Polypharmacy icon of two pills

Background details  - age, sex, occupation, baseline function

  • 58-year-old female
  • Works as a secondary school teacher
  • Still working full time

History of presentation/reason for review

  • Referred by GP due to productive cough, asking if she has COPD
  • On presentation at clinic, has had two episodes of chest infection requiring antibiotics in last six months. On both occasions, sputum grew Haemophilus influenzae
  • Daily production of yellow sputum
  • Minimal breathlessness
  • No chest pains

Current medical history and relevant co-morbidities

  • Severe chest infection at eight years (spent three months in hospital)
  • Was ‘chesty’ through adulthood

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

  • No current medication
  • Had been given SABA inhaler with no benefit
  • No drug allergies

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

  • Never smoker
  • Drinks alcohol on special occasions
  • Enjoys walking holidays

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

  • Localised bronchiectasis (right lower lobe), otherwise normal
  • No radiological evidence of NTM pulmonary disease
  • Spirometry is normal
  • Mycobacterial cultures were negative for NTM

Most recent consultations

First consultation

  • Given the diagnosis of localized bronchiectasis, likely due to childhood pneumonia.  No diagnosis of COPD.
  • Given instruction in airway clearance techniques by specialist respiratory physiotherapist.
  • Commenced on a mucolytic to assist sputum expectoration
  • Pulmonary Function Test (PFTs) showed no diagnosis

Follow up 3 months

  • Significant improvement in her ability to clear sputum
  • Improvement of day-to-day symptoms reported
  • However, further chest infection requiring antibiotics
  • Discussion regarding long term azithromycin treatment
    • consented to risks of reversible tinnitus/hearing loss associated with long term macrolide use
    • ECG carried out, showing normal QTc of 405
    • advised to continue azithromycin when on other antibiotics except quinolones
  • Azithromycin 250mg Monday/Wednesday/Friday commenced

Follow up 6 month review

  • Patient reported no further chest infection since commencing azithromycin
  • Routine sputum samples continued to be negative
  • Repeat mycobacterial culture was negative
  • After discussion azithromycin has been continued long term with good effect

 

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 PROMs questions to prepare for my review before their review

Person specific actions

  • Ongoing symptoms of productive cough, daily sputum production
  • Diagnosis of COPD

 

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

  • None

 

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

  • None

 

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

  • Localised bronchiectasis (right lower lobe), Normal spirometry. No diagnosis of COPD
  • Commenced a mucolytic to assist sputum expectoration
  • Airway clearance techniques taught by specialist respiratory physiotherapist
  • Long-term azithromycin therapy commenced following further antibiotic courses for chest infection

 

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

  • ECG carried out prior to long-term azithromycin therapy, normal QTc of 405
  • Risks explained of reversible tinnitus/hearing loss associated with long term macrolide use
  • If further antibiotics needed, can continue azithromycin apart from with quinolones

 

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

  • Regular long-term azithromycin reduces need for repeated courses of short-term antibiotics and improved patient outcomes

 

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 long-term azithromycin commenced (Monday /Wednesday /Friday)
  • Sputum clearance techniques

 

Key concepts in this case

  • Confirm diagnosis of bronchiectasis to allow appropriate management
  • Sputum management with mucolytics and sputum clearance techniques
  • Use of long-term azithromycin for regular exacerbations and discussion of side effects