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Pharmacotherapy of

CHRONIC OBSRUCTIVE PULMONARY DISEASE (COPD)

Submitted by

Afsar Ali Khan

Doctor of Pharmacy

(2011-2016)

DEPARTMENT OF PHARMACY

UNIVERSITY OF MALAKAND
I dedicate my project report to my parents who faced a lot of troubles
to serve me and my friends specially all of my university class
fellows and my well-wishers with whom I completed this task and
spent a lovely time....

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APPROVAL CERTIFICATE

It is certified that Mr. Afsar Ali Khan has completed his clinical Pharmacy Clerkship
at Saidu Teaching Hospitals, Swat on the title Chronic Obstructive Pulmonary
Disease for the partial fulfilment of the degree of Doctor of Pharmacy (Pharm. D).

SUPERVISED BY:
_______________________
Dr. M. Junaid
Associate professor,
Department of Pharmacy,
University of Malakand.

EXTERNAL EXAMINER:

________________________

CHAIRMAN:

_________________________

Dr. Waqar Ahmad


Professor,
Department of Pharmacy
University of Malakand.

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CONTENTS
ACKNOWLDGMENT ............................................................................................................ 5
Abbreviation table ................................................................................................................... 6
Aims and objectives ................................................................................................................. 8
Summary ................................................................................................................................... 9
Introduction ............................................................................................................................ 10
Methodology ........................................................................................................................... 18
Case histories .......................................................................................................................... 20
Case: 1 .................................................................................................................................. 20
Case 2 ................................................................................................................................... 23
Case 3 ................................................................................................................................... 25
Case 4 ................................................................................................................................... 28
Case 5 ................................................................................................................................... 30
Case 6 ................................................................................................................................... 32
Case 7 ................................................................................................................................... 35
Case 8 ................................................................................................................................... 37
Case 9 ................................................................................................................................... 40
Case: 10 ................................................................................................................................ 43
Conclusion .............................................................................................................................. 50
References ............................................................................................................................... 51

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ACKNOWLDGMENT

I have no words to express my deepest sense of gratitude towards Almighty Allah,


who enabled me to accomplish this task. I also acknowledge my deepest sense of
gratitude for whom this world has been made, the Holy Prophet (PBUH) who had
spread the light of learning in this world for the whole humanity.

I am heartily thankful to my honourable supervisors Dr. Nasiara kareem and Dr.


Muhammad junaid, Department of pharmacy, University of Malakand, whose
encouragement, timely supervision, productive criticism and endowment from initial
to final, enabled me to progress and materialize this task.

I expend my Heart full thanks and appreciation to Mr. Muhammad Yousaf chief
pharmacist Saidu group of teaching hospitals and Dr.fawad Ali due to their kind
support during wards rounds and data collection.

A genial smile to my friends and all my class fellows who accompanied me in


hospital and encouraged me and helped me in completing this task

Last but not the least my parents for whom I have no words of acknowledgment to
express my gratitude and emotions. My success and all the abilities are due to their
kindness, their parenting skills, their guidance and their prayers. May Allah give them
a long and happy life and give me the ability to make them happy and to serve
humanity.

Afsar Ali Khan

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Abbreviation table

Word Abbreviation

AAT Alpha-1 antitrypsin

AMP Adenosine mono phosphate

BD two times a day

COPD Chronic obstructive pulmonary disease

CXR Chest x-ray

D/S Dextrose solution

ESR Erythrocyte sedimentation rate

FEV forced expiratory volume

FEV1 .forced expiratory volume in one second

FVC Forced expiratory vital capacity

Gm Gram

GOLD Global initiative for obstructive lung disease

HCT Hematocrate

HGB Haemoglobin level

HTN Hypertension

I/v Intravenous

INF Infusion

INJ Injection

L Litre

LABA Long acting beta 2 agonist

Lfts Liver function tests

mg Milligram

MMW-B male medical ward-B

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N.M not mentioned

NEB Nebulizer/nebulisation

OD once daily

P/O Oral

R/L Ringer lactate solution

RBS Random blood sugar level

Rfts Renal function tests

S.br Serum bilirubin level

S.cr Serum creatinine

SABA Short acting beta 2 agonist

SOB shortness of breath

Sos When needed

SYP Syrup

TAB Tablet

TDS three times a day

TSF tea spoon full

WBCs White blood cells

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Aims and objectives

The clinical aim and objectives of this project are

1) To get familiar with clinical pharmacy practice in hospital

2) To detect, collect, report and discuss data about rational therapy of COPD in
Saidu group of teaching hospitals, Swat.

3) To encourage and educate patients about rational therapy of COPD in Saidu


group of teaching hospitals Swat.

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Summary

COPD is the chronic disease of lungs which consist of two pathological conditions.
Bronchitis and emphysema, due to these conditions obstructions occur to air passage
in the lungs and the patient feel signs of dyspnoea, productive cough, weight loss and
fever. WHO estimates it as the 3rd leading cause of deaths and fifth leading cause of
disability by 2020.Worldwide approximately ten to twenty percent of the population
whose age is more than 40 years and makes round about 80 million people are
effected with COPD and contributing to 3 million deaths per year. So for treatment of
COPD the drugs most commonly used are bronchodilators including 2 adrenergic
agonists like salbutamol, anticholinergic like ipatropium methyl xanthenes like
theophyline .along with these inhaled corticosteroids, antibiotics and oxygen therapy
are the options for treatment.

The main causes of this disease include cigarette smoking. Dust, fumes, and smokes
may be also the leading causative factors for COPD.

Smoking is considered to be the most common cause of COPD but the cases
evaluated during this study shows that six patients out of ten were not smokers but
were coal workers and two in ten patients were smokers.
This project was completed in the medical ward-B of Saidu teaching hospital Swat.
Total 10 cases have been discussed in detail and to collect data and record histories of
COPD patients, I designed a Performa which include the personal information,
Medical and surgical history, complaints of patient ward level medication, medication
prescribed for home ADRs and drug interactions .at the end of each case I also had
given my comments and suggestions.

I felt intense need of clinical pharmacist at wards because I noted many drug
interactions and lack of patience compliance.

So pharmacist should be present in the ward to counsel the patients and guide the
prescribers and patients regarding the drugs and its use.

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Introduction

Chronic obstructive pulmonary disease


Chronic obstructive pulmonary disease abbreviated as COPD is enfeebling,
perniciously, slowly progressive and not fully reversible but treatable and preventable
pulmonary disorder in which there is obstruction to air passage and characterized by
chronic bronchitis and pulmonary emphysema [1].

