This patient demonstrates the destabilizing effects of a respiratory infection on asthma, and her mother’s comments demonstrate the common (and dangerous) phobia about “overuse” of bronchodilator or steroid inhalers. The patient has signs of imminent respiratory failure, including her refusal to lie down, her fear, and her tachycardia, which can-not be attributed to her minimal treatment with albuterol. Critically important immediate steps are to administer high-flow oxygen and to start albuterol by nebulization. Adding ipratropium (Atrovent) to the nebulized solution is recom-mended. A corticosteroid (0.5–1.0 mg/kg of methylpred-nisolone) should be administered intravenously. It is also advisable to alert the intensive care unit, because a patient with severe bronchospasm who tires can slip into respiratory failure quickly, and intubation can be difficult. Fortunately, most patients treated in hospital emergency departments do well. Asthma mortality is rare (fewer than 4000 deaths per year among a population of more than 20 million asthmatics in the USA), and when it occurs, it is often out of hospital. Presuming this patient recovers, she needs adjustments to her therapy before discharge. The strongest predictor of severe attacks of asthma is their occur-rence in the past. Thus, this patient’s therapy needs to be stepped up to a higher level, like a high-dose inhaled cortico-steroid in combination with a long-acting βagonist. Both the patient and her parents need instruction on the importance of regular adherence to therapy, with reassurance that it can be “stepped down” to a lower dose of inhaled corticosteroid (although still in combination with a long-acting β agonist) once her condition stabilizes. They also need instruction on an action plan for managing severe symptoms. This can be as simple as advising that if the patient has a severe, frightening attack, she can take up to four puffs of albuterol every 15 minutes, but if the first treatment does not bring significant relief, she should take the next four puffs while on her way to an emergency department or urgent care clinic. She should also be given a prescription for prednisone, with instructions to take 40–60 mg orally for severe attacks, but not to wait for it to take effect if she remains severely short of breath even after albuterol inhalations. Asthma is a chronic disease, and good care requires close follow-up and creation of a provider-patient partnership for optimal management. If she has had several previous exacerbations, she should be considered a candidate for monoclonal anti-IgE antibody therapy with omalizumab, which effectively reduces the rate of asthma exacerbations—even those associated with viral respiratory infection—in patients with allergic asthma. Alternatively, if the patient is found to have blood eosino-philia, treatment with an anti-IL-5 monoclonal antibody (eg, mepolizumab) should be considered as well.
Introduction to the Pharmacology of CNS Drugs
John A. Gray, MD, PhD*
Drugs acting in the central nervous system (CNS) were among the first to be discovered by primitive humans and are still the most widely used group of pharmacologic agents. These include medications used to treat a wide range of neurologic and psychiatric conditions as well as drugs that relieve pain, suppress nausea, and reduce fever, among other symptoms. In addition, many CNS-acting drugs are used without prescription to increase the sense of well-being.