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Prescription Review

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4. Acute Bronchitis

• Antibiotic not indicated. Current guidelines explicitly recommend against routine antibiotic use in acute uncomplicated bronchitis in the absence of pneumonia (Appropriate Antibiotic Use for Acute RTI in Adults, p. 2). Acute bronchitis is predominantly viral. Antibiotics provide minimal benefit and increase adverse events and antimicrobial resistance.
• The alternate drugs (Co-trimoxazole, Ciprofloxacin) are also not indicated for routine acute bronchitis.
• Bromhexine as a mucolytic/expectorant is acceptable as symptomatic relief, but evidence for mucolytics in acute bronchitis is weak. Quantity of 10 tablets only covers about 3.3 days at TDS — should be 21 tablets if prescribed for 7 days.
• What should be prescribed instead: Symptomatic treatment — antipyretics/analgesics (paracetamol/ibuprofen), adequate hydration, honey (evidence-based for cough), and patient reassurance. Antibiotics are reserved only for patients with suspected secondary bacterial infection, the elderly, immunocompromised, or those with significant comorbidities.

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5. Acute Exacerbation of COPD (AECOPD)

• Amoxicillin-clavulanate: Appropriate choice for AECOPD when antibiotics are indicated. However, GOLD 2025 recommends an antibiotic duration of 5 days, not 7 days. If the intent is 5 days, only 15 tablets are needed, not 21. The 7-day/21-tablet course is a common clinical practice in some settings and is not grossly wrong, but 5 days is now the preferred duration per GOLD 2025 (p. 121).
• Salbutamol dose: The prescription states 1.25 µg — this is likely a typographical error. The correct nebulisation dose for salbutamol is 1.25 mg to 2.5 mg, not micrograms (µg). This is a significant error that must be corrected.
• Ipratropium 0.5 mg nebulisation dose is correct.
• Prednisolone 40 mg OD × 5 days is precisely in line with GOLD 2025 guidelines: "duration of therapy should not normally be more than 5 days" (p. 121). ✓
• Alternate drugs: Azithromycin and levofloxacin are appropriate antimicrobial alternatives. ✓
• Methylxanthines (Deriphylline): GOLD 2025 explicitly states "methylxanthines are not recommended due to increased side effect profiles." This should be removed from alternates or flagged with a caution. Budesonide as an alternate inhaled corticosteroid is acceptable.

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6. Lobar Pneumonia (Community-Acquired)

• Amoxicillin-clavulanate is an appropriate first-line choice for mild-to-moderate CAP, particularly when covering atypicals is not required. The 10-day duration is acceptable, though some guidelines support 5–7 days for mild CAP. ✓
• Formulation error: Amoxicillin-clavulanate is typically available as a tablet, not a capsule. The prescription labels it as "Capsule" — this should be corrected to "Tablet."
• Paracetamol for fever/antipyresis is appropriate. ✓
• Alternate drugs: Azithromycin and doxycycline are appropriate alternatives, particularly for atypical coverage. ✓
• For lobar (typical) pneumonia, coverage for Streptococcus pneumoniae is the priority, and amoxicillin-clavulanate addresses this adequately.

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Patient Education

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Summary of Key Corrections Needed

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Prescription Review: Asthma (Steps 2–4)

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7. Mild Persistent Asthma (Step 2)

• BDP as daily low-dose ICS is the cornerstone of Step 2 therapy. 1–2 puffs BD (100–200 µg/day) is appropriate low-dose ICS. The ceiling of 400 µg/day is correctly stated. ✓
• Salbutamol (SABA) as needed for relief is appropriate and consistent with traditional Step 2 management. ✓
• However, GINA guidelines have evolved: the current preferred reliever at all steps (including Step 2) is an ICS/formoterol combination as needed (e.g., budesonide/formoterol), because even mild asthma carries mortality risk and as-needed SABA monotherapy is no longer preferred. NAEPP/US guidelines endorse ICS/formoterol from Step 3 onward. This prescription follows the older, still-acceptable traditional approach but is not aligned with the most current GINA 2023 recommendations. (Harrison's 21st Edition, p. 7937)
• Alternate drug — Sodium cromoglycate: Acceptable older alternative, though now rarely used. ✓
• Alternate drug — Oral theophylline: Not a preferred Step 2 alternative due to narrow therapeutic index, significant drug interactions, and side effect burden. Its use as a first-line alternative is not recommended by current guidelines. Should be flagged as a last-resort option only.
• Patient counselling on MDI use is correctly included. ✓