Emphysema is the condition of alveolar wall destruction and enlargement of air-


spaces while chronic bronchitis is condition of having chronic cough with sputum for
[2]
at least three month in year and consecutively for two years . This leads to
anatomical changes in of the lungs and results in devolved air exchange and
ventilation [3]. This term is also used to cover the other terms like chronic obstructive
lung disorder [COLD] or chronic obstructive airways disease [COAD]. The
obstruction to air passage is progressive and as well as accompanied with abnormal
inflammatory conditions of the lungs to injurious particles or gasses [4].

Epidemiology
[14]
COPD is the fourth leading cause of deaths in the United States while WHO
estimates as the third leading cause of deaths and fifth leading cause of disability by
2020[13].Worldwide approximately ten to twenty percent of the population whose age
is more than 40 years and makes round about eighty million people are effected with
COPD and contributing to three million deaths per year [17, 18]. A survey whose results
were displayed by Asian Pacific Society of Respiratory Diseases 6.2 percent of COPD
patients in the world are found in 11 Asian countries [19].

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Mortality rate of COPD
A graph of data given by WHO which show the mortality rate of COPD in males and
females on the base of age is given below [20].

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Etiology of COPD
There may be a number of causes for COPD but cigarette smoking is the main cause
[5]
of COPD and majority of COPD patients found are smokers and the patients who
smokes, are twelve to thirteen times more prone and susceptible to death than that of
[6, 7].
non smoker patients Other than cigarette other harmful and irritating gases,
genetic factors, dusts, pollutants ,previous history of pulmonary infections in
childhood, and the socioeconomic conditions of the patients are also risk factors and
may be counted as the causes of COPD [8].

Due to genetic deficiency the body fails to produce a protein called Alpha-1
antitrypsin [AAT], which is responsible for the protection of lungs, leads to
emphysema and COPD [9].The risk factors are also discussed as under.

Smoking: Increase in intensity of smoking of cigarette, pipe, and cigar etc


results in increase risk of COPD but there is large variation in individual
susceptibility and female are more susceptible than that of males because their
alveolar response is quicker and sensitive than that of males [12].
Age: Aging is also risk factor but not only increase in age result the disease
but along with other infections of lung or intense smoking age increase the
risk of COPD because with increase in age the lungs become week and
ventilation is also effected which increase the risk factor of COPD[10,11].
Gender: As women alveolar response is more active and they experience in
faster decline in FEV so they are at high risk of COPD than the males.
Occupation: The people who are associated with the occupation of mining
,cement industry, grain business or other occupations in which there are more
chances of dust , fumes and fuming chemicals and pollutants are more prone
to the COPD[12].
Genetic factors: absence of AAT is main genetic cause for increasing the risk
of COPD [9].
Air Pollution: As the air pollution is more and there are more dust and fumes
in urban areas so the people of these areas are at more risk than those of rural
area.
Economic conditions: The people who have low financial resources for the
treatment of COPD or they are even unable to spend money on diagnostic

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tools or early diagnosis and treatment of COPD are at high risk of sever
COPD.
Oxidative stress: lungs are directly damaged by the imbalance between
oxidants and anti oxidants and leads to lung inflammation [20].

Signs and symptoms


The main signs and symptoms of COPD are as follow

Relentless cough with sputum production ,the sputum may also have blood
Dyspnoea (difficulty or shortness of breath) for months or even long time
Cyanosis in severe case
Weight loss
Fever

Diagnosis of COPD
COPD is diagnosed on the basis of physical analysis of signs and symptoms, taking
patient medical record and considering risk factors. Diagnostic tests play an important
role in the determination of disease, in which some test should be done for all
suspected like patients spirometry while some should conducted on special population
like alpha-1 AAT deficiency test. The most important one is FEV (forced expiratory
volume) test .COPD is also classified into different stages on the basis of FEV1 and
ratio of FEV1/FVC.

Upon the results of spirometry COPD is classified into four main types which are
shown as [21, 23].

Post-Bronchodilator FEV1% GOLD 2009*:


FEV1/FVC Predicted

<0.7 > 80% Stage1-Mild Stage


<0.7 50-79% Stage 2- Moderate
<0.7 30-49% Stage 3 -Severe
<0.7 < 30% Stage 4-Very Severe
*: means global initiative for chronic obstructive lung diseases standards 2009

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Along with test other techniques may also be conducted for diagnosis of COPD which
may include bronchodilator reversibility test and six minutes walk test, chest
radiography, arterial blood gas analysis and full blood count [20, 22].

Pathophysiology in COPD
A patient suffering from COPD has actually abnormality or damage in four parts of
lungs which are central airways, peripheral airways parenchyma cells of the lungs and
pulmonary vasculature [24]. These abnormalities may due to mainly smoking but other
foreign harmful particles like smoke dust and fumes may cause these abnormalities
which irritate the mucosa of lung which in turns increase the numbers of neutrophils
,macrophages and CD8+ lymphocytes which mediates inflammation and also by these
imbalances and irritation and break down and repair of alveoli, hyper inflation of
lungs occur which give flatness to the diaphragm and make the rib cage larger than
normal in the lung occurs.[,25,27] which results increase secretions of mucus and
difficulty in expiration i.e. shortness of breath dyspnoea and productive cough , and
imbalance in the gases exchanges and pulmonary hypertension which may result cor
pulmonale [26,28].
Management of COPD
COPD is a curable and preventable disease. The main objective of the management is
the dilation of air ways. The pre management plan for COPD is to stop cigarette
smoking and prevention from fumes, smokes, dust and other irritating gases and
prevention from exacerbation of the disease by earlier diagnosis and treatment [29].

Pharmacotherapy of COPD
Pharmacotherapy of COPD means the use and management of disease through
medicines. The aim of therapy is to reduce exacerbation and also to relieve the
symptoms of the patient, in case of COPD the route of administration which is
preferred is inhalatory route because that has proven to be the most effective.

The major classes of drugs used in the treatment of COPD are [30],

Bronchodilators
Corticosteroids
Antibiotics
Oxygen therapy

Along with these agents mucolytics are also useful in COPD. [31] Bronchodilators
further have many classes i.e. 2 agonists, anti cholinergic and xanthenes derivatives.

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2 agonists have further two classes i.e. short acting and long acting 2 agonists.

