NUR 602 Module 4 Pharmacotherapy Plan Example

One Inhaler for Both Jobs: A Pharmacotherapy Plan for Uncontrolled Asthma in a 14-Year-Old

[Student Name]

Southern New Hampshire University

NUR 602: Advanced Pharmacology Across the Life Span

Module Four Pharmacotherapy Plan

[Instructor Name]

[Date]

The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.

One Inhaler for Both Jobs: A Pharmacotherapy Plan for Uncontrolled Asthma in a 14-Year-Old

Adolescents with asthma are often described as nonadherent, as if the problem were only motivation. A regimen that asks a 14-year-old to take one inhaler every morning and evening whether or not she feels ill, and carry a different one for symptoms, is a regimen designed around adults who plan ahead. This plan argues that for an adolescent with uncontrolled asthma, a single inhaler containing a corticosteroid and formoterol, used both daily and for relief, fits the drug to the patient, and that the plan is only complete once her technique has been watched and corrected.

Assessment

Jasmine is 14, weighs 52 kg and plays club soccer. Her asthma was diagnosed at age 6. She was prescribed fluticasone propionate 44 mcg, two puffs twice daily, a year ago, but says she uses it a few times a week at most. She uses albuterol four or five days a week, before most practices and after coughing spells, and wakes with cough about twice a week. In April she needed a 5-day course of prednisone after a cold. Her Asthma Control Test score today is 14, well below the threshold of 20 that suggests control. Spirometry shows an FEV1 of 78% of predicted with a 14% improvement after albuterol. Demonstrating her albuterol inhaler at the visit, she presses the canister before she starts to breathe in and then holds her breath for about two seconds.

By the NAEPP classification, her impairment and her recent oral steroid course indicate asthma that is not well controlled on Step 2 therapy (Cloutier et al., 2020). Before stepping up, the guideline asks clinicians to check adherence, technique and triggers. All three are problems here, and none of them is solved by a larger dose of the same inhaler.

Therapeutic Goals

The goals over the next three months are an Asthma Control Test score of 20 or higher, reliever use on no more than two days a week outside of exercise, no night waking from asthma, no oral steroid course and full participation in soccer. Lung function should return to her personal best.

Drug Selection

For patients 12 and older whose asthma is not controlled at Step 2, the 2020 focused update favors one inhaler that pairs budesonide or another steroid with formoterol, taken every day and also whenever symptoms flare, often called single maintenance and reliever therapy, at Step 3 (Cloutier et al., 2020). The recommendation rests largely on a systematic review of 16 randomized trials with 22,748 patients. In the trials of patients aged 12 and older, flare-ups fell by roughly a third when the combination inhaler also served as the reliever rather than being taken on a fixed schedule at the same dose (risk ratio 0.68), and the benefit held even against a larger fixed dose (risk ratio 0.77; Sobieraj et al., 2018). The Global Initiative for Asthma also prefers corticosteroid-formoterol as the reliever across its treatment tracks for adolescents and adults (Reddel et al., 2022).

The pharmacology explains why. Formoterol has a fast onset, similar to albuterol, and a long duration, so it can serve as a reliever. Every time Jasmine reaches for relief, she also takes budesonide, so the anti-inflammatory dose rises when her asthma worsens, which is when she needs it. Her pattern of skipping the daily inhaler and using the reliever often becomes much less dangerous.

The prescription is budesonide-formoterol 80/4.5 mcg metered-dose inhaler, two puffs twice daily, plus one or two puffs as needed for symptoms, not to exceed 12 puffs in a day. She stops the fluticasone and the albuterol. Before soccer she takes one or two puffs of the same inhaler instead of albuterol. Adverse effects to discuss are hoarseness and oral thrush, reduced by rinsing and spitting after doses, and tremor or a fast heartbeat from formoterol if she uses many puffs. Using more than 8 puffs on any day is her signal to call.

Can She Use It?