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8. Moderate Persistent Asthma (Step 3)

• BDP dose is insufficient for Step 3. Step 3 requires either a medium-dose ICS (BDP 200–400 µg/day) or a low-dose ICS + LABA. At 1–2 puffs of 50 µg BD, the maximum delivered is only 200 µg/day — borderline low-to-medium dose. The prescription should specify at least 2 puffs BD (200 µg/day) clearly, or preferably upgrade to a higher-strength inhaler (BDP 100 µg/puff) for practical compliance.
• Salmeterol as LABA add-on is appropriate for Step 3. ✓ However, salmeterol should NEVER be used without concomitant ICS — the ICS and LABA should ideally be prescribed as a fixed-dose combination inhaler (e.g., salmeterol/fluticasone or formoterol/budesonide) to ensure the patient never takes LABA alone, which carries a boxed warning for asthma-related death when used as monotherapy.
• Salmeterol dose: The standard dose is 50 µg BD (2 puffs of 25 µg = 50 µg per dose, BD). At 2 puffs BD, total = 100 µg/day, which is the correct total daily dose. ✓
• ICS/LABA fixed combination (e.g., budesonide/formoterol or salmeterol/fluticasone) is strongly preferred over separate inhalers at this step for safety and adherence.
• Alternate drug — Deriphylline (Etophylline + Theophylline): As noted previously, GOLD and GINA guidelines caution against methylxanthines due to a narrow therapeutic index, need for monitoring serum levels, and significant drug interactions. Theophylline is considered a third-line add-on only when other options fail. Listing it as a routine alternative is not ideal and needs a caution.

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9. Severe Persistent Asthma (Step 4)

• BDP 200 µg/puff, 1–2 puffs BD: This delivers 400–800 µg/day, which falls in the medium-to-high dose ICS range appropriate for Step 4. ✓ However, specifying 2 puffs BD (800 µg/day) would be clearer for Step 4.
• Salmeterol 2 puffs BD alongside high-dose ICS is appropriate for Step 4. Same caution as Step 3 applies: a fixed ICS/LABA combination is safer. ✓
• Prednisolone — significant issues:
  • "40 mg in 4 divided doses" is incorrect. Oral prednisolone for asthma exacerbation/severe persistent asthma is given as a single morning dose (OD), not in divided doses. Divided dosing increases adrenal suppression and side effects unnecessarily.
  • Taper of 5 mg/week is overly slow for a short course. For a short burst (up to 7–10 days), prednisolone can be stopped abruptly without tapering if the duration is less than 3 weeks, as adrenal suppression is not clinically significant. A 5 mg/week taper from 40 mg would take 8 weeks, which is not appropriate for Step 4 controller therapy.
  • Oral corticosteroids at Step 4 should be used at the lowest effective dose, and long-term use should be avoided due to systemic side effects (osteoporosis, hyperglycemia, adrenal suppression). If used as a short course for exacerbation, 40 mg OD × 5–7 days without taper is standard.
• Alternate drugs:
  • Theophylline at Step 4 is a possible add-on, but a distant option due to its side effect profile. ✓ (with caution)
  • Sodium cromoglycate is not appropriate at Step 4. It is a mild mast cell stabilizer used only in Step 2 (mild disease). It has no role in severe persistent asthma and should be removed from Step 4 alternatives.