The management plan is shown in the figure below

Treatment plan for COPD

self management and risk factors avoidence

Bronchodilators

inhaled carticosteriods

pulmonary rehabilitation

Oxygen therapy

Bronchodilators

Bronchodilators are the main class of drugs used for COPD. This class include
adrenergic agonists i.e. beta 2 adrenergic agonists, methyl xanthenes and anti
cholinergic.

Bronchodilators improves the lung capacity for inspiration by minimizing the


pulmonary emptying time [33] and by such way the shortness and difficulty in
breathing may be relieved.[ 32]

2 agonists

2 agonists are the drugs which are used more frequently for the treatment of COPD
they may be short acting or long acting also known as SABA and LABA respectively.

Mechanism of Action

They act on 2 receptors present in the smooth muscles of lungs. They interact with
the G protein and produce the cyclic AMP which in turn stimulate protein kinase A
and which is responsible for phosphorylation and hence relaxation of smooth muscles
occurs. The exact targets are unknown but it is believed that it involves protein kinase
and calcium dependent potassium channels [34].

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Short acting 2 agonists (SABA)

SABA are very helpful in the management of COPD and studies shows that if a
patient use SABA for regular a week so his lung function can be improved and
dyspnoea may also be reduced [35]. Combination of two SABAs is proven to be more
effective than the single one drug [36].

Albuterol is the drug of this class which is frequently and mostly used. These drugs
show their effect within five minutes and its reach to maximum rate only in 15
minutes and total duration of time is almost 4 hours.the other examples includes the
drugs namely levosulbutamol terbutaline levelbuterol, metaproterenol. Retodrine and
pirbuterol,

Long acting 2 agonists (LABA)

Long acting 2 agonists also used for bronchodilator effect with good efficacy and are
first line drugs in treatment of COPD but their duration of action is longer than the
short acting and their effect remains up to twelve hours so the frequency of dose are
low in this case and hence therapy cost also becomes low.

Common examples are salmetaro, .formetarol and bambuterol.

Adverse effects

Usually on low therapeutic doses no sever adverse effects occurs but some patients
may also report adverse effects like tachycardia, .hypokalemia Tremors or
nervousness even on low doses and specially the use of these agents should be made
with conscious and more care in the patients of diabetes mellitus and heart diseases
and albuterol is contra indicated in Cardiac tachyarrhythmia. [6.52]

Anti cholinergic agents


Anti cholinergic drugs produce bronchodilatory effect by blocking the acetylcholine
in the nervous system which is responsible for involuntary movements of smooth
muscles. The most common example of this class is ipatropium bromide which is
more effective in than 2 agonists. Its peek effectiveness level is achieved after two
hours and last for six hours.

Combination of 2 agonists and anti cholinergic drugs shows more effective results in
the treatment of COPD.

Methyl xanthenes
Theophyline and aminophyline are the examples of this class of bronchodilators .they
block the phosphodiesterase enzymes competitively and inhibit inflammatory
mediators and thus are useful in bronchodilaton and reducing the bronchitis. They are

16
given orally or parentally but the dose strength should be properly monitored because
they are drugs having narrow therapeutic index.

Inhaled corticosteroids
They reduce the inflammation of airways in the lungs and helpful in COPD the
commonly used corticosteroids in COPD are bechlomethasone, dexamethasone,
fluticasone and budesonide.

These agents alone are not effective but are prescribed in combination with
bronchodilators for good results and smoothing of lung muscles.

The common side effects include change in voice, sore throat.

Oxygen therapy

The patients having exacerbation of COPD are often found to be cyanosed and having
severe dyspnea so for those patients immediate oxygen therapy required .the
haemoglobin level of such patients is also high because not enough oxygen can reach
the body so body produce more haemoglobin . Oxygen therapy is the emergency
based option of therapy for COPD.

Expectorants

Expectorants are generally used for the reduction of productive cough in the patients
and for soothing effect. The mucolytics agents are generally used and the dosage form
used is syrups.

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Methodology
For compilation of my internship project report and proper record of patients
medication history, I had to interview the patients and ask some questions from them
so for that I designed a Performa which served as a base for my whole study regarding
the patient and medicines used for the treatment of patients of COPD. The Performa
contain the following important information.

Name............................................. Age...................... Sex.....................

Ward.......... Bed number ......... physician......................................

Address............................................................Addiction...................

Admission date..................................Interview date...........................

Previous surgery record

Chief complaints (signs and symptoms with which patient was admitted)
1
2
3
4
5
Diagnostic tests advised
Test Result Test Result

Diagnosis (disease of the patient)

Previous medication record for this disease (medicines used before admitted at
hospital)

Dosage form Trade name Generic name strength route Frequency

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Ward level medication (treatment of patient in hospital)

Date......................

Dosage form Trade name Generic name strength route Frequency

Date......................
Dosage form Trade name Generic name strength route Frequency

Medication prescribed for home (medicines prescribed at discharge time )


Dosage form Trade name Generic name strength route Frequency

Response to therapy (how the patient feels after using the medicines? is the patient
satisfied or is the condition of patient improving or no)?

Complaints with current therapy (any complaint from patient side due to use of the
drugs it include side effects or conditions due to drugs interactions)

Drug interactions if any (drug interactions which may possibly exist between the
prescribed drugs)

Comments and recommendations: (conclusion or remarks regarding the case


discussed and suggestions for the prescriber or patients)

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Case histories

Case: 1
Name: A1 Age: 80 years Sex: Male
Ward: MMW-B Bed number: 20 physician: Dr.Fayaz
Address: Kohistan Addiction: snuffing only
Admission date: 22-8-2016

Chief complaints
1 SOB (shortness of breath)
2 chest pain
3 legs pain
4 cyanosed
5 congested eyes

Diagnostic tests advised


Test Result Test Result
S.creatinine 1.2mg/dl Hematocrate 53.8%
SGPT 30 IU/L HGB 18.18 mg/dl
RBS 230 mg/dl CXR
ECG

Diagnosis
COPD
Conjunctivitis
Cor pulmonale

Previous medication record for this disease


Patient has received medication at home but dont know about them and even have no
record of those medicines.
Previous surgery record YES /NO
No

Ward level medication

Dosage form Trade name Generic name strength route Frequency


Inj Decadron Dexamethasone 2cc I/v B.D
Neb Ventolin sulbutamol 2cc neb TDS
Inj Ceftriaxone ceftrixone 1gm I/v BD
Inj Zantac Rinitidine 50mg i/v -

20
Tab Prostreate Tamsulosin 0.4mg oral OD
Inj Lasix furosemide 40mg I/v Stat
Tab Loprin aspirin 75mg oral OD
Inh Oxygen Oxygen therapy - inhalation -

Same therapy was continued and following drugs were added to the previous therapy

Syp Cramaffin Magnesium 2 tsf oral TDS


hydroxide
Inf Dextrose Dextrose 1000ml I/V 1bottle
solution

Same therapy was continued as the previous day and one more drug was added to
therapy plan which is
Cap Synasma Doxophylline 400mg oral OD

Same therapy continued as the last day and venesection was done along
with these remedies which were added to therapy,
Ventolin (sulbutamol) ...nebulizer...... QID
INJ... leflox (levofloxicin)...........I/v.... OD

Same therapy was continued to the patient and after 7 days injection
levofloxicin was stopped.

