Background details  - age, sex, occupation, baseline function

  • 47-year-old female
  • Works as cleaner in local high school, but currently on sick leave
  • Has had 16 courses of oral prednisolone therapy in 12 months without any face-to-face review with a clinician
  • Has ordered 24 salbutamol pMDIs in 12 months
  • Breathless, nocturnal wheeze most nights
  • Never tested positive for Covid


History of presentation/reason for review

  • Referred to primary care healthcare professional due to OCS use and high-volume ordering of salbutamol, despite current treatment with Airflusal® pMDI (fluticasone 250 micrograms /salmeterol 25 micrograms) two puffs twice daily
  • Worsening symptoms over the past year
  • Multiple courses of oral prednisolone therapy


Current medical history and relevant co-morbidities

  • Asthma


Current medication and drug allergies (include OTC preparation and herbal remedies)

  • Airflusal® pMDI 250/25 two puffs twice daily, only ordered six inhalers in 12 months
  • Salbutamol pMDI two puffs, as required, 24 inhalers ordered in 12 months


Lifestyle and current function (incl. frailty score for >65yrs) alcohol/smoking/diet/exercise

  • Lives with husband and 3 children
  • Has 2 dogs, 1 cat
  • Current smoker of 10 cigarettes per day with 18 pack years
  • Overweight with BMI 31
  • Little motivation to engage with physical activity


Results e.g. biochemistry, other relevant investigations or monitoring

  • Asthma Control Test (ACT) 7/25
  • RadioAllergosorbent Test (RAST) – High positive dogs, moderate positive cats, low positive pollen, dust mite. Await Total IgE and aspergillus serology
  • Normal eosinophils.  TFTs, FBC, U&Es, bone, glucose, ANA, ANCA, CRP, iron studies and B12- normal
  • Referred chest X-Ray (CXR) and pulmonary function tests (PFTs)


Most recent consultations

First consultation

  • Discussed symptoms and ACT 7/25. Carried out full asthma serology screen. Referred for full PFTs, CXR and DEXA scan
  • Chest exam-NAD. SpO2 98% room air
  • Discussed concerns over multiple prednisolone courses, high volume salbutamol use and poor adherence to Airflusal® in the context of symptoms and ACT score, adherence to preventer therapy discussed
  • Agreed move to Fobumix® Easyhaler® DPI (budesonide 320 micrograms/ formoterol 9 micrograms) two puffs twice daily and Easyhaler® salbutamol, as inhaler technique poor with MDI and good with Easyhaler®. Discussed this in line with health board’s green agenda. Discussed physiology of asthma and concerns, as identified as at risk
  • Explained side effect risks from prednisolone and need for DEXA scan
  • Discussed smoking cessation and Very Brief Advice (VBA) given. Will consider referral to Quit Your Way
  • Full asthma screen and review arranged for following week


Follow up appointment

  • Given blood results and awaiting Total IgE and Aspergillus serology. Discussed addition of montelukast given RAST positivity and pets. Agreed with plan
  • Awaiting date for PFTs and CXR
  • Further education and discussion around managing asthma
  • Aware dependent on awaited results may need referral onto Difficult Asthma Clinic
  • Personalised Asthma Action Plan discussed, agreed and written copy issued. Advised that this may change dependent on results
  • Further appointment made for four weeks for review


Background (age, sex, occupation, baseline function)

  • 57 years old
  • Male
  • Self-employed taxi driver

History of presentation/reason for review

  • Referral to Weight Management Service from GP
  • Reports that he “drank and ate too much in his 20’s” but active in his job. Since becoming a taxi driver and quitting smoking his weight increased
  • Works 12 hour shifts 5-6 days a week, leaving little time for physical activity
  • Tried commercial slimming clubs in the past but regained weight once stopped attending
  • Reports overeating in response to stress
  • Does no cooking at home – meals mostly on the go, grabbing convenience foods whilst driving his taxi

