Question

Salem is a 15-year-old male weighing 46.6 kg. He is known to have asthma and. He accidently fell down and broke his leg while playing football. For that reason he was admitted to the hospital for surgery. Since he was 6 year-old, he presented to the emergency department many times and had 4 hospital admissions for asthma, two of them were to the intensive care unit. He often required a course of oral steroids for one month every few months. However, in the last two years his asthma was well controlled on fluticasone (inhaled steroid) and salbutamol (inhaled β-adrenergic agonist) and he didn’t need any oral steroids. Also, he had not visited the emergency department or been admitted to the hospital for the last two years.

On the day of the accident, the patient had no signs or symptoms of asthma. When he and his father were asked if he had tried aspirin or NSAIDs in the past they said they were not sure. When pain control was discussed, the father wanted to avoid morphine for its addictive effects. Consequently, the doctor prescribed him ibuprofen and planned to give him the first dose in the hospital under close observation soon after the surgery.

The surgery and anaesthesia went fine. One hour later, the patient was given a tablet of ibuprofen 400 mg orally for pain control. 10 minutes after that he began to show symptoms of asthma (shortness of breath and wheezing). For that he used his salbutamol inhaler 8 times. However, his symptoms became worse over the next 20 minutes and he was not able to talk. Soon after that, the patient became cyanosed and needed oxygen by face mask. Salbutamol inhaler was repeated and Hydrocortisone 100mg IV was given. Within 20–30 minutes his condition started to improve. Salbutamol was given every 4 hours and oral Prednisolone 50 mg once daily was initiated (for 6 days). To control the pain of his surgery he was given Morphine 5mg/4h orally and was observed closely overnight for the symptoms of asthma. He was discharged after one week. That week Salem didn’t experience any further asthma symptoms and returned home on his usual inhalers.

1.       What is the most likely explanation (at the biochemical level) for Salem’s symptoms that developed after he was given the oral ibuprofen?

2.       How do you explain the successful relief of the patient’s ibuprofen-induced symptoms after he was treated with hydrocortisone and prednisolone?

3.       In this case study, β-adrenergic agonist and steroids were used to treat and/or prevent asthma symptoms. Mention the other two medication types useful in the treatment of asthma that are mentioned in eicosanoids metabolism chapter of your course. (0.5 mark for each medication type (1 mark total))

Answer 1

1. This is a case of aspirin senstivity, in which case ibuprofen can trigger symptoms of asthma. In such a case ibuprofen can trigger symptoms of asthma or allergy. Symptoms of severe allergic reaction usually develop within a few hours after taking the drug.

Aspirin/Ibuprofen work by inhibiting cyclooxygenase (COX) pathway and reduce prostaglandin synthesis. This leads to  activation of  the lipoxygenase pathway, leading to increased leukotriene synthesis and risk of bronchospasms or asthma exacerbation.

2. Hydrocortisone sodium succinate and prednisolone does not cross-react with aspirin in aspirin-sensitive patients with asthma. They act by  relieving the muscle spasm and also by reversing the mucosal edema, decreasing vascular permeability by vasoconstriction, and inhibiting the release of LTC4 and LTD4.

3. prostaglandins, thromboxanes, and leukotrienes are the eicosanoids that are used for treatment of asthma