I would make the following recommendations;
- Glucocorticoid: Beclomethasone dipropionate (QVAR), MDI: 40µg/inhalation 40mcg per spray, twice daily.
- CXR for her increased issues with asthmatic episodes.
- Possible CT scan or MRI for her chronic knee pain, and Physical therapy evaluation and treatment.
- Ibuprofen 400mg by mouth every 4-6 hours as needed for pain not to exceed 1200mg per day for 10 days, as well use ice with elevation for her chronic knee pain until full assessment has been done and CT scan/ and MRI results are in.
- Discuss possible options in initiating contraceptive therapy and what would fit her lifestyle in regards to the side effects with each option. Ask the patient why she would like begin a different type of birth control? Her family planning goals, if she has a constant sexual partner/ relationship for a long period of time, and inquire about STD testing for both partners. Personal preference is a huge aspect in providing the drive needed for consistent implementation of a birth control method. Even the best form of contraception will be ineffective if not adhered to and the importance of personal preference cannot be overemphasized (Rosenthal & Burchum, 2021). Practitioners should take measures to educate patients about the contraceptive methods available so that selection and use can be based on their understanding.
- I would not recommend a medication for weight loss based off of the information given on a mainly healthy 26 year old patient. It would be helpful to know the patient’s current BMI and her family history and if it is linked to obesity (Rosenthal & Burchum, 2021). I would recommend calorie restriction, healthy diet, exercise, and lifestyle changes/possible behavior modifications first before any medications. I would encourage her to get involved in a group exercise class of her choice a few times a week to help her get confidence and gain workout companions which should help with her exercise adherence. Or encourage other exercise options that she finds exciting.If that patient can loose a little weight it may also help with her chronic knee pain.
For the treatment of asthma, it should always be combined with an inhaled glucocorticoid (Rosenthal & Burchum, 2021).Inhaled glucocorticoids are very effective and are much safer than systemic glucocorticoids and are the first-line therapy for managing the inflammatory component of asthma. An inhaled glucocorticoid can help with therapeutic effects such as; nighttime awakenings, peak expiratory flow, symptom frequency and symptom intensity, effect on normal activity, and short-acting β2 agonist use (Rosenthal & Burchum, 2021). By suppressing inflammation, glucocorticoids reduce bronchial hyperreactivity and decrease airway mucus production. There is also some evidence that glucocorticoids may increase the number of bronchial β2 receptors as well as their responsiveness to β2 agonists (Rosenthal & Burchum, 2021). As the patient is already on an Albuterol inhaler which is a B2 agonist, by adding an inhaled gulcocorticoid can help the responsiveness of her Albuterol. I would assess the patient and question nighttime asthma attacks, symptom intensity, and any changes in lifestyle and BMI.
Potential side effects and drug interactions
The most common adverse effects are oropharyngeal candidiasis and dysphonia (hoarseness, speaking difficulty) and both are from the localization of inhaled glucocorticoids. To decrease these effects, patients should rinse their mouth out with water and gargle after each dose. Utilizing a spacer device can be helpful also, if candidiasis develops, it can be treated with an antifungal drug.
Long-term use of inhaled glucocorticoids may promote bone loss. Luckily, the amount of bone loss is much lower than the amount caused by the oral glucocorticoids. To minimize bone loss, patients should; use the lowest dose that controls symptoms, make certain adequate intake of calcium and vitamin D, and engage in weight-bearing exercises (Rosenthal & Burchum, 2021).
Adverse effects of NSAIDs (Ibuprofen) with long term use are; gastric ulceration, acute renal failure, and bleeding. In addition, all NSAIDs except aspirin increase the risk for thrombotic events.
Patient Education & non-pharmacological interventions
- Educate the patient that glucocorticoids are for preventive use to prevent attacks- but cannot abort an ongoing asthma attack.
- Instruct patient to administer glucocorticoids on a regular schedule, not when they feel they need it, for the medication to work properly.
- Teach patients with chronic asthma to monitor and record peak expiratory flow (PEF), symptom intensity, symptom frequency, nighttime awakenings, effect on normal activity, and SABA/ albuterol use (Rosenthal & Burhcum, 2021).
- Also instruct patient to go to the Emergency Room if asthma attack is not relieved by current medications.
- Advise patients to rinse their mouth and gargle after using their MDI to minimize risk of dysphonia and oropharyngeal candidiasis.
- I would also advise the patient not to combine acetaminophen with alcohol, even in moderate amounts, because it can result in potentially fatal liver damage (Rosenthal & Burchum, 2021).
- I want to provide the patient with tools to be informed on her birth control options. Planned Parenthood has created a step-by-step electronic tool that is accessible online at https://tools.plannedparenthood.org/bc/birth_control_quiz. This tool includes all of the factors regarding birth control options. The patient can use this to read, think about, and compare her options- as well as the side effects, and costs before choosing her birth control method.
- I would also give this patient information on massage, acupuncture, trigger points, and physical therapy as they can all alleviate knee pain or muscles triggering the pain (Rahou-El-Bachiri et al., 2020) .
- Ask patient follow up in 1-2 weeks to reassess status, new glucocorticoid medication, results of scans, and birth control decision.
PDR. (2021). Ibuprofen Tablets | Drug Information. Www.pdr.net; Prescriber’s Digital Reference. https://www.pdr.net/drug-information/ibuprofen-tablets?druglabelid=2618
Rahou-El-Bachiri, Y., Navarro-Santana, M. J., Gómez‐Chiguano, G. F., Cleland, J., Villanueva, I. L., Fernández‐de‐las‐Peñas, C., Ortega‐Santiago, R., & Plaza‐Manzano, G. (2020). Effects of Trigger Point Dry Needling for the Management of Knee Pain Syndromes: A Systematic Review and Meta-Analysis. Journal of Clinical Medicine, 9(7), 2044. https://doi.org/10.3390/jcm9072044
Rosenthal, L. D., & Burchum, J. R. (2021). Lehne’s Pharmacotherapeutics For Advanced Practice Nurses and Physician Assistants (2nd ed.). Elsevier