ASTHMA

1
PROJECT ON
PHARMACOTHERAPY OF
ASTHMA
By
MUHAMMAD ABBAS
FINAL PROFESSION
DOCTOR OF PHARMACY
(Pharm-D)
REG NO: AWKUM-18F-73367
DEPARTMENT OF PHARMACY
ABDUL WALI KHAN UNIVERSITY MARDAN
KHYBER PAKHTUNKHWA PAKISTAN

(Session 2018-2023)
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CERTIFICATE OF APPROVAL
Clinical Clerkship Report “PROJECT ON PHARMACOTHERAPY OF

ASTHMA“ prepared by MUHAMMAD ABBAS in partial fulfillment for the degree of
Doctor of Pharmacy (Pharm-D) is hereby accepted.
SUPERVISOR
Dr, SALIM ULLAH
(B.Pharm, M.Phil, MPH, Ph.D, R.Ph)
PROFESSOR,
Department of Pharmacy
Abdul Wali Khan University Mardan.
CHAIRMAN
Professor Dr. Haroon Khan
Abdul Wali Khan University Mardan.
Khyber Pakhtunkhwa
EXTERNAL EXAMINER
ACKNOWLEDGMENT
First and foremost, thanks to ALLAH, the Almighty, for giving me the
strength and ability to complete this project.
I would then like to express my sincere gratitude to, my project
supervisor, Sir Dr Salim Ullah for his guidance and suggestions.
I am particularly grateful for the valuable assistance and
encouragement provided by, Professor Haroon khan, Chairman Department
of pharmacy Mardan.
Finally, I wish to thank my beloved parents for their constant support
throughout my study.
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ABSTRACT
Asthma is a major noncommunicable disease (NCD), affecting both children and adults, and is the
most common chronic disease among children.
Inflammation and narrowing of the small airways in the lungs cause asthma symptoms, which can
be any combination of cough, wheeze, shortness of breath and chest tightness.
Asthma affected an estimated 262 million people in 2019 (1) and caused 455 000 deaths.
Inhaled medication can control asthma symptoms and allow people with asthma to lead a normal,
active life.
Avoiding asthma triggers can also help to reduce asthma symptoms.
Most asthma-related deaths occur in low- and lower-middle-income countries, where under-
diagnosis and under-treatment is a challenge.
WHO is committed to improving the diagnosis, treatment and monitoring of asthma to reduce the
global burden of NCDs and make progress towards universal health coverage.
Aims and Objectives

The theoretical knowledge which I had learnt in the five years i.e., the knowledge of
pharmacology, clinical pharmacy, therapeutic drug monitoring and that of hospital pharmacy
utilization is the basic aim of the clinical clerkship, and in order to implement this basic
knowledge practically in the hospital settings and at this« ward level for the rationalization of the
drug therapy is the basic objective of my clerkship.
SUMMARY:
After evaluation of the histories, I concluded that for the achievement of Rational therapy for
the management of Asthma patients on rational grounds, first we should follow those standard
procedures for the management which are mentioned by reference books and should also
overcome those problems which are common at ward IeveI»I like drug-drug interactions, side
effects, adverse drug reactions, compliance rate and poor patient education. Counseling of
the patients should be performed at ward level. Awareness programs should be launched for the
Health professionals and patients and seminars should be conducted. News Letters and Drug
bulletins about the prevention and management of Asthma patients should be published.
Pharmacoeconomic evaluation should also be. encouraged. All these are possible when Clinical
Pharmacist is induced at the ward level.
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1. INTRODUCTION
Asthma is a word which means ‘PANTING”. Asthma is a broad term used for the disorder of
the respiratory system which is followed by complexity in breathing which is for long time. The
national United Kingdom guidelines (BTS/SIGN 2005) defined asthma as a chronic disease of
the airways in affected individuals. Inflammatory system is related with extensive airflow
obstruction and an elevated airway response to many stimuli. Obstruction of air way may be
reversible either with treatment or spontaneously are certain period of time. [1j.
1.1 DEFINITION
Asthma is the disease of airway and is characterized by chronic inflammation, hypersensitivity,
with contact to wide varieties of stimuli, and obstruction with variable airflow limitation. As a
result, patients will have paroxysm of cough, dyspnea, chest tightness, and wheezing [2].
1.2 EPIDEMIOLOGY
It has been found from the survey that about 4 % of the American and British populations have
asthma and about 5.1 million people are treated for asthma in the UK “National asthma
campaign 2001”. Asthma mortality rate is estimated which tell that it is about 0.4 in 100,000 and
1500 deaths in a year in UK. The asthma like symptom in children is about in between
5% and 12% with the fact that boys are more prone to asthma then from girls, and those
children whose parents have an allergic disorder. But in adulthood 30% to 70% of children
become symptom free. The incidence of asthma seems to be a growing in spite of advance in
therapy, except there is some doubt in relation to this due to the variable criteria for the basic
diagnosis of asthma used in different studies. Asthma is now days considered as due to the
western civilization and associated with so many environmental factors which are considered
the pre disposing factors. From the industrialized sources and transportation air pollution
interacting with smoking, dietary and so many other factors lead to the occurrence of this
asthma [1]
In recent times, bronchial asthma has been increasing worldwide. However, there appears to be
no published data on the prevalence of allergic diseases among school children (3 to 16 years of
age) in Karachi, Pakistan, with only limited data available among few age groups under one
ISAAC study [3]
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1.3 TYPES
Asthma has been classified into two types on the bases of presence or absence of primary immune disorder
system
1.3.1 EXTRINSIC ASTHMA
This type of asthma starts due to Type-I hypersensitivity reaction initiated with contact to
extrinsic antigen. There are three types of extrinsic asthma.
1. occupational asthma
2. Atopic asthma
3. Allergic bronco pulmonary aspergillosis.
The most common type of asthma is atopic asthma, and occurs in 1st two decades of life and
usually accompanied with allergic characteristics in the patient also with other family members.
In this the strum Ige levels are usually increased as is the blood eosinophil count raise. This type
of asthma is considered to be driven by TH2 sub set of CD4+T cells.
1.3.2 INTRINSIC ASTHMA
The cause for this type of asthma is non-immune. There are so many stimuli that have slight or
no effect in normal persons and they can activate bronchospasm. Such factors comprise of
pulmonary infections and mainly those. which are caused by cold, Virus exercise, psychological
stress and inhaled irritants such as ozone and SiE2. There is no family or personal history of
allergic description and serum Ige levels are normal. These patients are considering containing
an asthmatic diathesis [4].
1.4 ETIOLOGY
Factors accountable for asthma development are divided into genetic, host and environmental
factors.
i. They include multiple genes and chromosomal regions accompanied with the
occurrence of asthma. Cultural and racial difference has also noted in asthma but
they are due to the result of socioeconomic predisposition.
ii. They are wide environmental factors that take part in the development and
persistence of asthma. Early in life severe viral infection mostly respiratory syncytial
virus and rhinovirus is accompanied with the development of asthma
in early childhood and play a role in its pathogenesis.
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iii. Exposure of the body in childhood and sensitivity to SD many allergens and
irritants substances like cigarette smoke which play an important part in the onset
of asthma but the accurate cause of this relationship is not yet fully clarify [2].
1.5 PRICIPITATING FACTORS

a. Abrupt changes in climate.
b. Chilly air.
c. Atmospheric pollution, dust and tobacco smoke.
d. Exercise.
e. Viral respiratory infections.
f. Tension (emotional.)
g. Drugs like aspirin and other NSAIDs, beta-blockers e.g., propranolol.
1.5 PRESENTATION OF BRONCHIAL ASTHMA