Current medical history and relevant co-morbidities

  • T2DM diagnosed 3 years ago
  • Essential hypertension
  • Gastro-oesophageal reflux disease (GORD)
  • Depressive disorder
  • Family history of CVD and T2DM with a family member requiring an amputation due to peripheral vascular disease
  • High stress levels during the COVID-19 pandemic and lack of income

Current medication and drug allergies (include OTC preparation and herbal remedies)

  • Candesartan 8mg tablets - one tablet daily
  • Metformin 500mg tablets – two tablets twice daily
  • Sildenafil 100mg tablets - one tablet daily as required
  • Trazadone 50mg capsules - one capsule at night

Lifestyle and current function (including frailty score for >65yrs) alcohol/smoking/diet/physical activity

  • Alcohol – social drinker
  • Ex-smoker
  • Physical activity level low – struggles to walk any distance without pain

“What matters to me” (patient ideas, concerns and expectations of treatment)

  • His own aims are to put his Type 2 diabetes into remission, stop his medications and improve his mobility and quality of life

Results e.g., biochemistry, other relevant investigations or monitoring

  • Height 1.85m
  • Weight 148.6kg
  • BMI 43.4 kg/m2
  • HbA1c 67mmol/mol.
  • Blood pressure normal range on antihypertensive medication
  • LDL cholesterol 3.3mmol/L

Most recent relevant consultations

  • Attended a few appointments with team psychologist prior to starting the intervention. Discussed concerns around eating behaviours including boredom/comfort eating and high stress levels
  • Placed on the NHS Scotland/Counterweight Plus Remission Programme - total diet replacement (TDR) – 800 calorie per day soups and shakes diet (4/day) for an initial 12 weeks. Fortnightly appointments with the specialist dietitian for treatment through the programme
  • Metformin and candesartan stopped on day 1 of the intervention as per the agreed medical management protocol
  • 31kg weight lost at the end of 12 weeks of TDR – blood glucose, weight and blood pressure were checked every 2 weeks at appointment with the dietitian
  • After 12 weeks of TDR, food was slowly reintroduced
  • A further 13kg was lost over the 12 weeks on the food reintroduction stage
  • BP medications were reintroduced due to a rebound increase in resting BP, at half the dosage at the start of the intervention
  • At 6 months:
    • Appointments monthly
    • Weight loss was 29% of body weight, 10 inches lost from waist
    • Metformin stopped, BP medications dosage halved
    • Patient was jogging multiple times per week – 5km distances
    • HbA1c had reduced from 65 to 46 mmol/mol – now in remission.
  • Progressing with second year of weight loss maintenance in the type 2 diabetes remission programme, including monthly appointments with dietician
  • Maintaining lifestyle changes and continuing to regularly monitor measurements
    • Wife attended a cooking class and supports with planning and cooking meals
    • Takes meals with him in his taxi instead of buying food on the go, also helps with cooking evening meal
    • Has progressed from being unable to walk round block to regularly running 5km distances
  • Current medications:
    • Candesartan 4 mg OD
    • Trazadone 50 mg
  • Current measurements:
    • Weight: 99.9 kg
    • BMI: 29.2 kg/m2
    • Total weight loss: 32.7%
    • HbA1c 36 mmol/mol
    • Cholesterol: 2.7 mmol/l
    • Remains in remission


7 Steps: Person specific issues to address for asthma case study 

1.  Aims: What matters to the individual about their condition(s)?

Review diagnoses and consider:

  • Therapeutic objectives of drug therapy
  • Management of existing health problems
  • Prevention of future health issues, including lifestyle advice 

Ask patient to complete Patient Reported Outcomes Measures (PROMs) questions to prepare for my review before their review

Person specific actions

  • Worsening symptoms of asthma and poor control, resulting in multiple courses of oral steroids and high volume of salbutamol use
  • Getting back to work as a cleaner


2.  Need: Identify essential drug therapy

Identify essential drugs (not to be stopped without specialist advice*)

  • Drugs that have essential replacement functions (e.g. levothyroxine)
  • Drugs to prevent rapid symptomatic decline (e.g. drugs for Parkinson’s disease, heart failure)