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Summary Table of Corrections

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Chronic COPD — Standard Prescription

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Initial Assessment Before Prescribing

1. Symptom burden — assessed by mMRC dyspnoea scale or CAT score
2. Exacerbation risk — number of exacerbations in the past year, prior hospitalisation

• Group A — Low symptoms, low risk (mMRC 0–1, CAT < 10, 0–1 exacerbations, no hospitalisation)
• Group B — High symptoms, low risk (mMRC ≥ 2, CAT ≥ 10, 0–1 exacerbations, no hospitalisation)
• Group E — High exacerbation risk (≥ 2 exacerbations OR ≥ 1 leading to hospitalisation, regardless of symptoms)

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Recommended Prescriptions by GOLD Group

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Group A — Mild, Low-Risk COPD

Rx
Inhalation Salbutamol 100 µg/puff (MDI)                    (1)
Direction: 1–2 puffs as needed for breathlessness

OR

Inhalation Ipratropium bromide 20 µg/puff (MDI)            (1)
Direction: 2 puffs four times a day

• A short-acting bronchodilator (SABA or SAMA) as needed is the recommended initial therapy.
• Either a SABA (salbutamol) or SAMA (ipratropium) is appropriate.

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Group B — Symptomatic, Low-Risk COPD

Rx
Inhalation Tiotropium 18 µg/capsule (HandiHaler)           (1)
Direction: 1 capsule to be inhaled once daily

OR

Inhalation Salmeterol 25 µg/puff (MDI)                     (1)
Direction: 2 puffs to be inhaled twice daily

Inhalation Salbutamol 100 µg/puff (MDI)                    (1)  [rescue]
Direction: 1–2 puffs as needed

• A long-acting bronchodilator (LAMA or LABA) is preferred.
• LAMA (tiotropium) is generally preferred over LABA for COPD as it reduces exacerbations more effectively.
• LAMA + LABA dual bronchodilation is an option when single agent is insufficient.

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Group E — High Exacerbation Risk COPD

Rx
Inhalation Tiotropium 18 µg/capsule (HandiHaler)           (1)
Direction: 1 capsule to be inhaled once daily
+
Inhalation Salmeterol/Fluticasone 25/250 µg/puff (MDI)    (1)
Direction: 2 puffs to be inhaled twice daily

OR (if blood eosinophils ≥ 300 cells/µL)

Inhalation Budesonide/Formoterol/Glycopyrrolate            (1)
[Triple therapy — ICS/LABA/LAMA]
Direction: As per device instructions once or twice daily

Inhalation Salbutamol 100 µg/puff (MDI)                    (1)  [rescue]
Direction: 1–2 puffs as needed

• LAMA + LABA is the preferred initial therapy for Group E.
• ICS addition (triple therapy: ICS + LABA + LAMA) is recommended when:
  • Blood eosinophils ≥ 300 cells/µL, OR
  • Continued exacerbations on dual bronchodilator therapy
• ICS should NOT be initiated if blood eosinophils < 100 cells/µL due to increased pneumonia risk with no exacerbation benefit.

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Role of Oral Medications

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Non-Pharmacological Measures (Essential)

• Smoking cessation — single most effective intervention; slows FEV₁ decline
• Pulmonary rehabilitation — improves exercise tolerance and quality of life in all groups
• Vaccinations — influenza (annual), pneumococcal, COVID-19, pertussis, RSV (in eligible patients)
• Oxygen therapy — for resting SpO₂ ≤ 88% or PaO₂ ≤ 55 mmHg; long-term oxygen > 15 hours/day improves survival
• Patient education — inhaler technique, recognising exacerbation symptoms early
• Avoid triggers — smoking, biomass fuel smoke, occupational dust, pollutants

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Key Points to Remember

1. Methylxanthines (theophylline, deriphylline) are not recommended in stable COPD — GOLD 2025 explicitly advises against them due to the risk-benefit profile.
2. ICS should not be used as monotherapy in COPD — always in combination with a LABA.
3. Blood eosinophil count guides ICS use: ≥ 300 cells/µL — strong indication; 100–300 — consider; < 100 — avoid ICS.
4. LAMA is preferred over LABA when choosing a single long-acting bronchodilator.
5. Salbutamol (SABA) is always kept as rescue in all COPD patients on maintenance therapy.
6. Inhaler technique and adherence must be assessed before escalating treatment.