It may be either episodic or chronic. It has been seen that there is a tendency for atopic
individuals to develop episodic asthma while non-atopic individuals have chronic asthma.
1.6.1 EPISODIC ASTHMA

In this type of disease, the patient has no respiratory symptoms between episodes of asthma.
Dyspnea and wheeze attack almost occur at any time and onset may sudden. Factors which
precipitate episodic asthma include exercise, allergens, viral infection such as common cold.
The attack of duration may vary from few minutes to several days.
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1.6.2 CHRONIC ASTHMA
There symptoms may be chronic until relieved by appropriate therapy. The symptoms are
wheeze at night. Mucoid sputum in productive cough and respiratory infection is common at
recurrent episode.
1.6.3 SEVERE ACUTE ASTHMA (STATUS ASTHMATICUS)
It is a life-threatening attack of asthma. Both acute and chronic types may lead to this state. In it
there is prolonging attack of asthma accompanied by arterial hypoxemia and respiratory
distress. Respiratory symptoms include tachycardia, sweating, pulsus paradoxus and central
cyanosis. There is vesicular breathing accompanied by inspiratory and expiratory rhonchi. In
status asthmatics there is limited airflow that rhonchi are no longer produced and this condition
is called silent chest. In this situation the patient adopts an upright position, fixing their
shoulder girdle to support the respiratory muscles.
1.7 CLINICAL FEATURES OF ACUTE ASTHMA
1.7.1 SYMPTOMS
1. Feeling of chest tightness.
2. Dyspnea incident.
3. No productive cough which leads to aggravate dyspnea.
4. wheezing.
1.7.2 ON EXAMINATION
A. Mild attack
1. Tachypnea and also minor tachycardia.
2. With prolong expiration there be vesicular sounds.
3. Mild diffuse wheezing (rhonchi).

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B. Moderate attack
1. Use of supportive muscle of respiration.
2. Low breath sound.
3. Loud wheezing.
4. Intercostals muscles withdrawal.
5. Hyper-resonant of chest.
C. Severe attack
1. Cyanosis.
2. Failure to maintain in lying position.
3. Pulses paradoxus.
4. In audible breath sounds (silent chest) with diminished rhonchi [5].
1.8 INVESTIGATION
e.g. chest X-RAY
In all patients with the following indications chest x-ray will be done.
• In acute severe asthma when there is poor reaction to treatment.
• A rare but potentially fatal difficulty of the pulmonary hyper-inflation which is

produced by severed hindrance of airflow in asthma.
1.8.2 CHEST RADIOGRAPH

Chest radiographic imaging is an important means in the I examination of patients with an
exacerbation of asthma, but patients should not be lek waiting in the treatment room for a
radiograph before treatment. Chest radiography is the first imaging assessment in most
individuals with symptoms of asthma. The value of chest radiography is in revealing
complications or alternative causes of wheezing and the slight importance of wheezing in the
diagnosis of asthma. It usually is more useful in the initial diagnosis of bronchial asthma than
in the detection of exacerbations, although it is valuable in excluding complications such as
pneumonia and asthma mimics, even during exacerbations [6].

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1.8.3 PEAK EXPIRATORY FLOW RATE (PEFR)

In this there is a device used called peak flow meter which can show the severity of airflow
limitation. Certain factors like age, weight, sex and height vary the values of PEFR and 450-
650 L/min. in men and 350-500 L/min in women. Severe ventilatory dysfunction shows that
the value is fall under 100-200 L/min. a marked diurnal variation in PEFR is recorded in
asthma, the values are taken in the morning, because PEFR should be measured in morning,
middle of day and before bed. PEFR is helpful in assessment of the patient disease for long
term and response to treatment [7].
1.8.4 ARTERIAL BLOOD GASES (ABGs)

Arterial blood gas pressure (pao2 and paco2) measured is essential in the management of
severe acute asthma. A normal arterial blood gases in mild attack, but respiratory alkalosis
(decrease pco2) and mild hypoxemia is usually found in more severe situations, worsens
hypoxemia and respiratory alkalosis disappears when respiratory muscle fatigue» prevents
hyperventilation. An increased pco2 indicating respiratory failure, which need mechanical
ventilation. Less than 60 mmHg of paco2 may be a sign of severe attack.
Table 3. differential
diagnosis of asthma
Differential diagnosis Asthma Left ventricular dysfunction COPD Upper airway obstruction
Difficulty breathing Episodic, paroxysmal, Parox mal, Wheezing, Inspiratory
or expiratory orthopneic exertional dyspnea
Other symptoms D cough, Palpations, Chron c cough, Depending on the causes
chest tightness pink frothy sputum sputum of obstruction
Signs Mostly wheezing Wheezing sounds, Coexistence of dry Inspiratory stridor
sounds extensive moist rales and moist rales
HiStO Exposure to allergens. Hypertension Long-term smoking, Foreign body aspiration
family history in some or heart diseases exposure to harmful gases
patients
Imaging studies Nonspecific Pulmonary congestion, Increased lung markings, Foreign body or tumor
pulmonary edema. and which are rough and mass in the upper
enlarged heart shadow deranged: apical features airways
of emphysema
Response to Can be relieved quickly Ttemporary or no Somehow relieved No obvious relief
bronchodilators significant relief (
None None Foreign body or tumor
seen on bronchoscopy

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1.9 MANAGEMENT
1.9.1 PREVENTION
i. Prevent contact to causative allergens such as grass pollens, chemicals and house dust mitI«,
pets.
ii. Early chest infection treatment.
iii. Avoid use of beta-blockers as they worsen bronchospasm.
iv. Avoid use of ACE-inhibitors drugs which aggravate cough.
v. In case of patients with moderate severe asthma yearly influenza vaccination and
pneumococcal vaccination.
vi. Avoid cigarette smoking.
vii. Hypo sensitization, in this condition small dose of extract of allergen which is responsible
for asthma should be injected subcutaneously. This type of therapy improves symptoms,
decrease drug requirement and raises bronchial hypersensitivity although it presents a risk of
producing acute anaphylactic reaction, but injection of adrenaline, hydrocortisone and
atropine should be in your hand to prevent reaction [8].
Controller oDtions Select one Select one Medium- or high-dose Add either or both
Low-dose ICS Low-dose ICS plus Sustained-release

theophylline (lowest dose)
SU5tained-relez5e Low-do5e ICS plU5 LABA (aero5ol) release
LABA (aerosol)
Low-dose ICS plus leukotriene

modifier

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1.9.2 DRUG TREATMENT OF ASTHAMA
A. LONG TERM CONTROL MEDICATIONS
a. CORTICOSTERIODS
These are the most effective anti-inflammatory potent agents used both in chronic and acute
inflammation and also its prevention. They are classified as;
• INHALED CORTICOSTERIODS
These are the first line maintenance therapy in case of patients on beta2-adrenergic agonist
inhaler therapy.
i. Bacoside inhaler contains 50mcg betamethasone per dose taken as 2 puffs 2 to 4 times
daily. It is low dose treatment.
ii.Belforte inhaler contains 250mcg betamethasone per dose and a high dose given as 2
puffs 2 to 4 times daily.
Side effects
i. Oral candidiasis and hoarseness.
ii. High dose corticosteroids greater than 800mcg/day cause systemic effects as
osteoporosis, skin thinning, cataract and adrenal suppression.
• ORAL CORTICOSTERIODS
These are essential for those patients who are not well responded to inhaled corticosteroids,
the dose should be given as on alternate day, to avoid side effects. Prednisolone (tab.
deltacortril) 30 to 60 mg/day given orally as a single dose. Early therapy of severe asthma
attacks with suKicient doses of oral corticosteroids relieves symptoms and prevents
hospitalization.