Medication prescribed for home


Dosage form Trade name Generic name strength route Frequency
Tab Moxibact moxifloxicin 400mg p/o BD 10days
Inh Ventoline sulbutamol inh Sos
Tab Loprin aspirin 75mg p/o OD
Cap Synasma Doxophylline 400mg p/o OD 2weeks
Tab Prostreate Tamsulosin 0.4mg oral OD 10days
Syp Adicos Aminophyline, 2tsf oral TDS
diphenhydramin

Response to therapy
Medicines are effective and show good response

21
Complaints with current therapy
Heart burn

Drug interactions if any


a) Dexamethasone and furosamide may lead to hypokalemia.[ 37,38]
b) Sulbutamol along with magnesium hydroxide and also with moxifloxicin
may produce irregular heart rhythms. [39,40]
c) Furosamide may potentiate or increase the nephrotoxic effect of
cephalosporin like ceftrixone.[41.42]
d) Ranitidine may increase the plasma level of doxophylline and may
produce doxophylline toxicity.[43]
e) Sulbutamol and furosamide may also lead to hypokalemia [51]
Comments and recommendations
The patient potassium level should be monitored carefully and if needed
should be given potassium supplements.
Rfts (renal function tests) should be done and monitored carefully because
there are chances of nephrotoxicity and if nephrotoxicity occurs then the
antibiotic should be replaced with another class of antibiotics.
The prescriber also have not mentioned the frequency for ranitidine
injection.
The patient is also suffering from heart diseases so the use of
bronchodilators should be done with caution and heart activities and ECG
should be regularly properly checked.

22
Case 2

Name: A2 Age: 60 Sex: male


Ward: MMW-B Bed number: 9
Address: kohistan Addiction: history of smoking Admission
date: 28-8-2016

Chief complaints
1. Fever for 1 week
2. SOB (seasonal more in winter) from last 10 years
3 Joints pains
4 Insomnia
5 loss of appetite
Diagnostic tests advised
Test Result Test Result
CXR B.urea 31 mg/dl

ESR 10 mm/hr S.cr 0.9 mg/dl

Sputum AFB Negative

Diagnosis
COPD

Previous medication record for this disease


Dosage form Trade name Generic name strength route Frequency
Inj Astexone ceftrixone 1 gm I/v BD,1 day

Previous surgery record YES /NO

NO

Ward level medication

Dosage form Trade name Generic name strength route Frequency


Inj Astexone ceftrixone 1 gm I/V BD

Dosage form Trade name Generic name strength route Frequency


Tab Panadol paracetamol 500mg p/o Sos

23
Inj Decodran dexamethasone 2cc I/V B.D
Neb Ventoline sulbutamol 2cc neb OD
Medication prescribed for home

Dosage form Trade name Generic name strength route Frequency


Syp Adaline Aminophylline.di 2tsf p/o Tds
phenhydramine
Inh Ventoline Sulbutamol 2puffs Inh[p/o] Sos
Tab Pedrol Paracetamol 500mg p/o 2tabs [sos ]
Tab Leflox Levofloxicin 205mg p/o BD 7days

Response to therapy
Not satisfactory

Complaints with current therapy


No

Drug interactions if any

No interactions exist between the prescribed drugs

Comments and recommendations


The patient was referred to hospital from private health clinic after
receiving ceftrixone injection. In hospital on first day he received the
same drug and didnt received proper medications, on the first day he
was given only antibiotic injection while he needed some therapy for
COPD and SOB .
The patient was not satisfied from the drugs he was taken and left the
hospital on his own will.

24
Case 3
Name: A3 Age: 40 years Sex: male

Ward: MMW-A Bed number: 17 Physician: Dr. Fayaz

Address: shangla Addiction: snuffing and smoking (1 year)

Admission date: 2-9-2016

Chief complaints
1. SOB
2. Chest pain
3. Oedema
4. Productive cough

Diagnostic tests advised


Test Result Test Result
ESR 21mm/hr RBS 121mg/dl
B.urea 48 mg/dl WBCs 13500 mg/dl
Platelets 312000 mg/dl Cxr

Diagnosis
COPD

Previous medication record for this disease


Dosage form Trade name Generic name strength route Frequency
Syp Bronkal albuterol 1 TSF oral TDS
Syp Adicos Aminophyline,dip 1TSF oral TDS
henhydramn

Previous surgery record YES /NO


NO

25
Ward level medication

Dosage form Trade name Generic name strength route Frequency


INF R/L Ringer lactate 1000ml I/v B.D
Inj Decodron Dexamethasone 2cc of I/v B.D
10mg vial
Neb Ventoline sulbutamol 2cc Inh TDS
Tab Panadol paracetamol 500mg oral Sos
Inf Mofest moxifloxicin 400mg I/v OD
Inh Oxygen Oxygen - Inh Sos
Neb Atem Ipatropium - Neb B.D

Dosage form Trade name Generic name strength route Frequency


INF R/L Ringer lactate 1000ml I/v B.D
Inj Decodron Dexamethasone 2cc of I/v B.D
10mg vial
Neb Ventoline sulbutamol 2cc Inh TDS
Tab Panadol paracetamol 500mg oral Sos
Inf Mofest Moxifloxicin 400mg I/v OD
Inh Oxygen Oxygen - Inh Sos
Neb Atem Ipatropium - Neb B.D
Syp Muconyl terixiteline 2 tsf oral TDS
Inj Vitamin-D Vitamin-D I/m OD
Tab Qalsan-D minerals - oral OD

Same therapy was continued and following drugs were added

Dosage form Trade name Generic name strength route Frequency


Inj Lasix Furosamide 400mg I/V OD
Neb Clenil Albuterol. Neb p/o BD
bechlomethasone

