Chronic disease pharmacologic therapy

The intensity of pharmacologic therapy is based on the severity of the disease, and the least amount of medications necessary to meet the goals of asthma therapy should be used.1,3 Stepwise therapy for the treatment of chronic asthma based on disease severity is shown in Table 11—1. 

The underlying cause of anemia (e.g., blood loss iron, folic acid, or vitamin B12 deficiency or chronic disease) must be determined and used to guide therapy. As discussed previously, patients should be evaluated initially based on laboratory parameters to determine the etiology of the anemia (see Fig. 63-3). Subsequently, the appropriate pharmacologic treatment should be initiated based on the cause of anemia. 

Buhl R, Farmer SG. Current and future pharmacologic therapy of exacerbations in chronic obstructive pulmonary disease and asthma. Proc Am Thorac Soc. 2004 1 136-142. 

Although medication nonadherence is the primary focus of this article, it is only one form of nonadherence. Poorer health outcomes may also result when a patient does not adhere to recommended lifestyle changes, such as exercise or smoking cessation, or to prescribed non-pharmacologic interventions, such as physical therapy or dietary plans. Pharmacists who counsel patients with chronic diseases, such as asthma, hypertension, or diabetes, need to assess and promote adherence to these non-pharmacologic treatments as well. 

Patients with renal impairment should not receive metformin. Other contraindications include hepatic disease, a past history of lactic acidosis, cardiac failure requiring pharmacological therapy, or chronic hypoxic lung disease. The drug also should be discontinued temporarily prior to the administration of intravenous contrast media and prior to any surgical procedure. The drug should not be readministered any sooner than 48 hours after such procedures, and should be withheld until renal function is determined to be normal. These conditions all predispose to increased lactate production and hence to the potentially fatal complication of lactic acidosis. The reported incidence of lactic acidosis during metformin treatment is less than 0.1 cases per 1000 patient-years, and the mortality risk is even lower. 

Ferguson GT Update on pharmacologic therapy for chronic obstructive pulmonary disease [review]. Clin... 

Adjunctive pharmacological therapies, aimed primarily at the cardio-respiratory system, will have a modest role initially, but as the disease becomes more chronic, there is a reduction in the potential for medications to contribute substantially. Therefore, although medications are prescribed in an attempt to optimize performance, it is important to do so in a way that minimizes the possibility of detrimental effects that can occur, for example, from corticosteroids or short-acting beta agonists. The following comments highlight some of the adjunctive therapies for the ventilated patient. 

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