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B. LONG-ACTING BRONCHODILATORS
I. BETA- ADRENERGIC AGONISTS
Bronchodilation for 12 hours after a single dose is achieved by the administration of long-
acting beta2-adrenergic agonists. As their onset Of action is delayed so cannot be used in acute
asthma. Salmeterol (servant inhaler) is used to prevent nocturnal symptoms of asthma and
exercise induced bronchospasm.
II. PHOSPHODIESTERASE INHIBITORS
Theophylline induced mild bronchodilation also has anti-inflammatory effects. Sustained-

release theophylline (theograd 350mg) used as adjuvant therapy to treat nocturnal symptoms of
asthma. Dose is 200 to 500mg bid.
C.MEDIATOR INHIBITORS
I. CROMOLYN SODIUM (INTAL) AND NEDOCROMIL SODIUM
These are anti-inflammatory agents that prevent activation of many inflammatory cells,
especially eosinophils, mast cells and epithelial cells. These» have not direct effect of
bronchodilation so are not used in acute asthma. Dose is 2 puffs 4 times daily or 10 to 15
minutes before exercise. Cromolyn have no side effects while nedocromil can cause cough,
headache and taste disturbances.
II. LEUKOTRINE RECEPTOR ANTAGONISTS
These relieve airway obstruction and asthma symptoms by contracting airway smooth muscles,
attracting inflammatory cells, increasing vascular permeability and mucous secretion. These are
effective for long term control of asthma. Montelukast, zafirlukast and zileuton are considered
as to low-dose inhaled corticosteroids in treatment of mild persistent asthma.
Montelukast (tab. Singulair 5 mg and 10 mg) od at bed time.

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D. QUICK RELIEF MEDICATIONS
I. BETA —ADRENERGIC AGONISTS
Salbutamol and terbutaline are known to be the first line of treatment for acute bronchospasm.
a. INHALED BETA-ADRENERGIC AGONISTS
These are very effective in acute asthma as of rapid onset of action (<5min) have less side
effects such as palpitation. Metered dose inhaler is elective as nebulizer if someone inhaled
with coordination. Nebulization treatment may be more effective in those patients who are not
coordinating inhalation of medication from a metered dose inhaler due to severity of the
exacerbation and age.
Dose: salbutamol (Ventolin inhaler) or terbutaline (bricanyl) 2 puffs as needed.
b. ORAL BETA-ADRENERGIC AGONISTS
Elective in such patients who do not use inhaled medications. Salbutamol (tab. Ventoline) is
available in 2 mg, 4 mg and given 3- 4times daily.
II.SYSTEMIC CORTICOSTERIODS
These are elective in those patients with mild to severe exacerbations or for those who do not
respond to inhaled beta2-adrI»nergic agonist.
Prednisolone (tab. Deltacortil 5 mg) given as 0.5-1 mg/kg/day in once or twice divided doses
orally for 3- 10 days.
Hydrocortisone ( inj: solucortef 100 mg, 250 mg, and 500 mg) are administered as 2.4- 4 mg/kg
I/V 6 hourly in status asthmaticus.
III. ANTICHOLINERGIC
Ipratropium bromide (Atem inhaler and Atrovent nebulizer solution) is effective in the
following situations.
• If due to beta blocker agent's bronchospasm is inferior to bronchitis.

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• Patients who do not respond to beta-agonists.
• Used as adjuvant to short acting beta2-adrenergic agonists in mild to acute asthma

exacerbation.
• Those who cannot tolerate beta2-adrenergic agonists given as an alternate.
IV. AMINOPHYLLINE
I/V aminophylline is very efficient in status asthmaticus. Aminophylline infusion is given to

improve diaphragm contractility [9].

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table 4. Common asthma medications. Classes

Pharmacological effects Corticosteroids Usual dose Comments
Inhaled They inhibit multiple
Beclomethasone 200- I .000 µg/d
corticosteroids aspects of airway dipropionate Strong topical anti-inflammatory effect and

inflammation. and reduce Budesonide 200-800 µg/d relatively milder general adverse reactions;
microvascular Fluticasone long-term use may cause throat discomfort,
25-SOO µg/d
permeability' and airway propionate hoarseness, and candidiasis; high doses
hyperresponsiveness.
Ciclesonide 60-I 20 µg/d may be associated with osteoporosis,
hypertension, diabetes mellitus, suppression
of hypothalamic-pituitary- adrenal axis,
obesity, cataracts, glaucoma, and skin
ecchymosis; patients with co-morbidities,
such as active tuberculosis, osteoporosis,
glaucoma, diabetes mellitus, severe or
peptic ulcer, should be cautioned about
Systemic these.
steroids Prednisone 30-40 mg/day,
Oral steriods For 5-10days Systemic adverse reactions are more
Methylprednisolone 24-32 mg/d frequent and severe than those associated
Hydracartisone sodium I 00-200 mg IV drip, with inhaled preparations.
Intravenous steroids succinate repeated in 4-6 h if
necessary
Methylprednisolone
4O—80 mg IV drip,
sodium succinate
repeated in 4- 1 2 h
if
necessary
Dexamethasone
5- 10 mg IV drip or Strong and long-lasting inhibitory effects
bolus on the pituitary and adrenal glands
II β 2-agonists
Rapid-acting/ By acting on the β 2 - salbutamol aerosol
I -2 puffs each time, avoid long term regular use alone
Short acting receptor on the surface
as needed
of the airway smooth Terbutaline aerosol
1-2 pulls each time,
muscles and mast cells,
as needed
they relax the airway Formoterol dry-
smooth m uslce reduce I -2 puffs each time;
powder inhaler
the degranulation and
Slow-acting/
madiator release of the I -2 puffs tid or kid
short-acting mast cells and basophils,
reduce
Slow-acting/ salbutamol tablets I
mircovascular
long-acting Salmeterol dry-powder
permeability, increase inhaler
Transdermal
the mucocliary motions' , Tulobuterol patch 1 puff bid
formulations and thus relieve asthma
I patch qid (0.5-2mg)
Oral use
Normal tablets They relax bronchial Aminophylline o.1–0.2 g tid For this class, the therapeutic plasma
Smooth muscles, Doxycycline 0.1 - o . 2 g b i d concentration is close to toxic concentration.
Sustained-rælese 0.2-o.4 g bid concomitant use of Cimetidine. Quinolone,
Sustained release increase heart theophylline tablets or macrolides
contractility and Aminophyiline 4-6mg/kg loading may Interfere with the metabolism of
Intravenous use
increase dose, followed by theophylline, resulting in slow excretion
renal blood flow.
0.5—0.8 mg/kg/h and higher toxicity.
Doxofylline 0.3 g qd
Anticholinergics
Short-acting By binding to the M3 Ipratropium aerosol 20-60 µg {2-3 puffs} They can cause symptoms such as dry tid
receptor on the airway or qid mouth; should be used with caution
smooth muscle, they lpratropium bromide 0.25-0.5mg ( I -2 mL in early pregnancy er in patients
relax the bronchi. nebulizer solution tid qid with glaucoma benign prostatic
tiotropium dry- I 8 µg ( I inhalation) qd h hypertrophy,
powder
c nd eosinophils and thus alleviate their asthma-inducing and

e inflamrzsatory effe<:ts.
Long- acting
l
leukotriene They can inhibit the inhaler
l
modifiers release of cysteinyl montelukast tablets
s
leukotrienes by mass a
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Aims and Objectives

