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Prescriptions in Respiratory System

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A) Single Drug Prescription — Adult Patient with Seasonal Asthma

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Name: Mr./Ms. ___________ Age: ___ years | Date: ___________

Rx

Drug	Dose	Quantity
Inhalation Salbutamol 100 mcg/puff (MDI)	1–2 puffs to be inhaled as and when required (PRN), not more than 4 times a day	__(1 MDI)

Direction: Shake inhaler well before use. Inhale 1–2 puffs during symptomatic episodes or 15 minutes before known allergen/trigger exposure. Rinse mouth after use.

Patient Education:

• Avoid known seasonal allergens (pollen, dust mites, cold air)
• Correct MDI technique to be demonstrated and practiced
• Seek medical review if needing rescue inhaler more than twice a week

Alternate Drug: Terbutaline inhaler (SABA)

Dr. ___________ | Reg. No. ___________

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B) Drug Therapy Prescription — Adult Patient with COPD

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Name: Mr./Ms. ___________ Age: ___ years | Date: ___________ Diagnosis: Chronic Obstructive Pulmonary Disease (COPD)

Rx

Drug	Dose	Quantity
Inhalation Tiotropium 9 mcg/puff (MDI)	1 puff to be inhaled once daily	__(1 MDI)
Inhalation Formoterol 6 mcg/puff (MDI)	1 puff to be inhaled twice daily	__(1 MDI)
Inhalation Salbutamol 100 mcg/puff (MDI)	1–2 puffs as and when required (rescue)	__(1 MDI)

Direction:

• Tiotropium: Inhale 1 puff every morning at the same time.
• Formoterol: Inhale 1 puff morning and evening.
• Salbutamol: Use only for acute breathlessness/rescue; do not exceed 4 puffs/day.

Patient Education:

• Stop smoking — most critical intervention in COPD
• Correct MDI/DPI inhaler technique to be demonstrated
• Pulmonary rehabilitation referral
• Annual influenza vaccination; pneumococcal vaccination
• Avoid smoke, dust, fumes, occupational irritants
• Monitor for worsening breathlessness, increased sputum (signs of exacerbation)

Alternate Drugs:

• LAMA: Glycopyrronium, Umeclidinium
• LABA: Salmeterol, Indacaterol
• Inhaled corticosteroid (ICS) to be added if frequent exacerbations or eosinophil count ≥ 300 cells/µL

Dr. ___________ | Reg. No. ___________

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C) Critique, Correction and Rewriting of Prescription for Acute Exacerbation of COPD

Original Prescription (to be evaluated):

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Detailed Criticism:

• ❌ Dose is critically inadequate. The evidence-based and GOLD 2025 recommended dose is 40 mg prednisolone equivalent per day for 5 days (GOLD 2025, p. 129). The prescribed 5 mg is 8× too low — completely subtherapeutic and will not shorten recovery, improve FEV₁, or reduce relapse risk.
• ❌ Duration of 10 days is excessive. The standard course is 5 days. Longer courses are associated with increased risk of pneumonia, sepsis, and mortality (GOLD 2025, p. 129).
• ✅ Route (oral) is acceptable — oral prednisolone is equally effective to IV.

• ❌ Theophylline is NOT recommended for acute exacerbation of COPD. GOLD 2025 guidelines do not recommend IV aminophylline or oral theophylline for acute exacerbations due to lack of efficacy evidence and significant toxicity risk (narrow therapeutic index, arrhythmias, seizures, GI effects).
• ❌ 400 mg BD = 800 mg/day is at the upper limit and risks toxicity without therapeutic benefit in this setting.
• ❌ Omission of bronchodilators: The prescription lacks short-acting bronchodilators (nebulised Salbutamol ± Ipratropium), which are the first-line bronchodilator treatment in acute COPD exacerbation.