Same therapy was continued and addition of following drugs was done

Dosage form Trade name Generic name strength route Frequency


Tab Ramipace ramipril 1.25mg p/o OD

Medication prescribed for home


Dosage form Trade name Generic name strength route Frequency
Tab Btno bambuterol 10mg p/o OD 30days

26
Tab Spiromide Spironolactone.fu 20mg p/o OD
rosamide
Tab Calzam daltiazim 30 mg p/o OD
Tab Leflox levofloxicin 500mg p/o 1 for 10 days

Response to therapy

Not satisfactory on first 2 days but later on patient was feeling well with the therapy

Complaints with current therapy


Oedema

Drug interactions if any


a) Moxifloxicin and dexamethasone given at same time may cause
tendinitis or tendon rapture.[44]
b) Dexamethasone and furosamide given at same time may cause
hypokalemia.[37 .38]
c) Derxamethasone reduces the antihypertensive effect of ramipril.
d) Albuterol and furasomide may also give rise to hypokalemic
conditions.[45]

Comments and recommendations


Four drugs prescribed to the patient have interactions and may lead to
hypokalemia so the patient potassium level should be properly monitored and
upon lethargy or muscle pain potassium supplement should be given to the
patient.
The patient age is also more than 60 years and at this age there are more
chances of tendon rapture by the interaction of drugs moxifloxicin and
dexamethasone so there should be some time gap between administrations of
both drugs to decrease the interaction.

27
Case 4

Name: A4 Age: 68 years Sex: Male

Ward: MMW-B Bed number: 04 Physician: Dr. Fayaz

Address: Saidu sharif Swat Addiction: smoker up to ten years back

Admission date: 12-9-2016

Chief complaints
1. SOB
2. Wheezing chest sound
3. Weight loss/ weakness

Diagnostic tests advised


Test Result Test Result
CXR ESR 21mm/hr
S.cr 0.8 mg/dl SGPT 33 IU/L
RBS 115 mg/dl HGB 15.1mg/dl

Diagnosis

COPD
HTN

Previous medication record for this disease


Dosage form Trade name Generic name strength route Frequency
Neb/capsules Combivair Budesonide: 400mcg neb OD
Formoterol &6mcg
Neb/cap Airotec Albuterol.bechlo 400&200 OD
methasone mcg.
Tab Ventolin sulbutamol 4mg p/o OD
Inh Ipneb ipatropium 2cc inh -

Previous surgery record YES /NO


NO
Ward level medication

Dosage form Trade name Generic name strength route Frequency


Inj Dexa dexamethasone 2cc IV BD

28
Neb Ventoline sulbutamol 2cc neb Tds
Tab Ascard plus aspirin 75mg p/o OD
Inh arotec sulbutamol 200mcg inh 2 puffs sos

Same therapy was continued and the following drug was added
Dosage form Trade name Generic name strength route Frequency
Inj lasix furosemide 40mg I/v OD

Medication prescribed for home


Dosage form Trade name Generic name strength route Frequency
Syp Adicos Aminophyline,dip 2 TSF oral TDS
henhydramn
Neb/cap airotec Albuterol.bechlo 400&200 OD
methasone mcg.
Tab ascard aspirin 75 mg p/o OD
Tab Ramipace Ramipril 10mg p/o BD

Response to therapy
Very good
Complaints with current therapy
No

Drug interactions if any


Dexamethasone and furosamide may lead to hypokalemia.
Aminophyline and albuterol concomitant administration may lead to
cardiovascular toxicities like elevation of Blood pressure and
palpitation.[46]
Furosamide and sulbutamol may also lead to hypokalemia.[45]
Dexamethasone and aspirin used at same time may lead to GIT toxicity
i.e. GI bleeding and ulcers.[47]

Comments and recommendations:


The patient serum potassium level should be regularly monitored because four
of the prescribed drugs may lead to hypokalemia which may be severe.

29
Case 5

Name: A5 Age: 83 years Sex: Male

Ward: MMW-B Bed number: 18 physician: Dr. Fayaz

Address: Sangota swat. Addiction: NO

Admission date: 15-9-2016

Chief complaints
1 SOB
2 productive cough
3 weight loss

Diagnostic tests advised

Test Result Test Result


ESR 7 mm/hr CXR
B.urea 44 mg/dl S.cr 1.3 mg/dl

Diagnosis
COPD

Previous medication record for this disease


Patient was using syrups for cough but he dont know about the names
and have no paper record of that drugs

Previous surgery record YES /NO
NO

Ward level medication


Dosage form Trade name Generic name strength route Frequency
Inf R/L R/L 1L I/V OD
Inj Astexone Ceftrixone 1 gm I/V BD
Inj Zantec Ranitidine 400mg I/V BD
Inj Neurobion Multi vitamins - I/V OD
Tab Panadol Paracetamol 500mg P/O SOS

Medication prescribed for home


Dosage form Trade name Generic name strength route Frequency
Syp Acefyl Aminophylline 2 tsf p/o BD

30
Tab Pedrol Paracetamol 500mg p/o SOS
Inh salmicort Salmeterol + inh 2 puffs
Fluticasone
propionate
Tab Moxibact Moxifloxicin 400mg p/o 1 tab TDS for
10 days

Response to therapy

Good

Complaints with current therapy

NO

Drug interactions if any


Salmetarol and aminophyline may have interaction for cardiovascular
side effects. [46]
Moxifloxicin and salmeterol may cause potassium depletion and
cardiovascular toxicity i.e. Q T prolongation.[48]

Comments and recommendations


The patient is at risk of cardiovascular toxicity due to the drug interactions
between the prescribed drugs so the patient blood pressure and other heart
related parameters should be properly monitored.
Ceftrixone and I/v electrolyte solution like R/L may have potentials to form
ceftrixone-calcium crystal which may accumulate in lung and liver and may
be fatal but this is more prominent in children. No data is available for these
conditions in the old people.