The theoretical knowledge which I had learnt in the five years i.e., the knowledge of
pharmacology, clinical pharmacy, Therapeutic drug monitoring and that of hospital pharmacy
utilization is the basic aim of the clinical clerkship, an in order to implement this
basic knowledge practically in the hospital settings and at the ward level for the rationalization
of the drug therapy is the basic objective of my clerkship.
Besides all of the above mentioned the other aims and objectives includes:
1. To know about the treatment of asthma.
2. To know about the causes, occurrence and pathophysiology of asthma.
3. To increase the compliance rate about drugs and management of asthma.
4. To avoid drug-drug and drug-food interactions if noted.
5. To know about the rational use of drugs in the treatment of asthma.

6. To know about that how much the patient responded to the current therapy.
7. To avoid the dosage error of the drug administered.

8. To avoid poly pharmacy in the treatment of asthma.
9. To know about the Pharmacoeconomics study in the treatment of asthma.
METHODOLOGY
Data from patients suffering from asthma were collected on the prescribed patient medication
profile form. This medication profile was designed by our clinical subject teacher. This is a
proforma and its contents are concerned with special emphasis on taking of the respective case
history of the patient. Before going to the hospital, we were trained about that Proforma and
about taking of the respective history. Most of the cases were diagnosed by the respective
consultants of the wards Those cases which were diagnosed and treated so we have collected
all the data recovered from that case and written in the patient medication profile in detail. A
copy of the empty proforma is attached herewith.

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CLINICAL CASES:
CASE NO 01:
CLINICAL PHARMACY PATIENT MEDICATION PROFILE
Patient’s Name: Said khan Age: 40 years
Gender: Male Ward: PULMONOLOGY
Bed ND' 06 Date of Admission: 14 Feb 2023
Weight: About 60kg. Address: takhtbhai
Chief Complaints:
Known asthmatic complaint
for 25 years SOB=1 day
Past medication history: Used Ventoline (Salbutamol) 4 mg OD.
LAB INVESTIGATIONS:
DATE TEST RESULTS NORMAL RANGE
14 Feb 2023 Blood urea 24 mg/dl 10-40 mg/dl
Serum creatinine 0.9 mg/dl 0.5-1.5 mg/d
Blood sugar (Random) 133 mg/dl 110-170 mg/dl
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GENERAL PHYSICAL EXAMINATION:
Good
CNS Semi-conscious NAD
98 F° Chest
72 B/min 120/70 mm Hg
Soft & Non tender.
DIAGNOSIS: Asthma, acute exacerbation.
TREATMENT PROVIDED AT WARD:

Date Route and Timing
strength
14 Feb 2023 Inj: Cefiral l gm Cefriaxone I/V BD.
Inj: 1.Jecadrone Dexameihasone 2cc I/V TDS.
Inj: Zanax 0.5 mg I/V BD.
Inhaler: Xaltide mcg 2 Puffs BD.
IEC@
Tab: Mykast 10 mg l * Noct.
20 Feb 2023 Tab: Baydal l0 mg Cetirizine l * OD.
Inhaler: Clinil 2 Puffs 4-6 * a day.

dipropionate 50 rncg

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Inj: Solu corief l Ofl mg Hydrocortisone I/V BD.
Tab: BTNO 10 mg Bambuterol 1 * BD.
Tab: Quibron T/SR 300 Theophylline anhydrous I * OD.

mg SR
14 Feb 2023 Inf: Provas 300 mg
OTHER PATIENT INFORMATIONS:
Date
inhalation
DATA ANALYSIS
SIDE EFFECTS/ADVERSE EFFECTS NOTED:
Dry mouth
Dizziness Palpitation
DRUG INTERACTION:
1. Hydrocortisone with NSAIDs (paracetamol) increase risk of GIT ulceration [ l]
2. Salbutamol with corticosteroids (dexamethasone) cause increase risk of “hypokalemia [11].
3. Bambuterol causes increase risk of hypokalemia with theophylline with increase doses [11].
COMPLIANCE:
All the medications are given by the nurse at the right time and right doses, so patient
compliance is good.
COMMENTS AND RECOMMENDATIONS:
The doctors have adopted the polypharmacy which lead to drug interactions, interactions
co8icosteroids with salbutamol cause hypokalemia which is dangerous for patient health.
Polypharmacy should be avoided.

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Case No.2
Patient's Name: Abdur raziq Are.: 60 years
Bed No: D5 Date of Admission: 14 Feb 2023
Weight: About 70 kg Address. Mardan
CHIEF COMPLAINTS:
Headache,
SOB,
Chest pain radiate to hand and shoulders,
Asthma exacerbation.
PAST MEDICATION HISTORY:

Use anti asthmatic drugs.
14 Feb 2023 Blood urea 27 gm/dl 10-4() gm/dl
Serum creatinine 0.71 mg/dl 0.5-1.5 mg/dl
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GENERAL PHYSICAL EXAMONATION:
food intake: Poor Sleep Nor good
CNS Conscious GIT NAD

Temperature 98 F° Chest Clear
Pulse 70 B/min B.P 120/80 mm Hg
CVS S1+S2+0 Abdomen Soft & Non tender
DIAGNOSIS: Acute exacerbation of asthma.
MEDICINE(S) TAKEN BEFORE ADMISSION:
Tab: Ventoline (salbutamol) 4 mg BD.
TREATMENT PROVIDED AT WARD
Date Medicine's
14 Feb 2023 Inj: Central 1 cm Ceftriaxone
Inj: Decadrone 2cc 4 mg/ml I/V Stat.
Inj: Zantac 50 mg Ranitidine
14 Feb 2023 Int: R/Lactate Calcium chloride 2H20 I/V OD.

0.2gm, KCl 0.3 gm,
NaCl gm,
lactate 3.1 gm ,dextrose
50gm,WFI
Tab: Loprin 75 mg Aspirin 1 * OD.
Tab: Monest 5 mg Montelukast 2 * Noct.
Tab: Crestat 5 mg Rosuvastaiin 1 * OD.

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Tab; Lasoride Frusemide 1 * OD

Amiloride HCl 5 mg
Inhaler: Xaltide Salbutamol mcg, 2 Puffs BD.