Person specific actions

  • Inhaled corticosteroids for asthma control, currently prescribed as a combination MDI, Airflusal® (not being ordered regularly)


3.  Need: Does the individual take unnecessary drug therapy?

Identify and review the continued need for drugs

  • what is medication for?
  • with temporary indications
  • with higher than usual maintenance doses
  • with limited benefit/evidence for use
  • with limited benefit in the person under review (see Drug efficacy & applicability (NNT) table)

Person specific actions

  • Salbutamol is used frequently (24 inhalers ordered in 12 months), unnecessary if preventer therapy used effectively
  • Past frequent courses of oral steroids (16 courses in 12 months) increasing potential for adverse effects


4.  Effectiveness: Are therapeutic objectives being achieved?

Identify the need for adding/intensifying drug therapy to achieve therapeutic objectives

  • to achieve symptom control
  • to achieve biochemical/clinical targets
  • to prevent disease progression/exacerbation
  • is there a more appropriate medication to achieve goals?

Person specific actions

  • Discussion and education regarding adherence to preventer therapy and salbutamol use. MART therapy also discussed as an option
  • Checked inhaler technique with MDI to ensure able to use
  • Inhaler changed to a DPI (Fobumix® Easyhaler®, containing an ICS/LABA) as MDI technique was poor
  • RAST positivity and presence of pets at home, therefore addition of montelukast to trial


5.  Safety: Does the individual have or is at risk of ADR/ side effects? Does the person know what to do if they’re ill?

Identify individual safety risks by checking for

  • appropriate individual targets
  • drug-disease interactions
  • drug-drug interactions (see ADR table)
  • monitoring mechanisms for high-risk drugs
  • risk of accidental overdosing

Identify adverse drug effects by checking for

  • specific symptoms/laboratory markers
  • cumulative adverse drug effects (see ADR table)
  • drugs used to treat side effects caused by other drugs 

Medication Sick Day guidance

Person specific actions

  • Advised of potential for adverse effects from multiple oral steroid courses. DEXA scan arranged. Inhaled corticosteroids treat the condition with reduced exposure to systemic effects, therefore reduced ADRs
  • Risk of hypokalaemia with salbutamol over-use, U and Es were normal
  • Personalised Asthma Action Plan reinforces advice to take when symptoms of asthma control deteriorate


6.  Sustainability: Is drug therapy cost-effective and environmentally sustainable?

Identify unnecessarily costly drug therapy by

  • considering more cost-effective alternatives (but balance against effectiveness, safety, convenience)

Consider the environmental impact of

  • Inhaler use
  • Single use plastics
  • Medicines waste
  • Water pollution 

Person specific actions

  • MDI changed to DPI (Easyhaler®) due to inhaler technique, and discussed environmental impact of propellant gases in MDI compared to DPI
  • Salbutamol DPI (Easyhaler®) has a dose counter, so will provide reassurance of medication availability, but with education and discussion about management of asthma to reinforce the importance of regular preventer therapy


7.  Patient centeredness: Is the patient willing and able to take drug therapy as intended?

Does the person understand the outcomes of the review?

  • Consider teach-back

Ensure drug therapy changes are tailored to individual’s preferences. Consider

  • is the medication in a form they can take?
  • is the dosing schedule convenient?
  • what assistance is needed?
  • are they able to take medicines as intended?

Agree and communicate plan

  • discuss and agree with the individual/carer/welfare proxy therapeutic objectives and treatment priorities
  • agree with them what medicines have an effect of sufficient magnitude to consider continuation or discontinuation
  • inform relevant health and social care providers of changes in treatments across the transitions of care

Ask patient to complete the post review PROMs questions after their review 

Agreed plan

  • Regular preventer therapy issued in an inhaler which they are able to use correctly
  • Personalised Asthma Action Plan discussed and agreed, with a written copy given
  • Discussed smoking cessation and Very Brief Advice (VBA) given. Considering referral to Quit Your Way
  • Possible that a further referral to the Difficult Asthma Clinic may be needed, dependent on full results and outcomes from improved education and inhaler technique
  • Review appointment made for four weeks’ time.