The plan fails if the drug does not reach her lungs. In a study of 3,660 patients, pressing a metered-dose inhaler before starting to breathe in was made by about a quarter of users and was associated with uncontrolled asthma (Price et al., 2017). Jasmine makes exactly this error. At today's visit she should practice with a placebo device and a valved holding chamber: breathe out fully, press as she begins a slow, deep breath and hold for about 10 seconds. She should then demonstrate it back, and the demonstration should be repeated at every visit rather than assumed.

A spacer is awkward for a teenager to carry to school, so she can keep one at home and practice slow inhalation with the device alone for school and practice. A dose counter on the inhaler lets her and her mother see whether the twice-daily doses are being taken. She should keep a second inhaler in her soccer bag with a copy of her action plan, and the school nurse should receive the plan and a self-carry authorization.

Education, Action Plan and Follow-Up

Her written action plan has three zones. In the green zone she takes two puffs morning and evening and one or two before soccer. In the yellow zone, with cough, wheeze or night waking, she takes extra puffs as needed up to the daily maximum and calls if she needs more than 8. In the red zone, with severe breathlessness or no relief after extra puffs, she seeks emergency care. The plan should be explained to Jasmine directly, not only to her mother, since she manages her own inhaler at school.

Follow-up is in 4 weeks to check the Asthma Control Test score, reliever puffs, thrush and technique. If control is reached and maintained for three months, the daily dose can be reviewed. If not, the next step is medium-dose budesonide-formoterol before any add-on therapy.

Conclusion

Jasmine's asthma is uncontrolled because her regimen did not match how a 14-year-old uses medicine and because her technique was wrong. One budesonide-formoterol inhaler, used daily and for relief with a clear maximum, gives her anti-inflammatory treatment each time she feels symptoms, and watching her use it makes the prescription real.

References

Cloutier, M. M., Baptist, A. P., Blake, K. V., Brooks, E. G., Bryant-Stephens, T., DiMango, E., Dixon, A. E., Elward, K. S., Hartert, T., Krishnan, J. A., Lemanske, R. F., Ouellette, D. R., Pace, W. D., Schatz, M., Skolnik, N. S., Stout, J. W., Teach, S. J., Umscheid, C. A., & Walsh, C. G. (2020). 2020 focused updates to the asthma management guidelines: A report from the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group. Journal of Allergy and Clinical Immunology, 146(6), 1217-1270. https://doi.org/10.1016/j.jaci.2020.10.003

Price, D. B., Roman-Rodriguez, M., McQueen, R. B., Bosnic-Anticevich, S., Carter, V., Gruffydd-Jones, K., Haughney, J., Henrichsen, S., Hutton, C., Infantino, A., Lavorini, F., Law, L. M., Lisspers, K., Papi, A., Ryan, D., Stallberg, B., van der Molen, T., & Chrystyn, H. (2017). Inhaler errors in the CRITIKAL study: Type, frequency, and association with asthma outcomes. Journal of Allergy and Clinical Immunology: In Practice, 5(4), 1071-1081. https://doi.org/10.1016/j.jaip.2017.01.004

Reddel, H. K., Bacharier, L. B., Bateman, E. D., Brightling, C. E., Brusselle, G. G., Buhl, R., Cruz, A. A., Duijts, L., Drazen, J. M., FitzGerald, J. M., Fleming, L. J., Inoue, H., Ko, F. W., Krishnan, J. A., Levy, M. L., Lin, J., Mortimer, K., Pitrez, P. M., Sheikh, A., . . . Boulet, L.-P. (2022). Global Initiative for Asthma Strategy 2021: Executive summary and rationale for key changes. American Journal of Respiratory and Critical Care Medicine, 205(1), 17-35. https://doi.org/10.1164/rccm.202109-2205PP

Sobieraj, D. M., Weeda, E. R., Nguyen, E., Coleman, C. I., White, C. M., Lazarus, S. C., Blake, K. V., Lang, J. E., & Baker, W. L. (2018). Association of inhaled corticosteroids and long-acting beta-agonists as controller and quick relief therapy with exacerbations and symptom control in persistent asthma: A systematic review and meta-analysis. JAMA, 319(14), 1485-1496. https://doi.org/10.1001/jama.2018.2769