31
Case 6

Name: A6 Age: 30 years Sex: Male

Ward: MMW-B Bed number: 9 physician: Dr.Fayaz

Address: Kokarai swat. Addiction: NO but is coal worker

Admission date: 24-9-2016

Chief complaints
1 SOB
2 Productive cough
3 High temperatures
4 weaknesses

Diagnostic tests advised


Test Result Test Result

S.br 0.5 mg/dl SGPT 30 IU/L

RBS 315 mg/dl S.cr 1.5 mg/dl

HGB 18 mg/dl Sputum AFB negative

HCT 55% CXR

Diagnosis

COPD
Anaemia

Previous medication record for this disease

Dosage form Trade name Generic name strength route Frequency


Inh sulbo sulbutamol Not inh Sos
known
Syp Adicos Diphenhydramine Not p/o Tds
Aminophylline: known
Neb ventoline sulbutamol Not neb Sos
known
Tab claritek calithromycin 500mg p/o OD

Previous surgery record YES /NO


NO

32
Ward level medication

Dosage form Trade name Generic name strength route Frequency


Inj Astexone Ceftrixone 1 gm I/V BD
Inj solocartif hydrocartisone - i/v BD
Inj Lasix Furosamie 40mg I/V OD
Neb Clenil Albuterol. Neb p/o BD
Bechlomethasone
Neb ventoline sulbutamol BD
Inj Dexa Dexamethasone 2cc i/v BD

The same therapy was continued and the following drugs were added to therapy
Dosage form Trade name Generic name strength route Frequency
Tab Myrin fort Rifampicin: 150mg, p/o OD
Ethambutol 275mg,
Isoniazid:, 75mg
Pyrazinamide: 400mg
Tab vitab Vitamins - p/o OD

Medication prescribed for home


Dosage form Trade name Generic name strength route Frequency
Inh Ventoline Sulbutamol 2puffs Inh Sos
Syp muconyl Terbutaline 2tsf p/o TDS
Tab Rimactel INH Rifapicine.isoniaz 300 &150 p/o OD before
ide mg meal
Tab Risek Omeprazole 20mg p/o BD

Response to therapy

Satisfactory

Complaints with current therapy


Stomach burden
Loss of appetite

Drug interactions if any


Dexamethasone and furosamide may lead to hypokalemia.[ 37,38]
Albuterol and furasomide may also give rise to hypokalemic conditions.[45]
Dexamethasone and anti TB drugs administered at same time lower the effect
of dexamethasone.[49]

33
Comments and recommendations
The potassium level of the patient should properly monitor and if needed
potassium supplements should be given to the patient.
Rifampicin the anti TB drug induce hepatic metabolism of dexamethasone so
its therapeutic effect may be lowered so if needed dose adjustment should be
done.
The physician also has marked the patient as anaemic but his HGB level is
more than the normal which is a sign of emphysema but not of anaemia.

34
Case 7

Name: A7 Age: 90 years Sex: Male

Ward: MMW-B Bed number: 16 physician: Dr.Fayaz

Address: Balogram Swat . Addiction: yes tobacco +cheelam

Admission date: 1-10-2016.

Chief complaints
1 SOB
2 productive cough from 20 days
3 fever

Diagnostic tests advised


Test Result Test Result
CXR ESR 21mm/hr
S.cr 0.9 mg/dl RBS 124 mg/dl
B.P 140/90mmhg Sputum AFB negative

Diagnosis
COPD
IHD

Previous medication record

Dosage form Trade name Generic name strength route Frequency


Tab Progel Clopidegrol+ 75 mg p/o BD
aspirin
Tab Tritace Ramipril 5 mg p/o BD
Tab Rast Rosovastatine 5mg p/o OD

Previous surgery record YES /NO

No

35
Ward level medication

Dosage form Trade name Generic name strength route Frequency


Inj Decodran Dexamethasone 2cc i/v BD
Neb Ventoline Sulbutamol 2cc Neb BD
Tab Tritace Ramipril 5 mg p/o OD
Tab Rast Rovastatin 10mg p/o OD
Inj Astexone Ceftrixone 2 gm i/v OD
Inj Zantec Ranitidine 40mg i/v BD

Medication prescribed for home


Dosage form Trade name Generic name strength route Frequency
Tab Claritec Clarythromysin 500mg p/o OD
Inh Fosacor.S Bechlomethasone 2 puffs Inh BD
+formeterol
Tab Panadol Paracetamol 500mg p/o Sos
Syp Reltus Turbutaline 2tsf p/o TDS

Response to therapy
Good

Complaints with current therapy

No

Drug interactions if any


Derxamethasone reduces the antihypertensive effect of ramipril.

Comments and recommendations

Patient is also suffering from heart disease and is hypertensive so his cardiac activity
should be monitored along with management of COPD because corticosteroids
minimize the effect of antihypertensive drugs so there should be gap between the
administrations of the both drugs or the dose adjustment should be done if this
interaction is very much significant.

36
Case 8

Name: A8 Age: 68 years Sex: Male

Ward: MMW-B Bed number: 15 physician: Dr. fayaz

Address: Kohistan Addiction: No

Admission date: 10-10-2016.

Chief complaints
1 SOB
2 fever
3 irrelevant talking
4 productive cough
5general weakness

Diagnostic tests advised


Test Result Test Result

RBS 130mg/dl S.cr 1.7mg/dl

Esr 31mm/hr HGB 14.1mg/dl

WBC 25000mg/dl ECG -

PLT 144000mg/dl

Diagnosis

HTN
COPD
Previous medication record for this disease
Dosage form Trade name Generic name strength route Frequency
Tab Ventoline Sulbutamol 4mg p/o BD
Syp Reltus Chlorphiramin,am 2tsf p/o TDS
monium chloride
Tab Orpic Ciprofloxicin 500mg p/o BD
Tab Ramipace Ramipril 2.5mg p/o BD

Previous surgery record YES /NO

NO

37
Ward level medication

Dosage form Trade name Generic name strength route Frequency


Neb Ventoline Sulbutamol 1cc Neb TDS
Inj Astexone Ceftrixone 1gm I/V BD
Inj Decodran Dexamethasone 2cc I/V BD
Inj Neurobian Multivitamins - I/V OD
Tab Loprin Aspirin 75mg p/o OD

Dosage form Trade name Generic name strength route Frequency


Neb Ventoline Sulbutamol 1cc Neb TDS
Inj Decodran Dexamethasone 2cc I/V BD
Inj Neurobian Multivitamins - I/V OD
Tab Loprin Aspirin 75mg p/o OD
Inf D/S Dextrose 500ml I/V BD
Inj Vitamin D-3 2lack units I/M Stat
Tab Osam-D Ossein mineral - p/o OD
Complex vitamin
D

Medication prescribed for home


Dosage form Trade name Generic name strength route Frequency
Inh Fosacor.S Bechlomethasone 2 puffs Inh BD
+formeterol
Syp Adicos Diphenhydramine 2 tsf p/o TDS
Aminophylline:
Tab Ceflox Ceprofloxicin 500mg p/o BD
Tab Cozaar losartan 50mg p/o BD
Tab Loprin Aspirin 75mg p/o OD

Response to therapy

Good

Complaints with current therapy


No

Drug interactions if any

No drug interactions were found for the prescription.