Beclomethasone
dipropionate 50 mcg
Ltervention/Advice
14 Feb 2023 Ventoline nebulization
DATA ANALYSIS:
SIDE EFFECTE/ADVERSE DRUG REACTION(S) NOTED:
Weakness,
Stomach pain.
DRUG INTERACTIONS:
1. Ceftriaxone with loop diuretics (Frusemide) cause increase in nephrotoxicity.
2. Dexamethasone with NSAIDs (Aspirin) cause increase risk of GIT ulceration.
3. Loop diuretics (furosemide) with corticosteroids can cause potassium loss [10].
COMPLAINCE:
The patient follows the instructions of doctor so the patient compliance is good.
Too much steroids are used which have drug interactions with the aspirin and diuretics.
Minimum number of steroids should be prescribed.

25
CASE NO 03:
Patients’ Name: Asar khan Age: 16 years
Bed No: 07 Date of Admission: 14 Feb 2023
Weight: About 60 kg. Address: Malakand
Chief Complaints:
Dry cough= 2 days
SOB= 3 weeks.
LAB INVESTIGATIONS:
14 Feb 2023 Blood urea 20 mg/d1 10-40 mg/dl
Blood sugar (Random) 14() m /dl I l0- l7() m /dl
GENERAL PHYSICAL EXAMINATION:

Food intake: Good Sleep Good
Temperature 98 F* Chest Clear
Pulse 70 B/min B.P 150/8() mm Hg
CVS Si+S,+0 Abdomen Soft & Non tender

26
DIAGNOSIS: Asthma exacerbation.
Date generic name Signa
14 Feb 2023 Inj: Ceftral 1 gm Ceftriaxone
Ventoline nebulization Salbutamol TDS.
Inhaler: Xaltide Salbutamol 100 mcg, 2 Pulfs BD.

Beclomethasone
dipropionate 50 mcc
Inj: Solu cortef 10() mg Hydrocortisone I/V OD.
Inj: Decadron 4 mg/ml Dexamethasone 2cc BD.
Tab: BTNO 10 mg Bambuterol 1* BD.
Syp: Ventoline 2 mg Salbutamol 1 TSF TDS.
Tab: Panadol 500 mg Paracetamol 1* SOS.
Tab: Mykast 10 mg Montelukast 1* Noct.
21 Feb 2023 Inhaler: Salmicor 25/50 Salmeterol xinafoate 25 2 Puffs BD.

mcg, Fluticasone Propionate
50 mcq
Inj: Solu Cortef 100 mg Hydrocortisone I/V TDS.

27
OTHER PATIENT INFORMATION:

Intervention/Advice
14 Feb 2023
DATA ANALYSIS:
Headache
Nausea
DRUG INTERACTION:
1. Dexamethasone with NSAIDs (paracetamol) can cause increase risk of GIT ulceration
2. When Bambuterol is given with corticosteroids it causes hypokalemia [11].
COMPLIANCE:
The patient follows the instructions o? the doctors while taking the medications so patient
compliance is good.

There was no drug prescribed for the dry cough and there are drug interactions in the prescription.
Patient should be properly educated about the therapy of asthma as it requires continuous drug
therapy. Appropriate therapy should be adopted.

28
CASE NO 04:
Patient's Name: ayoub khan Age: 30 years
Gender: Male Ward: Pulmonology
Bed No: 12 Date of Admission: 14 Feb 2023
Weight: About 65kg. Address: S wabi
Chief Complaints:
Smoker since=2 years
SOB=3 days
Chest pain=3 days
Cough with Sputum=S days.
14 Feb 2023 Blood urea 24 mg/dl 10-40 mg/dl
Blood sugar (Random) 15() mg/dl I 1()-17() mg/dl
Serum creatinine 0.75 mg/dl 0.5—1.5 mg/dl

29
GENERAL PHYSICAL INFORMATION:
Food intake: Poor Sleep Good

Temperame 98 F* Chest Clear
nt
CVS Abdomen Soft & Non tender.
DIAGNOSIS: Asthma.
Date $ledicine’s Trade name Generic name Signa
14 Feb 2023 Inj: Ceftral 1 gm Ceftriaxone I/V OD.
Tab: Ventoline SR 2 Salbutamol
Inj: Hyzonate 500 mg

succinate
OTHER PATIENT INFORMATION:

Date
14 Feb Ventolin
2023 nebulization

30
DATA ANALYSIS:
Nil
DRUG INTERACTION:
1. When Salbutamol is given with corticosteroids it causes hypokalemia [11].
COMPLIANCE:
Patient compliance is good because the medications are given by the nurse at right
time at at right directions.
The patient has sputum in his while coughing and no test are advised for it.
Appropriate therapy is adopted.

31
CASE NO 05:
Patient's Name: shayan Age' 50 years
Bed No: 13 Date of Admission: 15 feb

2023
Weight: About 75 kg. Address: SWAB I
hi
SOB=2 months
Chest tightness= 5 days
Dry cough=2 months
Sleep disturbances=2 months.
Past Medications:
Tab: Ventoline SR 4 mg (Salbutamol) BD.
Tab: Theograde (Theophylline) 350 mg BD.
LAB INVESTIGATIONS:
15 feb 2023 Blood urea 20 mg/dl 10-40 mg/dl
$erum creatinine 0.fi mg/dl 0.5-1.5 mg/dl
8GPT 25 U/L Upto 40 U/L.

32
ESR 10.5 min/Ist hour 02-11 min.
hvsi
FODd intake: Good Sleep Good

Temperature 98 F° Chest Wheezy

72 B/min B.P 12()/fi() mm Hg
CVS S i+5*+0 Abdomen Soft & Non tender.
DIAGNOSIS: Asthma.
Date Medicine's Trade name Generic
15 feb 2023 Inj: Hydrocortisone 100
In1: Locus 500 mg
Inj: Zantac 50 BD.
Tab: Amodip-plus 2.5 mg 1*
15 feb 2023 Inhaler: Ventoline Salbutamol
2 TSF TDS.
6.25 mg
1* BD.
Tab: Moniget 10 me Montelukast 1*
S canne d iH th C amsc annex

Ltervention/Advice
15 feb 2023 Oxygen inhalation
DATA ANALYSIS:
Dizziness
Abdominal pain
Dry mouth
Pain in stomach.
DRUG INTERACTION:
1. Ranitidine. with Levofloxacin cause decrease absorption of levofloxacin [10].
2. H2-blokers (Ranitidine) can cause increased plasma concentration of amlodipine when
concurrently administered [10].
COMPLIANCE:
The medications are administered by the nurse so compliance is good.
The doctors have adopted the polypharmacy which result in drug interactions.
The interactions between ranitidine with levofloxacin cause decrease absorption of

levofloxacin so dose adjustment of levofloxacin should be properly monitored also
minimum drugs should be prescribed to avoid drug interactions.

34
CASE NO 06:
Patient's Name: saifullah Age: 45 years

Date of Admission: 15 feb 2023
Bed No: 22 Address: NOWSHEHRA
Weight: About 65 kg.
Chief Complaints:
Sore throat 3days
Fever=2 days
Cough= 1 week
SOB 1 week
Chest tightness=3 days
Past Medications:
Inhaler: Clinic 250 mcg ( beclomethasone dipropionate) 2 Puffs 2" a day.

35
LAB INVESTIGATIONS:
15 feb 2023 Blood urea 27 mg/dl 10-40 mg/dl
Blood sugar (Random) 135 mg/dl 110-170 mg/d1
serum creatinine 0.95 mg/dl 0.5-1.5 mg/dl
SGPT 32 U/L Up to 40 U/L.
ESR 8.7 min/Ist hour 02-11 min.
General physical examination:
Sleep Good
NAD
98P Chest
70 B/min 110/80 mm Hg
CVS Soft & Non tender.
DIAGNOSIS: Asthma.
Date Medicine's Trade name generic name Signa

with strength
15 feb 2023 Inj: Decadron 2cc dexamethasone PVBD
Int: l000cc Calcium chloride= 2,H20- I/V OD.