• ❌ Dose is subtherapeutic. For respiratory infections in adults, erythromycin is typically prescribed at 500 mg QID (2 g/day), not 250 mg QID (1 g/day).
• ❌ Drug choice is not first-line for COPD exacerbations. GOLD 2025 recommends Amoxicillin-Clavulanate or Azithromycin or Levofloxacin as preferred antibiotics. Erythromycin has high resistance rates among the common COPD pathogens (H. influenzae, S. pneumoniae, M. catarrhalis) and significant GI side effects.
• ❌ Prescription is incomplete — No nebuliser bronchodilators, no oxygen therapy instruction, no route of drug administration specified.
• ❌ Prescription format errors: No patient name/age, no date, no physician signature/registration number, no route (oral/inhaled), no tablet quantity mentioned.

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Corrected and Rewritten Prescription:

Name: Mr. ___________ Age: ___ years | Weight: ___ kg | Date: ___________ Diagnosis: Acute Exacerbation of COPD Allergies: NKDA

Rx

Drug	Dose	Quantity
Tab Amoxicillin 500 mg + Potassium Clavulanate 125 mg	One tablet to be taken three times a day for 7 days (with food)	__(21)
Inhalation Salbutamol 2.5 mg/2.5 mL + Ipratropium bromide 0.5 mg/2.5 mL (Nebuliser solution)	To be inhaled via nebuliser every 4–6 hours	__(1)
Tab Prednisolone 40 mg	One tablet to be taken once a day for 5 days (in the morning, with food)	__(5)

Additional instructions:

• Oxygen supplementation if SpO₂ < 90% (target 88–92% in COPD)
• Monitor for respiratory failure — escalate to hospital if worsening

Patient Education:

• Take all antibiotics for the full prescribed course
• Do not stop steroids abruptly if on a longer course
• Return immediately if breathlessness worsens, confusion develops, or oxygen is needed
• Smoking cessation counselling

Alternate Antimicrobials: Azithromycin 500 mg OD × 5 days; Levofloxacin 500 mg OD × 5 days Alternate Bronchodilator: Deriphylline (Etophylline + Theophylline) — if nebuliser unavailable

Dr. ___________ | Reg. No. ___________ | Signature: ___________

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Summary Table of Errors and Corrections:

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A) Prescription Image — Seasonal Asthma (Single Drug)

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B) Prescription Image — COPD Drug Therapy

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C) Corrected Prescription — Acute Exacerbation of COPD (Written Format)

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╔══════════════════════════════════════════════════════════════╗
║         DR. [NAME]  MBBS, MD (Pharmacology)                 ║
║         Reg. No.: ___________                               ║
║         City Hospital, [Address]   Date: __________         ║
╠══════════════════════════════════════════════════════════════╣
║  Patient: Mr. XYZ        Age: 55 yrs    Sex: Male           ║
║  Diagnosis: Acute Exacerbation of COPD                      ║
╠══════════════════════════════════════════════════════════════╣
║  Rx                                                         ║
║                                                             ║
║  1. Tab Amoxicillin 500 mg +                         (21)   ║
║     Potassium Clavulanate 125 mg                            ║
║     Direction: One tablet three times a day                 ║
║     for 7 days (with food)                                  ║
║                                                             ║
║  2. Inhal. Salbutamol 2.5 mg +                       (1)    ║
║     Ipratropium 0.5 mg (Nebuliser solution)                 ║
║     Direction: To be inhaled via nebuliser                  ║
║     every 4–6 hours                                         ║
║                                                             ║
║  3. Tab Prednisolone 40 mg                           (5)    ║
║     Direction: One tablet once daily                        ║
║     for 5 days (morning, with food)                         ║
║                                                             ║
║  Alternate: Azithromycin 500 mg OD × 5 days                ║
╠══════════════════════════════════════════════════════════════╣
║  Patient Education:                                         ║
║  • Complete full antibiotic course                          ║
║  • Do not stop steroids abruptly                            ║
║  • Return if breathlessness worsens                         ║
║  • Stop smoking immediately                                 ║
╠══════════════════════════════════════════════════════════════╣
║                          Dr. [Signature]                    ║
║                          Reg. No.: ___________              ║
╚══════════════════════════════════════════════════════════════╝

