Correspondence

Clinical Problem-Solving: Too Old for What?

N Engl J Med 1993; 329:509-510August 12, 1993

Article

To the Editor:

In the Clinical Problem-Solving feature (April 1 issue),1 an 87-year-old woman with no known heart or pulmonary disease went to see her physician because she was short of breath. The article does not address the inappropriate treatment for asthma that the patient was given early in her clinical evaluation -- theophylline (Theo-Dur), erythromycin, and bed rest.

There are at least two reasons not to institute asthma therapy with a theophylline preparation and erythromycin. First, as outlined in the National Asthma Expert Panel Report, inhaled beta₂-agonists should be the initial treatment for episodic asthma2. Second, even if initial management were to include a theophylline preparation, erythromycin should probably not be added unless theophylline levels are monitored closely. Erythromycin is known to decrease the metabolism of theophylline and increase its serum level,3 which might lead to harmful side effects in an 87-year-old woman with aortic stenosis.

Molly L. Osborne, M.D., Ph.D.
Michael Wall, M.D.
Oregon Health Sciences University, Portland, OR 97201

3 References

1. 1

   Thibault GE. Too old for what? N Engl J Med 1993;328:946-950
   Full Text | Web of Science | Medline

2. 2

   National Asthma Education Program: Expert Panel report. Guidelines for the diagnosis and management of asthma. Bethesda, Md.: National Institutes of Health, 1991. (NIH publication no. 91-3042.)
   

3. 3

   Larson EB, Ramsey PG, eds. Medical therapeutics: a pocket companion. Philadelphia: W.B. Saunders, 1989:144.
   

Author/Editor Response

Dr. Thibault replies:

To the Editor: I agree with Drs. Osborne and Wall that the physician who first saw the patient was in error in initiating erythromycin and theophylline therapy. They make valid points about the desirability of using inhaled beta₂-agonists as initial therapy for asthma and the potential for erythromycin to increase serum theophylline levels. These points were not brought out in the discussion of the case because the chief thrust was the diagnosis and management of aortic stenosis in the elderly. The failure of the first physician to appreciate the presence of aortic stenosis and its possible relation to the patient's symptoms posed a greater risk for the patient than the drugs themselves. Had the physician made the correct diagnosis, neither theophylline nor beta₂-agonists would have been indicated and erythromycin would not have been prescribed.

George E. Thibault, M.D.
Veterans Affairs Medical Center, West Roxbury, MA 02132