevent further exacerbations by adding an ICS to the PRN regimen. However the focus of this question was for chronic maintenance therapy.
Exam Competencies Covered:
Area 1 – Obtain, Interpret, or Assess Data, Medical, or Patient Information: 1.2 – From patients: treatment adherence, or medication-taking behavior; chief complaint, medication history, medical history, family history, social history, lifestyle habits, socioeconomic background; 1.5 – Signs or symptoms of medical conditions, healthy physiology, etiology of diseases, or pathophysiolo
Area 2 – Identify Drug Characteristics: 2.1 – Pharmacology, mechanism of action, or therapeutic class
Area 3 – Develop or Manage Treatment Plans: 3.11 – Evidence-based practice