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What Was Wrong in the Original (Quick Visual Summary):

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Prescription Review: Allergic Rhinitis, Dry Cough & Acute Otitis Media

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1. Allergic Rhinitis

✅ What is Correct:

❌ Errors Found:

• Xylometazoline is a decongestant nasal drop. It must NOT be used for more than 3–5 consecutive days — prolonged use causes rhinitis medicamentosa (rebound nasal congestion). The prescription does not state a limit.
• Correction: Add — "Not to be used for more than 3–5 days continuously."

• For moderate-to-severe or persistent allergic rhinitis, an intranasal corticosteroid (e.g., Mometasone/Fluticasone nasal spray) is the first-line drug per ARIA guidelines. If this is mild intermittent rhinitis, the prescription is acceptable; otherwise an INCS should be added.

• "Saline gargles and steam inhalation" is listed under patient education — this is more relevant for upper respiratory tract infection, not specifically for allergic rhinitis.
• More appropriate education: avoid allergens (dust, pollen, pet dander), avoid rubbing eyes/nose, use air purifiers.

Corrected Prescription 1:

Rx
Tablet Levocetirizine 10 mg                                    (7)
Direction: One tablet to be taken once a day for seven days.

Saline Nasal Drops                                        (1 bottle)
Direction: 1–2 drops to be instilled in each nostril 2–3 times a day.

Xylometazoline 0.05% Nasal Drops                          (1 bottle)
Direction: 1–2 drops to be instilled in each nostril 3–4 times a day.
⚠ Do NOT use for more than 3–5 days continuously.

Patient Education:
• Avoid known allergens (pollen, dust, pet dander)
• Do not rub eyes or nose
• Steam inhalation for symptomatic relief
• Seek review if symptoms persist beyond 7 days

Alternate drugs: Chlorpheniramine, Fexofenadine

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2. Dry Cough

✅ What is Correct:

❌ Errors Found:

• Standard adult dose of Dextromethorphan lozenges/tablets is 10–20 mg every 4–6 hours, not 5 mg.
• 5 mg is a pediatric/low dose. For an adult, this will have minimal to no antitussive effect.
• Correction: Dextromethorphan 15 mg (lozenge) three times a day.

• The prescription does not specify how many days to take the lozenges. Duration should be stated (typically 3–5 days for dry cough).
• Correction: Add "for 3–5 days or until cough resolves."

• If TDS × 5 days = 15 lozenges needed. 9 lozenges only covers 3 days at TDS — duration mismatch.
• Correction: Quantity should be (15) for 5 days TDS.

• Dry cough is a symptom, not a diagnosis. The prescription should ideally note the underlying cause (post-viral, ACE inhibitor-induced, etc.) and treat accordingly.

Corrected Prescription 2:

Rx
Lozenges Dextromethorphan 15 mg                               (15)
Direction: One lozenge to be taken three times a day
for five days or until cough resolves.

Patient Education:
• Avoid cold air, smoke, and irritants
• Stay well hydrated
• Seek review if cough persists beyond 2 weeks or blood is noticed

Alternate drugs: Codeine phosphate (narcotic — use only if refractory)

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3. Acute Otitis Media

✅ What is Correct:

❌ Errors Found:

• Levocetirizine is an antihistamine. There is no evidence that antihistamines help in AOM. AOM is caused by bacterial infection (S. pneumoniae, H. influenzae) — it is NOT an allergic condition.
• The inclusion of levocetirizine here is irrational and incorrect.
• Correction: Remove levocetirizine entirely from this prescription.