38
Comments and recommendations

The patient is hypertensive as well as has COPD so dexamethasone should


[50].
be administered with caution because it has ability of fluid retention
Which may be dangerous for the patient and as the patient already has
received intravenous infusion so it would be better to prescribe diuretic to
the patient like furosamide.

39
Case 9

Name: A9 Age: 63 years Sex: Male

Ward: MMW-B Bed number: 5

Address: Totano bandai swat Addiction: No

Admission date: 15-10-2016 .

Chief complaints
1 productive cough
2 wheezing from last two weeks
3 SOB
4 Fever
Diagnostic tests advised
Test Result Test Result

HGB 16.4 mg/dl HCT 55.8%

ESR 26mm/hr FBS 385mg/dl

FBS repeat 239mg/dl B.P 145/90mm of hg

CXR

Diagnosis
COPD
Diabetes mellitus
Known HTN

Previous medication record for this disease

Dosage form Trade name Generic name strength route Frequency


Tab Co-eziday Losarton. 50mg p/o OD
Hydrochlorothiazi 12.5mg
de
Inh Seritide Salmeterol 2 puffs Inh Sos
Tab Getryl glimepiride 2mg p/o BD
Inh Combiviar Formeterol 2 puffs Inh Sos
budisonide

Previous surgery record YES /NO

NO
40
Ward level medication

Dosage form Trade name Generic name strength route Frequency


Inh Seretide 25/250 Salmetarol, 2 puffs inh BD
fluticasone
Inj Decodron Dexamethasone 2cc i/v OD
Inj Astexone Ceftrixone I gm i/v BD
Tab Extor 5/80 Amlodopine 5mg p/o OD
velsortan 80mg
Tab Neodepar Metformin 250mg p/o 1 OD
Inj Zantac Ranitidine 50mg i/v 1 OD

The same therapy was continued and the following drugs were added to therapeutic
regimen
Dosage form Trade name Generic name strength route Frequency
Inj Humulin 70/30 Insulin 70/30 Subcutan 30 units
eous morning and
15 at night
Tab Cycin Ciprofloxacin 500mg p/o 1 OD

Same therapy was continued and injection lasix (furosamide) 40mg was given to the
patient in two divided doses of 20 mg each.

Medication prescribed for home


Dosage form Trade name Generic name strength route Frequency
Tab neopidar Metformin 250mg p/o 1 OD
Tab Getryl Glimeperide 2mg p/o BD
Inh Arotec-B Sulbutamol 2 puffs Inh Sos
bechlamethasone
Tab Cycin Ciprofloxacin 500mg p/o 1 OD
Tab Extor 5/80 Amlodopine 5mg p/o OD
velsortan 80mg
Response to therapy

Good

Complaints with current therapy

Stomach pain

Drug interactions if any

41
Corticosteroids may interact with anti diabetic drugs .corticosteroids have
hyperglycaemic effect
Dexamethasone and furosamide may lead to hypokalemia.[37,38]
Dexamethasone may reduce the effect of antihypertensive drugs.

Comments and recommendations

The patient is diabetic and as well as hypertensive so he should properly


monitor his glucose level and should not miss the dose of anti diabetic
drugs because high glucose level may cause hypertension and there may
also chances of pulmonary oedema and exacerbation of COPD so he
should take his drugs regularly at proper time.

42
Case: 10

Name: A10 Age: 70 years Sex: Male

Ward: MMW-A Bed number: 17 physician: Dr .fayaz

Address: puran shangla Addiction: No

Admission date: 18-10-2016

Chief complaints
1productive cough
2 Fever
3 SOB
4 hoarseness of sound
Diagnostic tests advised
Test Result Test Result
HGB 15.2mg/dl RBS 80mg/dl
SGPT 28IU/L S.cr 0.8 mg/dl
ESR 28 mm/hr Sputum AFB negative
CXR

Diagnosis
COPD
URTI

Previous medication record for this disease

Dosage form Trade name Generic name strength route Frequency


Syp Broxal Diphenhydramin. 2tsf p/o TDS
chlorphinramine
Neb Ventoline Sulbutamol 2cc Neb Sos
Tab Risek Omeprazole 20mg p/o BD

Previous surgery record YES /NO

NO
Ward level medication
Dosage form Trade name Generic name strength route Frequency
Inj Astexone Ceftrixone Igm i/v BD
Neb Ventoline Sulbutamol Neb Sos

43
Inj Decodron Dexamethasone 1gm I/v BD
Inh O2 Oxygen - inh Sos
Inj Zantec Ranitidine 50mg I/V BD
Inj neurobion Multivitamins - i/v OD
Inf R/L Ringer lactate 1000ml I/V OD
Inf N/S Normal saline 1000ml I/v Stat

Dosage form Trade name Generic name strength route Frequency


Inj Astexone Ceftrixone Igm i/v BD
Neb Ventoline Sulbutamol Neb Sos
Inj Decodron Dexamethasone 1gm I/v BD
Inh O2 Oxygen - inh Sos
Inj Zantec Ranitidine 50mg I/V BD
Inj neurobion Multivitamins - i/v OD
Syp Adaline Aminophyline&di 2tsf p/o TDS
phenhydramin

Same therapy was continued and the following drug was added
Inj.....lasix (furasamide)......40mg I/v OD

Medication prescribed for home


Dosage form Trade name Generic name strength route Frequency
Neb/cap airotec Albuterol.bechlo 400&200 p/o Sos
methasone mcg.
Tab Moxibact Moxifloxicin 400mg p/o BD
Tab Vexalt Multivitamins - p/o OD
Syp Adaline Aminophyline& 2tsf p/o TDS
diphenhydramin
Tab panadol paracetamol 500mg p/o BD/sos

Response to therapy

Good

Complaints with current therapy

Loose motion
Loss of sleep/ insomnia

44
Drug interactions if any
a) Dexamethasone and furosamide may lead to hypokalemia.[ 37,38]
b) Furosamide may potentiate or increase the nephrotoxic effect of cephalosporin
like ceftrixone.[41.42]
c) Ceftrixone and calcium present in ringer lactate solution may form ceftrixone-
calcium crystals which may accumulate in lungs and kidneys of the patient.
d) Sulbutamol and furosamide may also lead to hypokalemia [51]

Comments and recommendations


Potassium level of patient should be properly monitored because patient has
chances of hypokalemia due to drugs and also due to lose motion which he
complains after the use of the drugs and upon symptoms of potassium
deficiency like muscle weakness and muscles aches. Or when the potassium
level decreases the normal i.e. 3.5 mmol/litre the patient should take potassium
supplements in food or in drug from.
Rfts should also be done on daily basis for the patient because there are
chances of nephrotaxicity and if nephrotoxicity occurs the patient should take
another class of antibiotics because the same antibiotic means ceftrixone have
also chances to form crystals with calcium and that may accumulate in lungs
of the patient.