0.2p•m ,KCl=0.3gm, NaCl- 6
gm, Sodium lactate=S.lgm,
dextrose= 5()gm,WFI

36
Inhaler: clinil 250 mcg Bechlomethasone 2 Puffs BD.

dipropionate
Tab: Meptin 50 mcg Procterol HCl 1* BD.
Tab: Rieix 10 mg Cetirizine l* OD.
Date InterventionfAdvice
15 feb 2023
DATA ANALYSIS:
Dizziness
Dry mouth
Palpitation
DRUG INTERACTION:
1. Dexamethasone with procaterol can cause hypokalemia [1}
COMPLIANCE:
The patient follows the instructions of the doctors so compliance is good.

There were no drugs are prescribed for the fever and this prescription have a
few side effects.
There is drug interaction between procaterol and dexamethasone which lead to

hypokalemia. Side e1“fects and drug interactions should be properly be
monitored.

37
CASE NO 07:
Patient’s Name: Aurang zeb Age: 70 years
Bed ND' 02 Date of Admission: 1,march,2023
Weight: About 60 kg. Address: Mardan
CHIEF COMPLAINTS:
Sudden lost of unconsciousness
SOB=5 days
Epigasiric pain= 1 week
Chest pain=4 days
Past Medications:
Use anti asthmatic drugs.
LAB INVESTIGATIONS
RESULTS RANGE
1,march,2023
BlODd Sllgar (Random)
Serum creatinine

GENERAL PHYSICAL EXAMINATIONS:
CNS Semi-conscious NAD
98 F° Chest
70 B/min
CVS Abdomen Soft & Non tender.
DIAGNOSIS: Asthma.
Date Medicine's Trade name Signa
1,march,2023 Inj: Decadron 2cc dexamethasone
Inj: Ceftral 1 gm Celiriaxone
Inj: Zantac 50 mg Ranitidine
Inj: Neurobion Vit: B1 100 mg, B6 10() mg. I/V OD.

B12 1000 mcg
Inj: Serenece 5 mg Haloperedol I/V Stat.

39
Inhaler: Xaltide Salbutamol 100 mcc, 2 Puffs BD.

Bechlomethasone dipropionate
50 mcg
Tab: Loprin 75 mg Aspirin 1* OD.
Tab: Zodip 5 mg Amlodipine besylate 1* BD.
Tab: Progrel 75 mg Clopidogrel 1* OD.
Tab: Levo 250 mg LevolJoxacin 1* OD.
Date Ltervention/Advice
1,march,2023
DATA ANALYSIS:
Headache
Abdominal pain.
DRUG INTERACTION:
1. Dexamethasone with NSAIDs (aspirin) can cause GIT ulceration.
2. Am1odipine with H2-blockers (Ranitidine) increase. plasma

concentration of amlodipine.
3. Ciapidogrel with NSAIDs (aspirin) can cause increase risk of of bleeding.
4. Ranitidine causes reduced absorption of levofloxacin [10].
COMPLIANCE:
The patient follows the instructions of the doctor while taking the
40
medications so compliance is good.
No tests are advised for respiratory problem, the doctor just considered on only
physical examination. Poly pharmacy is adopted which should avoided. Drug
interactions are also observed which should come in
consideration.
41
CASE NO 08:
Patient's Name: Aman khan Age: 40 years
Bed NDT 20 Date of Admission: 02 mar 2023
Weight: About 70 kg. Address: charsadda
Chief Complaints:
Restless= 4 days
SOB= 1 reek
Slurred speech
Wheezy.
Past Medications:
Syp: Hyzonate 500 mg (Hydrocortisone), Syp: Aminophylline.
LAB INVESTIGATIONS:
02 mar 2023 HB 10.2 g/dl 13-18 g/dl
Serum creatinine 0.fi mg/dl 0.5-1.5 me/dl
Blood urea 22 mu/dl 10-40 mg/dl

42
30 U/L Upto 40 U/L
30-35 micd
GENERAL PHYSCIAL INFORMATION:
CNS NAD
80 B/min
Abdomen Soft & Non tender.
DIAGNOSIS: Asthma exacerbation.
Date P›eneric nanne Signa
02 mar 2023 Inj: Ceftral 2 em IV
Oxygen inhalation O2
Inj: Zantac 50 mg I/V BD.
Inj: Neurobion Vit: B 1 100 mg, B6 100 mg, D.

B 12 1000 mcg
Diazepam IV
02 mar 2023 Inj: Decadrone Dexamethasone I/V BD.
Syp: Acefyl 125 mg 2 TSF TDS.
TDS.

43
Tab: Calpol 500 mg Paracetamol 2* SOS.
Tab: Ventoline 4 mg Salbutamol 1* BD.
Tab: Montika 10 mg Montelukast 1* OD.
Tab; Deltacortril 5 mg Prednisolone 1* BD.
Ltervention/Advice
Nil
DATA ANALYSIS:
Headache
Dry mouth
Dizziness.
DRUG INTERACTION:
I. Dexamethasone with NSAIDs (aspirin) can cause GIT ulcerations.
2. Prednisolone with NSAIDs (Paracetamol) can cause increase risk of GIT ulceration
[10].
COMPLIANCE:
The patient compliance is good because the medications are administered by the nurse at right
time and at right doses.
Salbutamol is prescribed in two times in the prescription which causes increase in plasma
concentration which lead to arrhythmia one of the side effects of the beta2- agonists, this is
dangerous for patient so it should be avoided.

44
CASE NO 09:
Patient's Name: Gull khan Age: 16 years
Gender: Male Ward: PULMONOLGY
Bed No: 15 Date of Admission: 13

mar 2023
Weight: About 65 kg. Address: thakht bhai
Chief Complaints:
Fever, General body aches= 5 days
Epigastric pain= 1 week
Dry cough, Wheezing= 3 days.
Past Medications:
Used anti asthmatic drugs since one year.
LAB INVESTIGATIONS:
TEST RESULTS NORMAL RANGE
13 mar 2023 HB 10.2 m/dl 13-18 gm/dl
Blood urea 25 mg/dl 10-40 mg/dl

45
Good Sleep
Conscious NAD
Temperature
75 B/min 120/80 mm Hg
CVS 1+Sz+0 Soft & Non tender.
DIAGNOSIS: Asthma.

Medicine's Trade Generic name
13 mar 2023 Inj: Calamox 1.2 gm Clavulanic I/V TDS.
Tab' Ultima 500 mg Clarythromycin 1* BD.
Syp: Ventoline Salbutamol mg, 2 TSF TDS.

Expect Guaiphenesin 50 mg
Tab: Panadol 500 Paracetamol

46
DATA ANALYSIS:
Nil.
DRUG INTERACTION:
1. Food may vary the bioavailability of clarithromycin [10].
COMPLIANCE:
Patient compliance is good.
Food cause variation of the bioavailability of’ clarithromycin which lead to decrease response
to the therapy, so nurses and patient should be properly educated about the medications, their
doses, side effects and drug interactions.

