Exacerbations and to identify the potential cause of

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exacerbations, and to identify the potential cause of the exacerbation. This visit provides an opportunity for additional asthma education by a trained asthma educator or trained lay health care worker ( Gina Full Report 2020 , 2020, p. 116). Thus, for this patient, a semi-follow up review after 6 days will be sufficient to evaluate the effectiveness of the steroid burst given. 5. Outline appropriate monitoring for drug side effects, laboratory monitoring with rationale, and follow-up .
10 Since Symbicort is composed of combination medication, the 2 ingredients namely budesonide and formoterol have different adverse reaction that needs to be addressed. In the budesonide side, being a corticosteroid, it can cause hypercortisolism which may lead to adrenal crisis. Thus, a precaution in in using on patient with thyroid disease since the metabolic clearance of corticosteroids may increase in hyperthyroidism and decrease in hypothyroidism. Another side effect is increase in blood glucose level. One adverse effect of prolonged use of budesonide is a term called “steroid diabetes”. Corticosteroids are used to reduce harmful inflammation but can lead to diabetes in chronic use. Salt and water retention can happen in corticosteroid use. It can increase serum glucose and aggravate pre-existing diabetes mellitus and ketoacidosis. Being a steroid, it also affects the bone density with prolonged use. Corticosteroid decreases the bone mineral density which can lead to brittle bone/osteoporosis. Oral candidiasis has been reported in patient that have used Symbicort. Rinsing the mouth with water after inhaler use is a good practice to prevent oral thrush. Vasculitis has also been reported on patients that is taking Symbicort, particularly a condition called Churg-Strauss Syndrome (a form of eosinophilic granulomatosis with polyangiitis) on rare occasions. It is also being cautioned in patients with cataracts and/or glaucoma as it can cause ocular disease due to increased intraocular pressure, and proliferation of cataract with chronic use. Also, CYP3A4 inhibitors can enhance the effect of budesonide, therefore, monitoring the therapy is recommended. In the formoterol side, being a beta 2 antagonist, hypersensitivity reaction can occur such as urticaria, angioedema and rash has been reported. Furthermore, paradoxical bronchospasm was also seen with beta 2 antagonist use. Seizure precaution is also placed for chronic use due to its effect as CNs stimulator. The risk of arrythmias and ECG changes was also found including prolonged qt interval and flattened t waves which is also a manifestation of being hypokalemic. Monitoring of potassium level is
11 needed especially for patients taking loop diuretics. Other common side effects are headache, nasopharyngitis, pharyngolaryngeal pain, upper respiratory tract infection, tremor, nervousness, insomnia and cough have occurred (fda, 2008).

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