Question

Kiara is a 53-year-old female with severe chronic persistent asthma. She also has a history of osteoporosis, diabetes, and hypertension. Her daily treatment regimen for the control of her asthma is comprised of high-dose inhaled beclomethasone, inhaled salmeterol, slow-release theophylline, and monteleukast. She has complained to her specialist that she is still having frequent exacerbations and night-time symptoms. He then decides to put her on a short course of oral prednisone for 14 days.

a. How would prescribing additional glucocorticosteriods such as prednisone help in the treatment of the major symptoms of asthma? State two of these symptoms and the mechanism by which prednisone will treat them.

b. Considering her medical history, which factors should be taken into consideration by her specialist before prescribing oral prednisone? Substantiate your answer by referring to the mechanism by which prednisone would aggravate these conditions.

c. After two weeks of frequent asthma attacks, Kiara decides to double the dose of her theophylline. Comment on the appropriateness of her decision to double the dosage, and discuss the implications thereof. Justify your answer.

d. Which drug class should be used if she experiences an asthma attack? Justify your answer.

e. Following a thorough investigation, Kiara’s specialist establishes that her exacerbations are most likely due to improper inhaler technique. Too much of the drug is deposited in her mouth and as a result is not reaching the lungs. What can be done to overcome this issue? Justify your answer.

f. If Kiara had hepatic dysfunction, what would the implication be of prescribing the short course of oral prednisone? Justify your answer.

Answer 1

a) Prednisone is rarely the only asthma treatment. Usually it is often used along with other medicines, such as inhalers. When a person has a significant asthma attack, they often experience airway inflammation afterward. The airways become puffy and irritated. Prednisone is a laboratory-made medication, but it works much like the body’s steroid hormones.

Doctors often prescribe prednisone for acute asthma exacerbations.

The administration of prednisone causes body to confuse it to be a steroid hormone. These hormones enter the body’s cells and create chemical reactions that stimulate the body to stop poducing inflammatory compounds. As a result, a person is ideally able to breathe more easily because their airways are less narrow. They also create less mucus, making it easier to breathe.

Prednisone is a short-acting steroid, with a half-life of between 18 and 36 hours. Doctors prescribe prednisone instead of other steroids because it does not last as long in the body. The medicine lasts long enough to help a person overcome their acute asthma symptoms.

b) Glucocorticoid therapy is associated with an appreciable risk of bone loss. The increased risk of fracture has been reported with doses of prednisone or its equivalent as low as 2.5 to 7.5 mg daily. Since the client is already a k/cv/o osteoporosis, Glucocorticoids affect all bone cells, they result in osteocytic and osteoblastic apoptosis and decreased function of both osteoclasts and osteoblasts. However, they decrease osteoclastic apoptosis. Thus, the net effect is reduced bone formation and increased bone breakdown.

Steroids can make the liver less sensitive to insulin because they cause it to carry on releasing sugar, even if the pancreas is also releasing insulin. This continued release of sugar triggers the pancreas to stop producing the hormone. If this process continues, it causes insulin resistance. The cells no longer respond to insulin, regardless of whether the body produces it or a person injects it to control diabetes. This is also called steroid induced diabetes

The principal mechanism of corticosteroid- induced hypertension is the overstimulation of the mineralocorticoid receptor, resulting in sodium retention in the kidney. This results in volume expansion and a subsequent increase in blood pressure.

c) Theophylline has an extremely narrow therapeutic window. Theophylline toxicity occurs when serum theophylline levels surpass the levels in the therapeutic range. This can occur by intentional overdose. Cardiac dysrhythmias, seizures, and death can be seen with levels of 80 to 100 mcg/mL. Chronic toxicity can be seen at levels of 40 to 60 mcg/mL. Hence doubling the dose should never be done without the doctor's advice and blood level monitoring is necessary to know the level of drug.

d) Since the cloient has a chronic prsistant asthma, the preferred treatment is Anti-inflammatory: inhaled corticosteroid (high dose) and * Long-acting bronchodilator: long-acting inhaled 2 agonist, sustained-release theophylline, or long-acting 12 agonist tablets. Since asthma is a chronic inflammatory disease, long-term use of anti-inflammatory agents is an important part of therapy to control inflammation and to prevent exacerbations. Long-term use of inhaled corticosteroids is effective in managing nocturnal asthma. Also they have been shown to reduce both symptoms and the number of acute exacerbations of chronic asthma, thus also reducing the reliance on 12 agonists.

e) Help the client to optimise her inhaler technique.

• Describe the steps of using the inhaler device: breathing in the right way for the type of inhaler, shake your inhaler first,  wait least 30 to 60 seconds before taking the next puff, breathing out before using your inhaler, tight lip seal,  lifting the chin slightly before breathing in, Breathing in too early before pressing the inhaler canister some of the medicine will end up being sprayed in your mouth and hitting the back of your throat. It won't be carried down to your lungs where it’s needed or Breathing in too late after pressing the inhaler canister some of the medicine will end up in your mouth instead of being carried down to your lungs where it’s needed, hold your breath after using your inhaler,
• Show the patient how to do it.
• Ask the patient to show you how she would use the inhaler. Check if she is doing it correctly and, if needed, explain how she can improve the technique.

f) Prednisone is inactive in the body and, in order to be effective, first must be converted to prednisolone by enzymes in the liver. Therefore, prednisone may not work as effectively in people with liver disease whose ability to convert prednisone to prednisolone is impaired. Corticosteroids also have major effects on the liver, particularly when given long term and in higher than physiologic doses. Glucocorticoid use can result in hepatic enlargement and steatosis or glycogenosis. Corticosteroids can trigger or worsen nonalcoholic steatohepatitis