47
CASE NO 10:
Patient’s Name: sahib gull Age: 70 years
Bed No: 26 Date of Admission: 13 mar 2023
Weight: About 63 kg. Address: Shangla.
Chief Complaints:
Fever, rigors and chills= 1
week
SOB= 1 week
Pain, lower limb aches= 5 days
Nocturia= 9—10 episodes.
Past Medications:
Used anastomotic drugs since last eight months.

48
LAB INVESTIGATIONS:
RESULTS NO RANGE
13 mar 2023 11.2 gm/dl 13- 18 gm/dl
Serum creatinine 0.3 mg/dl 0.5- 1.5 mg/dl
Blood urea 119 mg/dl
SGPT 24 UL Upto 40 U/L
Sleep
Conscious NAD
70
CVS Soft & Non
DIAGNOSIS: Asthma.
Date Generic name
13 mar 2023 Inf: Levofioxacin 250
2* BD for 3
days.

49
Inj: Neurobion Vit B1 100 mg, Vit B6 10() I/V OD.

mg, Vit B12 1000 mcg
13 mar 2023 Tab: Lanoxin 0.25 m Digoxin 1* OD.
Tab: Loprin 150 mg Aspirin 1* OD.
Inj: Decadrone Dexamathasone I/V BD.
Syp: Hydryllin Aminophyllin 32 mg, 2 TSF TDS.

Diphenhydramine 8
mp•, Ammonium
chloride 30 mg,
Menthol 0.98 mg,
Alcohol 5% V/V
Tab: Relaxin 3 mg Bromazepam 1* Stat.
13 mar 2023 Int: Mofest 4()0 mg Moxikoxacin I/V OD.
Syp: Acefyl 125 mg Acefylline 2 TSF BD.
Ltervention/Advice
13 mar 2023 Ventoline nebulization

50
DATA ANALYSIS:
Dizziness
Dry mouth
Headache.
DRUG INTERACTION:
1. Aspirin can cause increase digoxin level.
2. Aspirin with corticosteroids can cause increase incidence of and severity of GIT
ulceration, enhances salicylate excretion [10].
COMPLIANCE:
Patient follows the instructions of the doctor while taking the medications. so compliance is
good.
COMMENTS A ND RECOMMENDATIONS:
Poly pharmacy is adopted which lead to drug-drug interactions that causes not only
hazard to patient but also increase the hospitalization also lead to economy lost.
Poly pharmacy should be voided and minimum number of drugs should be prescribed.

51
CASE NO 11:
PïZti4ïnt’s Name: Ihsanullah Age: 40 years
Gender: Male Ward: PULMONOLGY
Bed No: O6 Date of Admission: 15 mar 2023
Weight About 72 kg. Address: SWABI
Known asthmatic =25
years
SOB=1 day
Past medication history;
Used Ventoline (Salbutamol) 4 mg
LAB INVESTIGATIONS:
15 mar 2023 Blood urea 25 mg/dl 10-4() mg/dl
Serum creatinine ().8 mg/dl 0.5- 1.5 mg/d
Scanned eH th Camsc anne r

52
Food intake: Good
Semi-conscious NAD
98 F°
72 120/70 min Hg
CVS Soft & Non tender.
DIAGNOSIS: Asthmatic, acute exacerbation.
medicine's Trade name
Inj: Ceftral l gm Cefriaxone
Inj: Dexameihasone 2cc I/V TDS.
Inj: Zanax 0.5 mg I/V BD.
Inhaler: Xaltide mcg 2 Puffs BD.
IWC@
Tab: Mykast 10 mg l*
Tab: Baydal 10 mg 1* OD.

53
Inhaler: Clinil 2 Puffs 4-6 * a day.

dipropionate 50 mcg
Inj: Solu corief 100 mg Hydrocortisone I/V BD.
Tab: BTNO 10 mg Barnbuterol l * BD.
Tab: Quibron T/SR 300 Theophylline anhydrous l * OF .

mg SR
Inf: Provas 300 mg l/V Stat.
DATA ANALYSIS:
Dry mouth
Dizziness
Palpitation
DRUG INTERACTION:
i. Hydrocortisone with NSAIDs (paracetamol) increase risk of GIT ulceration [10].
2. 5a1butamol with corticosteroids (dexamethasone) cause increase risk of
hypokalemia [11].
3. Bambutero1 causes increase risk of hypokalemia with theophylline with increase

doses [11].

54
COMPLIANCE:
All the medications ve given by the nurse at the right time and right doses, so patient
compliance is good.
The doctors have adopted the polypharmacy which lead to drug interactions, interactions
corticosteroids with salbutamol cause hypokalemia which is dangerous for patient health.
Polypharmacy should be avoided.
S canne d iH th C amsc annex

55
CASE NO: 12
Patient’s Name: Ishaq Age: 60 years
Bed No: 05 Date of Admission: 17 mar 2023
Weight: About 70 kg Address: Mardan
Chief Ccomplaints:
Headache,
SOB,
Chest pain radiate to hand and
shoulders,
Asthma exacerbation.
Past medication history: Use anti asthmatic drugs.
INVESTIGATIONS:
17 mar 2023 Blood urea 27 gm/dl 10-40 em/dl
Blood sugar (Random) 300 mg/dl 1 l0- 170 mg/dl
Serum creatinine 0.71 mc/dl 0.5—1.5 mg/dl

56
Food intake: Poor Sleep Not good

Temperature 98 F° Chest Clear
CVS Si+Sz+() Abdomen Soft & Non tender
DIAGNOSIS: Acute exacerbation of asthma.
MEDICINE(S) TAKEN BEFORE ADMISSION:
Tab: Ventoline (salbutamol) 4 mg BD.
Date Generic name Signa
17 mar 2023 Inj: Ceftral 1 gm Ceftriaxone I/V BD.
Inj: Decadrone 2cc 4 mg/ml Dexamethasone I/V Stat.
Inj: Zaniac 50 mg Ranitidine I/V BD.

57
17 mar 2023 Inf: R/Lactate Calcium chloride 2H20 D.

0.2gm, KCl 0.3 gm,
NaCl gm,
lactate 3. 1 gm
50 gm,WFI
Tab: Loprin 75 mg Aspirin 1 * OD.
Tab: Monest 5 m Montelukast 2 * Noct.
Tab: Crestat 5 mg Rosuvastatin
Tab; Lasoride Frusemide 1* ZD

Amiloride Hcl 5 mg
Inhaler' xaltide Salbutamol 2 Pu%s BD.

Beclomethasone
Date Intervention/Advice
17 mar 2023 Ventoline nebulization
DATA ANALYSIS:
SIDE EFFECTE/ADVERSE DRUG REACTION(S) NOTED:
Weakness,
Stomach pain.

58
Drug Interactions;
1. Ceftriaxone with loop diuretics (Frusemide) cause increase in nephrotoxicity.
2. Dexamethasone with NSAIDs (Aspirin) cause. increase risk of GIT ulceration.
3. Loop diuretics (furosemide) with corticosteroids can cause potassium loss [10].
COMPLAINCE:
The patient follows the instructions of doctor so the patient compliance is good.
Too much steroids are used which have drug interactions with the aspirin and diuretics.
Minimum number of steroids should be prescribed.