45
Summarized form of case histories discussed

Pati Age Sex Addres DOA C/C Diagno Drugs Interacti


ent s sis Used on
I.D
Case 01 A1 80 M Kohistan 22-08- SOB COPD Inj Dexa, Dexa and
Yrs 2016 Chest pain Conjunct Salbutamol furosemide
Legs pain ivitis Inj cause
Cyanosed Cor Ceftriaxone hypokalemi
Congested pulmonal Inj a
eyes e ranitidine
Case 02 A2 60 M Kohistan 28-08- Fever COPD Inj No
Yrs 2016 SOB ceftriaxone, Interactions
Joint pains tab Found
Insomnia paracetamo
Loss of l
apetite Inj dexa
Salbutamol
Aminophyl
line+diphe
nhydramin
e
Case 03 A3 40 Yrs M Shangla 02-09- SOB COPD InjDexa, Dexa and
2016 Chest pain Inf R/L, moxifloxac
Odema Salbutamol ine lead to
Productive Moxifloxac tendintis
cough ine
ipratropium
Case 04 A4 68 M Saidu 12-09- SOB COPD Salbutamol Dexa+furos
Yrs sharif 2016 Wheezing HTN Dexa emide lead
swat chest sound Aspirine to
Weight loss furosemide Hypokalem
ia
Case 05 A5 83 M Sangota 15-09- SOB COPD inf Moxifloxac
Yrs swat 2016 Productive ceftriaxone, ine+salmet
cough Ranitidine erol cause
Weight loss Multivitam potassium
in depletion
Paracetemo
l
Moxifloxac
ine
Salmeterol

Case 06 A6 30 M Kokarai 24-09- SOB COPD Salbutamol Dexa and


Yrs swat 2016 Productive Anemia Aminophyl furosemide
cough line lead to
High Ceftriaxone hypokalemi
temperatur Hydrocorti a
e sone
Dexa
furosemide
Case 07 A7 90 M balogram 1-10- SOB COPD Aspirine+cl Dexa
Yrs swat 2016 Productive opidegrol reduce the
cough Ramipril antihyperte
Fever Dexa nsive effect
Salbutamol of Ramipril

46
Case 08 A8 68 M kohistan 10-10- SOB HTN Salbo No
Yrs swat 2016 Fever COPD Ciprofloxa Interactions
Irrelevant cin Found
talking Ramipril
Productive Dexa
cough multivitami
n

Case 09 A9 63 M Totano 15-10- Productive COPD Losartan Dexa


Yrs Bandai 2016 cough DM Salmeterol +furosemid
swat Wheezing Known Dexa e
SOB HTN Ceftriaxone Lead to
Fever Ranitidine hypokalemi
furosemide a

Case 10 A 10 70 M poran 18-10- Productive COPd Salbomuta Salbutamol


Yrs shangla 2016 cough URTI mol +
Fever Omeprazol furosemide
lead to
SOB e
hypokalemi
Hoarseness Ceftriaxone a
of sound Dexa
Ranitidine
Multivitam
in
furosemide

The statistical data of various drugs used during hospital medication for the discussed
patients is
S.NO Class of drug used for data of 10 patients Quantity %age
1 Bronchodilator 17 22.2%
2 Corticosteroids 14 18.5%
3 Antibiotics 13 17.2%
4 Oxygen therapy 3 3.9%
5 Others 29 38.25%

47
classes of drugs used

bronchodilator
22%
*others
38%

corticosteriod
19%

antibiotics
17%

oxygen
4%

*Other class of drugs includes the drugs which are used for other disease occurred
along with COPD and have no therapeutic role in management of the COPD.

The use of dosage form in the hospital for the discussed patients is summarized for
statistical data as

S.NO Type of dosage form for data of 10 patients Quantity %age


1 Inhaler and nebulizer 22 26.2%
2 Parental 47 56%
4 Tab/cap/ syp 15 17.8%

48
dosage form used

TAB/CAP/SYP
18% INHALER AND
NEBULIZER
26%

PARENTAL
56%

49
Conclusion

I worked for two months in the hospital and interviewed many patients and recorded
their histories. The main objective for the study and project was to know about the
rationale therapy of COPD so keeping in mind that the case histories were evaluated
deeply to check for drug interactions and drug related problems. The possible drug
interactions are discussed in detail at the end of each case.
Smoking is considered to be the most common cause of COPD but the cases
evaluated during this study shows that six patients out of ten were not smokers but
were coal workers and two in ten patients were smokers.
The most notable irrational points of therapy were that, no spirometric tests were
conducted even for a single patient while according to GOLD standards the severity
of the disease is related with the spirometry tests and the choice and strength of drugs
also depends upon that.
The main possibly resulted drug interaction to be occurred was hypokalemia so the
patients potassium level should be monitored carefully during the course of treatment
and potassium supplement in case of need should be prescribed.
It was also found that most of the patients were confirmed or at risk of cardiac
diseases so the use of drugs needed more caution and care.
It was found that some patients were not using the inhaler through proper way and
while inhaled the drugs they expelled the air quickly to dyspnoea so proper dose level
was not achieved.
Poly pharmacy and wrong dose or duplication of dose was also an issue regarding the
rational therapy, some of the patients who already had the drug under another trade
name were taking the same drug again under another trade name prescribed in
hospital, and hence at a time they were using two or more inhalers.
The second main clinically important objective of my project was to know about the
role of clinical pharmacist in healthcare settings so I found intense and immediate
need of the pharmacist who can insure the rationale use of drugs and rationale therapy
of drugs in the hospital. The need of pharmacist to assure rationale therapy was felt in
order to give information to physicians and to patients and to assure rationale therapy.
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