What is the recommended management for a 70-year-old lady with controlled hypertension on amlodipine 5 mg and well-controlled asthma using salbutamol (Asthalin) with normal oxygen saturation?

Management of Well-Controlled Asthma in a 70-Year-Old on Amlodipine

This patient with well-controlled asthma and hypertension should continue her current regimen of amlodipine 5 mg and as-needed salbutamol (Asthalin), while ensuring she is on appropriate inhaled corticosteroid (ICS) controller therapy if not already prescribed.

Current Status Assessment

• The patient demonstrates well-controlled disease with normal oxygen saturation (98%) and stable blood pressure on amlodipine 5 mg, which is the standard initial dose for elderly patients 1
• Amlodipine is particularly effective in elderly hypertensive patients, with studies showing significant blood pressure reduction (mean decrease of 22 mmHg systolic and 10 mmHg diastolic) without adverse effects on respiratory function 2
• The use of one nebulizer treatment of salbutamol (Asthalin) suggests either well-controlled asthma requiring minimal rescue medication or potentially inadequate controller therapy 3

Critical Management Decision: Controller Therapy

The most important question is whether this patient is on inhaled corticosteroid controller therapy:

• If the patient is using salbutamol more than twice weekly for symptom relief, this indicates inadequate control requiring immediate addition of low-to-medium dose ICS 4
• The British Thoracic Society emphasizes that frequent need for rescue medication (>2 times per week) indicates poor control requiring controller therapy escalation 4
• For patients with persistent symptoms requiring frequent rescue medication, immediate addition of ICS as controller therapy is recommended 4

Continuation of Current Medications

Amlodipine Management

• Continue amlodipine 5 mg once daily, which is appropriate for elderly patients with controlled blood pressure 1
• Elderly patients have decreased clearance of amlodipine with a resulting increase of AUC of approximately 40-60%, making the 5 mg dose particularly suitable 1
• Amlodipine is safe in asthmatic patients and does not interfere with bronchodilator therapy 5

Salbutamol (Asthalin) Use

• Continue as-needed salbutamol for acute symptom relief 3, 6
• Standard dosing via nebulizer is 2.5-5 mg as needed, or 4-8 puffs via MDI with spacer 3, 6
• Critical caveat: If salbutamol is needed more than twice weekly, this signals inadequate control requiring controller therapy escalation 4

Monitoring and Follow-Up Protocol

• Assess frequency of salbutamol use over the next 2-4 weeks to determine if controller therapy needs adjustment 4
• Monitor peak expiratory flow (PEF), symptom frequency, and activity limitation including exercise-induced symptoms 4
• Verify proper inhaler technique, as most treatment failures stem from poor technique 4
• Provide a written asthma action plan with clear instructions for recognizing worsening symptoms 4

When to Escalate Therapy

Seek immediate medical care if:

• Unable to complete sentences due to breathlessness 4
• Pulse >110 bpm or respirations >25/min at rest 4
• No improvement after 3 doses of salbutamol 4
• Respiratory rate >25 breaths/min, which indicates severe asthma requiring immediate intervention 3

Common Pitfalls to Avoid

• Do not assume well-controlled asthma based solely on current oxygen saturation; assess frequency of rescue medication use 4
• Do not delay adding ICS controller therapy if the patient requires frequent salbutamol use 4
• Ensure the patient is not using salbutamol regularly (four or more times daily), as this can reduce its duration of action and effectiveness 6
• Do not use beta-blockers for hypertension in asthmatic patients, as they can worsen bronchospasm; amlodipine is the preferred choice 5