59
CONCLUSION:
After evaluation of the above histories, it is concluded that for the achievement of Rational
therapy and for the management of Asthma patients on rational grounds, list we should follow
those standard procedures for the management which are mentioned by reference books and
should also overcome those problems which are common at ward level, like drug-drug
interactions, side effects, adverse drug reactions, compliance rate and poor patient education.
Counseling of the patients should be performed at ward level. Awareness programs

should be launched for the health professionals and patients and seminars should be
conducted. Ners Letters and Drug bulletins about the prevention and management of
Asthma patients should be published. Pharmacoeconomic evaluation should also be
encouraged. All these are possible when Clinical Pharmacist is induced at the ward
level.

60
Results and discussion:
The demographic data revealed that Asthma is most common among 40-70 years age people as shorn in
Table 1. Out of’ 12 male patients who showed Asthma also there was 8% diabetes mellitus (one cases),
16% heart diseases (two cases), and P% hypertension (one cases). Asthmatic attack was observed in 100%
(12/12) patients. Adverse drug reactions/side effects were observed in 90% of the patients, while drug-
drug interactions were 90%. No mismatching was observed in the prescriptions of the patient’s presenting
asthma.
Table 1. Demo hic and other relevant data of the atients

Case Case Case
Case 2
Gender(M/F)
Age (years) 40 30 50 70 70
Asthma yes Yes Yes yes Yes Yes yes yes Yes Yes Yes Yes
History
Hypertension yes Nil Yes Nil Nil Yes Nil Nil Nil Yes Yes Nil
DM Nil Nil Nil Yes Nil Nil Nil Nil Nil Nil Nil Nil
Asthmatic Yes Nil Nil Yes Nil Yes Yes yes Yes Yes Ast
c
tIC
Heart disease Nil Nil Nil Nil Nil Yes Nil yes Nil Nil Nil Nil
Concurrent
Disease
Hypertension No No Yes Nil Nil Nil Nil Nil Nil No No No
DM No No No yes Nn No Nil No No No No No
Drug
Yes Yes Yes Yes No Yes Yes Yes Yes Yes Yes Yes
Side e1“fects Yes Yes Yes Yes No Yes Yes Yes Yes Yes Yes Yes
Compliance Yes No Yes Yes Yes No Yes yes Yes Yes No

61
REFERENCES:
[l]. R. Walker and C. Whittlesea, clinical pharmacy and therapeutics, (4'h Edn) Marilyn
Meecham London, (2003). pp367.
[2]. Pulmonary disease Lee mertizis et al.The Washington Manual of Medical
Therapeutics {33rd edition).2az-zg4.
[3]. Prevalence of Asthma and Allergic Rhinitis Among SchooI Children of Karachi, Pakistan,
2OO7
[4]. Robins Basic Pathology 7th edition (June 15, 2002) pp455.
[5]. Clinical Features and Outcome in Patients with Acute Asthma Presenting with
Hypercapnia Am. J. Respir. Crit. Care Med. 1988; 138: 535-539.
Richard D. Mountain and Steven A. Sahn
[6]. Swain DG. Pneumothorax in acute asthma. Br Med J (Clin Res Ed). Jul 14
1984; 289(6437):109
[7]. National Asthma Education and Prevention Program: Expert Panel Report Guidelines
for the diagnosis and management of asthma. Bethesda, MD. National Hearl, Lung,
and Blood Institute, 2007. (NIH publication no. 08-4051)
www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm (Accessed on September 01,
2007).
[8]. Prevention of asthma

H. S. KAUFMAN, O. L. FRICK
Article first published online: 27 APR 2006 Clinical & Experimental Allergy Volume
11, Issue 6, pages 549-553, November 1951
[9]. M. I. Danish, short Textbook of Medical diagnosis and management, (8"
edition.), johar publications Karachi Pakistan (2009). pp 329-334.
2009, Vol. 46, No. l , Pages 86
Syed Muhammad Hasnain, PH.D, Muneeba Khan, MSc, Asma Saleem, MBBS and
Muhammad Anwar Waqar, PH.D.
[10]. Mosby’s drug interaction guide, 8" edition. 2006
[11]. British national formulary, 56t edition, 2008, drug interactions.

62
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1

ABDUL WALI KHAN UNIVERSITY MARDAN

KHYBER PAKHTUNKHWA PAKISTAN

Clinical Clerkship Report “PROJECT ON PHARMACOTHERAPY OF

Professor Dr. Haroon Khan

Abdul Wali Khan University Mardan.

Aims and Objectives

1.3.1 EXTRINSIC ASTHMA

3. Allergic bronco pulmonary aspergillosis.

1.3.2 INTRINSIC ASTHMA

S canne d eH th Camsc annee

1.5 PRICIPITATING FACTORS

1.5 PRESENTATION OF BRONCHIAL ASTHMA

1.6.1 EPISODIC ASTHMA

S canne d iH th Camsc annex

1.6.2 CHRONIC ASTHMA

1.6.3 SEVERE ACUTE ASTHMA (STATUS ASTHMATICUS)

1.7 CLINICAL FEATURES OF ACUTE ASTHMA

1. Tachypnea and also minor tachycardia.

2. With prolong expiration there be vesicular sounds.

3. Mild diffuse wheezing (rhonchi).

S canne d iH th Camsc annex

• In acute severe asthma when there is poor reaction to treatment.

• A rare but potentially fatal difficulty of the pulmonary hyper-inflation which is

1.8.2 CHEST RADIOGRAPH

S canne d iH th Camsc annex

1.8.3 PEAK EXPIRATORY FLOW RATE (PEFR)

1.8.4 ARTERIAL BLOOD GASES (ABGs)

S canne d iH th Camsc annex

ii. Early chest infection treatment.

iii. Avoid use of beta-blockers as they worsen bronchospasm.

iv. Avoid use of ACE-inhibitors drugs which aggravate cough.

vi. Avoid cigarette smoking.

Low-dose ICS Low-dose ICS plus Sustained-release

Low-dose ICS plus leukotriene

S canne d iH th Camsc annex

1.9.2 DRUG TREATMENT OF ASTHAMA

A. LONG TERM CONTROL MEDICATIONS

S canne d iH th Camsc annex

I. BETA- ADRENERGIC AGONISTS

II. PHOSPHODIESTERASE INHIBITORS

Theophylline induced mild bronchodilation also has anti-inflammatory effects. Sustained-

I. CROMOLYN SODIUM (INTAL) AND NEDOCROMIL SODIUM

II. LEUKOTRINE RECEPTOR ANTAGONISTS

S canne d iH th Camsc annex

D. QUICK RELIEF MEDICATIONS

I. BETA —ADRENERGIC AGONISTS

a. INHALED BETA-ADRENERGIC AGONISTS

b. ORAL BETA-ADRENERGIC AGONISTS

• If due to beta blocker agent's bronchospasm is inferior to bronchitis.

S canne d iH th Camsc annex

• Patients who do not respond to beta-agonists.

• Used as adjuvant to short acting beta2-adrenergic agonists in mild to acute asthma

• Those who cannot tolerate beta2-adrenergic agonists given as an alternate.

I/V aminophylline is very efficient in status asthmaticus. Aminophylline infusion is given to

S canne d iH th Camsc annex

table 4. Common asthma medications. Classes

corticosteroids aspects of airway dipropionate Strong topical anti-inflammatory effect and

c nd eosinophils and thus alleviate their asthma-inducing and

Aims and Objectives