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 

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

 

Person specific actions

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

 

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

 

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

 

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

 

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

 

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.