How can I distinguish cardiac asthma from typical bronchial asthma?

Certain clinical features of cardiac asthma, defined as congestive heart failure (CHF) associated with wheezing, may be useful in distinguishing it from bronchial asthma, particularly in older patients with COPD (1-3).
• Paroxysmal nocturnal dyspnea associated with wheezing
• Presence of rales or crackles, ascites or other signs of CHF
• Poor response to bronchodilators and corticosteroids
• Formal pulmonary function test with bronchoprovocation demonstrating minimal methacholine response.

 
Cardiac asthma is not uncommon. In a prospective study of patients 65 yrs of age or older (mean age 82 yrs) presenting with dyspnea due to CHF, cardiac asthma was diagnosed in 35% of subjects. Even in non-elderly patients, cardiac asthma has been reported in 10-15% of patients with CHF (2).

 
The mechanism(s) underlying cardiac asthma is likely multifactorial. Pulmonary edema and pulmonary vascular congestion have traditionally been considered as key factors either through edema in the interstitial fluid of bronchi squeezing the bronchiolar lumen or by externally compressing the entire airway structure and the bronchiole wall. Reflex bronchoconstriction involving the vagus nerve, bronchial hyperreactivity, systemic inflammation, and airway remodeling may also play a role (1,3). 

 
Treatment of choice for cardiac asthma typically includes diuretics, nitrates and morphine, not bronchodilators or corticosteroids (1,3). 

 
Bonus Pearl: Did you know that the term “cardiac asthma” was first coined by the Scottish physician, James Hope, way back in 1832 to distinguish it from bronchial asthma!

 

References
1. Litzinger MHJ, Aluen JKN, Cereceres R, et al. Cardiac asthma: not your typical asthma. US Pharm. 2013;38:HS-12-HS-18. https://www.uspharmacist.com/article/cardiac-asthma-not-your-typical-asthma
2. Jorge S, Becquemin MH, Delerme S, et al. Cardiac asthma in elderly patients: incidence, clinical presentation and outcome. BMC Cardiovascular Disorders 2007;7:16. https://www.ncbi.nlm.nih.gov/pubmed/17498318
3. Tanabe T, Rozycki HJ, Kanoh S, et al. Cardiac asthma: new insights into an old disease. Expert Rev Respir Med 2012;6(6), 00-00. https://www.ncbi.nlm.nih.gov/pubmed/23234454

 

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How can I distinguish cardiac asthma from typical bronchial asthma?

Should I consider fosfomycin in the treatment of urinary tract infection in my male patient with suspected prostatitis?

Although fosfomycin (FM) has been approved by the FDA only for the treatment of uncomplicated urinary tract infection (UTI) in women, it may also have a role in the treatment of acute and chronic prostatitis among males given its favorable levels in the prostate tissue. 1-5

Despite lack of studies comparing the efficacy of FM with that of commonly used antibiotics for treatment of prostatitis, the potential utility of FM is supported by several reports of its efficacy in the treatment of prostatitis, including those caused by extended-spectrum beta-lactamase (ESBL)-producing gram-negative rods. 1,4-5

When considering FM for treatment of prostatitis, a higher dose than customary may be needed (3 g once daily, not every 48-72 h) . 4 Although the optimal duration of therapy with FM is unclear in this setting, 12-16 weeks of therapy was used in 2 patients with recurrent UTIs and prostatitis due to multi-drug resistant ESBL-positive E. coli. 4

Given its pharmacokinetics and lack of proven efficacy, avoid FM in pyelonephritis, perinephric abscess or UTI with bacteremia. 2

References

  1. Falagas ME, Vouloumanou EK, Samonis G, et al. Fosfomycin. Clin Microbiol Rev 2016;29:321-347. https://www.ncbi.nlm.nih.gov/pubmed/26960938
  2. Wankum M, Koutsari C, Gens K. Fosfomycin use. Pharmacy Times. November 30, 2017. https://www.pharmacytimes.com/publications/health-system-edition/2017/november2017/fosfomycin-use
  3. Cunha BA, Gran A, Raza M. Persistent extended-spectrum β-lactamase-positive Escherechia coli chronic prostatitis successfully treated with a combination of fosfomycin and doxycycline. International J Antimicrob Agents 2015;45:427-29. https://www.ncbi.nlm.nih.gov/pubmed/25662814
  4. Grayson ML, Macesic N, Trevillyan J, et al. Fosfomycin for treatment of prostatitis: new tricks for old dogs. Clin Infect Dis 2015;61:1141-3. https://www.ncbi.nlm.nih.gov/pubmed/26063723
  5. Falagas ME, Rafailidis PI. Fosfomycin: the current status of the drug. Clin Infect Dis 2015;61:1144-6. https://www.ncbi.nlm.nih.gov/pubmed/26063717
Should I consider fosfomycin in the treatment of urinary tract infection in my male patient with suspected prostatitis?