Asthma is a chronic
condition involving the respiratory system in which the airway occasionally
constricts, becomes inflamed, and is lined with excessive amounts of mucus,
often in response to one or more triggers. These episodes may be triggered by such
things as exposure to an environmental stimulant (or allergen) such as cold
air, warm air, moist air, exercise or exertion, or emotional stress. In
children, the most common triggers are viral illnesses such as those that cause
the common cold. As said by Abramson MJ  the most effective
treatment for asthma is identifying triggers, such as pets or aspirin, and
limiting or eliminating exposure to them. Desensitization is currently the only
known "cure" to the disease. Specific treatments for asthma are
broadly classified as relievers, preventers and emergency treatment. The Expert
Panel Report 2 Guidelines for the Diagnosis and Management of Asthma (EPR-2) 
of the U.S.
National Asthma Education and Prevention Program, and the British Guideline on
the Management of Asthma. 
Asthma appears to be more prevalent in athletes than in the general
population. One survey of participants in the 1996 Summer Olympic Games, in Atlanta, Georgia,
showed that 15% had been diagnosed with asthma, and that 10% were on asthma
medication.  it is
becoming one of the chronic diseases and its mortality rate will increase in
incoming 10 years by 20%. Asthma is one of the most chronic diseases in the
world affecting more than 300 million people worldwide and causing about
255,000 premature deaths annually. Asthma accounts for at least one in every
250 deaths. Studies reveal that asthma deaths would increase by almost 20% in
the next 10 years if urgent action is not taken. Asthma occurs in almost all
countries regardless of level of development, however, over 80% of asthma
deaths occur in low and middle-income countries. The prevalence of asthma in Pakistan is
increasing day-by-day with an annual increase of 5% of which 20% to 30% are
children between 13 and 15 years of age. Nearly 20 million persons i.e 12% of
Pakistani adult population are already suffering from the disease.
A child patient 5 years
old (girl), weight 15kg, was presented in pediatric ward hospital, Rawalpindi, Pakistan
with chief complaints of high grade fever (101oF) from previous 3
days, fever was temporarily relieved by the medication such as Calpol (Paracetamol),
an analgesic. Fever was associated with shivering, rigor and chills. The child
was having cough from previous three days, its episodes become more severe at
night associated with vomiting, awakening with shortness of breath (SOB). She
was administered Beta-2 agonist (Salbutamol), to which she was not responding,
it became sever with this agent.
She was also having
upper respiratory tract infection, for which she was administered 2 antibiotics
clarithromycin and Ceftriaxone.
When two antibiotics are administered at a time, their dose must be adjusted
but that child was administered these without any dose adjustment. From about 2
days she was eating banana and oranges. Her pulse rate was normal according to
her age (102) but respiratory rate (36/min) was greater than the normal value
Asthmatic attacks had
become more frequent from last 1 year and also increase in severity in winter.
At night she had to use bronchodilators twice or thrice per month. She was
diagnosed asthmatic at the age of 4 months. She was hospitalized twice. Since
then initially attacks occur after every 3-4 months for which treatment was taken
and now from last year attacks occur every year. There was no family history of
asthma, she was having 2 brothers and 1 sister, and all were elder to her and
were not asthmatic.
On the basis of her
medical examination doctor prescribed her Injection Ceftriaxone-2gm for once
daily (7days), syrup calpol (Paracetamol)
1 tsp/4hr, Ventoline (Salbutamol or Albuterol) nebulizer 4cc plus 2cc N/S-
after every 4 hrs, Injection solucartef
(Hydrocortisone Sodium Succinate)-IV stat, after 2 days doctor added “nebulizer
with Clenil (Beclometasone Dipropionate) ½ ampoule + 2cc N/S, which is not
recommended for children under 6 years. Doctor also added injection Solucartef
(Hydrocortisone Sodium Succinate) -30mg V TDS, syrup- Klaracid (Clarithromycin)
5ml x BD Syrup- Ventoline (Salbutamol or aAbuterol) 2tsp- TDS.
Findings of the study
are acquiesced by Laga M, et al.,  who
reported that the Ceftraxone is 3rd generation cephalosporin, having
longer half life and therefore need to be given only once daily. it works by inhibiting the mucopeptide
synthesis in the bacterial cell wall. The beta-lactam moiety of Ceftriaxone
binds to carboxypeptidases, endopeptidases, and transpeptidases in the
bacterial cytoplasmic membrane. These enzymes are involved in cell-wall
synthesis and cell division. By binding to these enzymes, Ceftriaxone results
in the formation of defective cell walls and cell death. Indication includes
serious infections such as septicaemia, pneumonia and meningitis. While; Lamb HM et al.,
. reported that the calcium salt of Ceftriaxone forms a precipitate in
gall bladder, which may rarely cause symptoms but these usually resolve when
antibiotic is stopped. Its recommended dose is 1gm OD (50-100mg/kg/day) for
children as it is written in BNF, but a double dose of it was administered to
the child, which can be lethal.