• Ciprofloxacin (a fluoroquinolone) has poor coverage against Streptococcus pneumoniae, the most common AOM pathogen. It is not a preferred alternate for AOM.
• Better alternate: Azithromycin (acceptable) or Co-trimoxazole.

• For symptomatic relief of ear pain, topical analgesic ear drops (e.g., Benzocaine ear drops) can be added as adjunct therapy per Harrison's (p. 1058).

• Paracetamol 500 mg QID (2 g/day) is on the lower end for adults. Standard adult dosing is 500–1000 mg every 4–6 hours (max 4 g/day). Consider 1000 mg (two 500 mg tablets) TDS for better analgesic effect, or at minimum document the dose clearly.

Corrected Prescription 3:

Rx
Capsule Amoxicillin 500 mg + Potassium Clavulanate 125 mg     (21)
Direction: One capsule to be taken three times a day
for seven days (with food).

Tablet Paracetamol 500 mg                                     (28)
Direction: One to two tablets to be taken four times a day
for seven days (for pain/fever relief).

Patient Education:
• Complete the full antibiotic course even if feeling better
• Apply warm compress over affected ear for pain relief
• Do not insert anything into the ear canal
• Seek review if symptoms worsen or fever persists beyond 48 hours

Alternate drugs: Azithromycin, Co-trimoxazole

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Overall Summary Table

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GINA 2024 Guidelines — Asthma Management (India Context)

GINA = Global Initiative for Asthma — updated annually. The 2024 report is the current version. India follows GINA guidelines as the primary framework, with adaptations for drug availability and affordability.

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🔑 The Biggest Change in Recent GINA (2021 onwards, retained in 2024)

SABA-only therapy is NO longer recommended at any step.

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GINA 2024 — Two Treatment Tracks

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GINA 2024 — Step-by-Step Treatment (Adults ≥12 years)

TRACK 1 — Preferred (ICS-Formoterol based)

SMART = Single Maintenance And Reliever Therapy — Budesonide/Formoterol inhaler used as BOTH controller (daily) AND reliever (as needed). Supported by Harrison's (p. 7937) and Asthma Management Guidelines (p. 81, 84).

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TRACK 2 — Alternative (SABA-based reliever)

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Drugs Commonly Used in India (GINA-aligned)

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ICS Dose Table (GINA 2024 — Adults)

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GINA 2024 — Key Principles Relevant to India

1. Confirm Diagnosis Before Treating

• Spirometry (FEV₁/FVC < 0.7 + reversibility ≥12% with bronchodilator) confirms asthma
• Many Indian patients are treated empirically — GINA 2024 emphasizes objective confirmation

2. Assess & Treat Comorbidities

• Allergic rhinitis, GERD, obesity, smoking — all worsen asthma control
• Treat these alongside asthma

3. Inhaler Technique is Critical

• Poor inhaler technique is a major cause of uncontrolled asthma in India
• Always demonstrate and verify MDI/DPI technique at every visit

4. Step Down When Controlled

• After 3 months of good control → consider stepping down to the lowest effective dose
• Do not over-treat

5. Severe Asthma & Biologics in India

• Omalizumab (anti-IgE) — available in India; expensive; for allergic severe asthma
• Mepolizumab, Benralizumab — available for eosinophilic severe asthma
• Tezepelumab — newest biologic (TSLP blocker); limited availability in India currently

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Asthma vs. COPD vs. Asthma-COPD Overlap (ACO) — India

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Non-Pharmacological Management (GINA 2024)

• Smoking cessation — single most important intervention
• Allergen avoidance — dust mites, pollen, cockroach, mold (highly relevant in India)
• Exercise — encouraged; use reliever 15 min before exercise if needed
• Weight reduction in obese patients
• Vaccinations — annual influenza, pneumococcal
• Avoid NSAIDs/Aspirin in aspirin-exacerbated respiratory disease (AERD)
• Written Asthma Action Plan — give every patient a personalized plan

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Summary: Old vs. New GINA (Most Important Change for Exams)

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