docnikki
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A 64-year-old man is brought to the hospital with complaints of intolerable headache and blurry vision in the right eye for the past two hours. His medical history is significant for hypertension, diabetes mellitus, and bronchial asthma. In the past he was intubated twice during hospitalization for asthma exacerbations. He has asthma attacks at least once a day and frequently wakes up at night with shortness of breath. His medications include furosemide, enalapril, salmeterol, Atrovent, and steroid inhalers. For the past year, he started using fluticasone (Flovent) up to six times a day. Four months ago, his Flovent 110 inhaler was changed to Flovent 220. He is agitated and screaming. His temperature is 99.8 F, blood pressure is 190/100 mm Hg, heart rate is 104/min, and his respiratory rate is 22/min. The pain is focused in the right frontal area and right eye. The periorbital area on the right is hyperemic and edematous. The right pupil is mid-dilated and nonreactive to light. His eye movements are normal. There is photophobia on the right side. Meningeal signs and focal neurological deficits are absent. He is moderately short of breath and has wheezes on lung auscultation bilaterally. What will be most important for the long-term management of this patient's new medical problem?
(A) Pilocarpine eye drops for a long term
(B) Discontinuation of high-dose inhaled glucocorticoids
(C) Instruct to use salmeterol strictly twice a day
(D) Imaging studies of cavernous sinuses
([font size="2"]E) Lumbar puncture[/font]
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| anjushree
Forum Guru
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D
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| sandra
Forum Guru
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B?
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You become what you think you are!
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| dr.wad
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dont know 
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| docnikki
Forum Guru
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its B....but I wonder how will the asthma be controlled without the glucocorticoids.
This patient presents with an acute glaucoma attack precipitated by the administration of high doses of inhaled glucocorticoids. High-dose inhaled glucocorticoids may produce better asthma control for patients with moderate to severe persistent asthma. They include fluticasone (Flovent 44, Flovent 110, and Flovent 220). At the dose of 1,000 to 1,500 mg/day or more, they may lead to systemic absorption sufficient enough to cause adverse effects, such as ecchymoses, cataracts, elevated intraocular pressure, loss of bone mass, and suppression of the hypothalamic-pituitary-adrenal axis. Among patients older than 65 years, use of 1,500 mg a day of inhaled corticosteroids for at least three months leads to a 40% increased risk of elevated intraocular pressure or open-angle glaucoma. This risk is still less than that associated with the use of oral glucocorticoids. For this patient, the most important step in the long-term management of glaucoma in the future will be discontinuation of high-dose inhaled glucocorticoids. Pilocarpine and other eye drops will be ineffective if the patient continues using Flovent 220. Thrombosis of cavernous sinus is unlikely in the absence of gaze palsies. Salmeterol is a β2-selective-adrenergic agonist, which should be used with caution in cases of glaucoma. It is associated with a smaller risk of increased intraocular pressure compared with high-dose inhaled glucocorticoids
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| sherry39
Forum Junior
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aaaa glaucoma
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| farnsworth
Forum Newbie
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hmmmm. options for the patient: dying from asthma (intubated 2 times for exacerbation) or from glaucoma? :-(
So the patient is will be zafirlukast/montelukast + ipratropium (+ low dose inhaled glucocorticoids) and 'hibernating' hooked to a ventilator in the fall...? Nice perspective ;-)
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