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Asthma is a non-communicable chronic disease that impacts an estimated 235 million people worldwide (Papi et al., 2020). Asthma can result in persistent or episodic respiratory symptoms, including wheezing, chest tightness, cough, and shortness of breath, as well as airflow limitation due to bronchoconstriction, increased mucus, and airway wall thickening (Papi et al., 2020). Both subjective and objective information indicate the presence of uncontrolled chronic asthma in the 17-year-old female patient in this week’s discussion board. The subjective information reported by the patient includes reports of being awakened once a week during the night for the past month by a cough, as well as her report of shortness of breath when visiting her father’s workshop and during exercise. In addition, the patient reports her shortness of breath is not always exercise induced. The objective information presented in the scenario is the patient’s increased need for her albuterol MDI and her morning peak flows have decreased over the past several weeks from 400 L/min to 300 L/min.

Based on the subjective and objective data provided, the patient’s asthma is poorly controlled. This was determined by the patient’s reports of worsening symptoms and increased use of her albuterol inhaler. When reviewing the patient’s current medication regimen, as well as her reported use, there are a few problems that must be addressed. First, the patient is prescribed Flovent two puffs BID, but reports she uses the medication most days of the week. Flovent is an inhaled corticosteroid administered as a maintenance medication, which requires two weeks of therapy to yield significant clinical effects (Chisholm-Burns et al., 2022). It is important to educate the patient regarding proper use of the medication to achieve the maximum benefit in her asthma control. In addition, the patient needs to be educated on rinsing her mouth after using her inhaler to help prevent oral candidiasis. Instructing patients to rinse his or her mouth after inhaler use can help prevent oral candidiasis (Chisholm-Burns et al., 2022). Once the inhaler use is addressed, the patient will need to have her migraine medication regimen adjusted. The patient is currently on a beta-blocker (propranolol 80 mg PO BID) for migraine prophylaxis, which is not recommended in asthmatic patients. The treatment of asthma with beta-blockers is not recommended since the most crucial side effect is acute bronchoconstriction with leading asthma exacerbation (Huang et al., 2021). The goal of pharmacotherapy is to better control the patient’s asthma through proper use of her prescribed medications. Chronic asthma treatment incorporates avoiding triggers known to cause an exacerbation of asthma, as well as the use of long-term control and quick relief medications (Chisholm-Burns et al., 2022). Nonpharmacologic interventions include avoiding cigarette smoke, warm-up prior to physical activity, and identify and eliminate environmental exposures (Chisholm-Burns et al., 2022). This patient may benefit from updating her current asthma treatment to include a combined ICS/LABA. Utilizing combined products may lead to better regimen adherence due to the need for fewer inhalers and inhalations (Chisholm-Burns et al., 2022). Adding a combination medication consisting of the patient’s current medication, fluticasone (Flovent), with salmeterol may be beneficial. The patient is currently on Flovent HFA 44 mcg, so I would suggest starting with a low dose of Fluticasone/Salmeterol HFA MDI 45/21 mcg 2 puffs twice daily, increasing the dose if the low dose is not as effective as desired. The patient should continue with taking two puffs of her albuterol inhaler every 4-6 hours as needed. The patient should be instructed on proper use of her inhaler, as well as the use of a spacer. Decreased efficacy and increased adverse effects can be contributed to poor inhaler technique (Chisholm-Burns et al., 2022). It is recommended to use a spacer with a MDI to decrease the patient’s need for coordination of actuation with inhalation, increase drug delivery, and decrease oropharyngeal disposition (Chisholm-Burns et al., 2022).

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