KE is a 66-year-old male with a history of cigarette smoking (still currently smoking), COPD, atrial fibrillation, hypertension, osteoarthritis, and GERD. In this COPD case review, he reports that he is having a more difficult time breathing, in particular, he notes that he needs to rest after walking to the upstairs level of his house. His current medication list includes:
- Budesonide/formoterol 160/4.5, 2 inhalations twice daily
- Apixaban 5 mg BID
- Metoprolol 25 mg BID
- Lisinopril 20 mg daily
- Omeprazole 20 mg daily
- Ibuprofen 400 mg TID PRN
- Albuterol 2 puff QID PRN
In reviewing this brief medication list, the first question I would inquire about is the use of a long-acting antimuscarinic medication (i.e. umeclidinium, tiotropium, etc.). It isn’t clear why he wouldn’t be taking one of these agents for his COPD as this is preferred initially over inhaled corticosteroids. Depending upon the patient’s history, I would anticipate that adding one of these agents would be most appropriate to try to attempt to improve his respiratory symptoms. Depending upon insurance coverage, combination therapy would be a nice consideration so we don’t have to add another inhaler. Here’s a previous case and a refresher on the GOLD guidelines and medication selection.
If this is a follow-up patient for you as a clinician, you’ve likely asked him about quitting smoking a million times. I cannot stress the importance of utilizing a situation like this as an opportunity to readdress smoking cessation. He is coming to you with a problem related to a behavior that you would like to change to help improve his health. Walking up the stairs would likely be easier if he wasn’t smoking and emphasizing this point might be one more persuasive point to get him to quit smoking. Varenicline or nicotine replacement therapy would be reasonable considerations in a patient who is motivated to quit smoking.
Lastly (not related to COPD), I would like to address the use of ibuprofen. First I would ask about the frequency of use to get a baseline as to how much pain this patient is having. While the efficacy of ibuprofen is likely greater than acetaminophen in the management of osteoarthritis, acetaminophen would be a safer choice given the use of the anticoagulant apixaban. In addition to the GI bleed risk from ibuprofen, it may also contribute to GERD symptoms. If acetaminophen is unacceptable, topical agents would be a consideration if the osteoarthritis pain is localized.
What else would you review in this COPD case review?
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