The finding of this
case report also supported by Hinz, B et
al.,  who reported that the Calpol (Paracetamol) is non
opioid analgesic; it is a COX-2 inhibitor, having antipyretic anti-inflammatory
effects. Its peripheral anti-inflammatory effect is limited due to high level
of peroxide in inflammatory lesions. As reported by Weiler JM, et al,
.. the correct dose
of Paracetamol for a child does not depend on its age, but its weight. The
usual dose is 15 mg per kilogram of weight. In other words if a baby weighs 10
kg it should have 150 mg. This dose can be taken once every 4 hours, up to 4
times per day if needed.
Cullum et al. . reported Ventolin
is a beta-2 adrenergic agonist and thus it stimulates beta-2 adrenergic
receptors. Binding of Albuterol to beta 2 receptors in the lungs results in
relaxation of bronchial smooth muscles. It is believed that Salbutamol
increases cAMP production by activating Adenylate cyclase, and the actions of Salbutamol
are mediated by cAMP. Increased intracellular cyclic AMP increases the activity
of cAMP-dependent protein kinase A, which inhibits the phosphorylation of
myosin and lowers intracellular calcium concentrations. A lowered intracellular
calcium concentration leads to a smooth muscle relaxation. Increased
intracellular cyclic AMP concentrations also cause an inhibition of the release
of mediators from mast cells in the airways. In addition to ‘British National
Formulary for children’ it is also supported by Kamburoff et al.
. who recommend dose (2-6 years) 0.1 - 0.2 mg/kg body weight given 3
times daily. The maximal daily dose must not exceed 4 mg, 3 times daily, and
the daily dose for 6 - 12 years-old children is to 24 mg daily, divided in 3 or
4 doses. It was clearly mentioned in the preceding notes of patient’s file that she was not responding to Beta agonist (Ventoline),
and patient was administered Ventoline
for inhalation and syrup also, due to this her condition was getting
Clenil is the brand
name of Beclometasone Dipropionate, a corticosteroid. Willey
RF et al,  reported
that it is indicated for the prophylactic treatment of asthma. Its mechanisms
as reported by Salzman GA et al.,  that unbound corticosteroids cross
cell membranes and bind with high affinity to specific cytoplasmic receptors.
The result includes inhibition of leukocyte infiltration at the site of
inflammation, interference in the function of mediators of inflammatory
response, suppression of humoral immune responses, and reduction in edema or
scar tissue. The anti inflammatory actions of corticosteroids are thought to
involve phospholipase A2 inhibitory proteins, lipocortins, which control the
biosynthesis of potent mediators of inflammation such as prostaglandins and
leukotrienes. According to ‘Paediatric Formulary Committee (2009)  Beclometasone
is not a licensed drug for children under 6 years but in this case study
Beclometasone was not only indicated, but also its dose was not according to its
Irrational drug therapy
leads to development of adverse reactions, suboptimal effects, drug
interactions and non compliance; as seen in this case. So; rational medication
should be encouraged in actual clinical practice. Some of the understandable clinical
errors are not be give due care and needed to be addressed to improve the
current clinical services and pharmaceutical care. Moreover; it becomes more
important in poly-pharmacy or multi-disease therapy of certain seriously ill
overdose can cause diarrhea, muscle twitching, and seizures. Its overdose
can also severe asthma.
and maximum tolerated dose of ceftriaxone
for 3-6 years old child is 50-75 mg/kg/day approximately 1gm OD, so its
dose should not be doubled because it can severe the patient’s asthma.
is approved to treat a variety of different infections but its overdose
can cause nausea, vomiting, diarrhea, abnormal taste, indigestion and
heart burns. Recommended dose of clarithromycin
(Klaracid) is 2.5mL BD or 5mL OD.
adjustment of drugs is the factor which can not be neglected while
prescribing two antibiotics. Looking at the body weight not only both of
the antibiotic’s dose adjustment is neglected but also these are
prescribed 2 and 3 times greater than that of their recommended doses
respectively. When the patient was administered Ceftriaxone, her condition
was improving with one antibiotic, and there was no need of the second
one, and as she was also administered Clarithromycin, its dose must be
of Pharmaceutical sciences Riphah International University, G-7/4, 7th Avenue, Islamabad,
helped me to make this report productive.
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