What are the considerations for a patient with asthma experiencing persistent nocturnal cough and wheezing?

From the Guidelines

For persistent nighttime cough and wheezing in a patient with asthma, I recommend evaluating for poor asthma control and implementing a step-up in therapy, prioritizing inhaled corticosteroids (ICS) as the most effective anti-inflammatory medication, as indicated by the most recent and highest quality study 1. To address the patient's symptoms, consider the following steps:

• Ensure the patient is using their current medications correctly, particularly inhaler technique.
• Consider adding or increasing an ICS such as fluticasone (100-500 mcg twice daily) or budesonide (180-720 mcg twice daily), as these are the most effective anti-inflammatory medications available for treating the underlying inflammation 1.
• For patients already on an ICS, adding a long-acting beta-agonist (LABA) like salmeterol or formoterol in a combination inhaler may be beneficial.
• Ensure the patient has a rescue inhaler like albuterol (2 puffs every 4-6 hours as needed). Some key points to consider:
• Nighttime symptoms often indicate inadequate control and may be exacerbated by gastroesophageal reflux disease (GERD), postnasal drip, or environmental triggers in the bedroom.
• Recommend elevating the head of the bed, using allergen-proof bedding covers, and removing potential triggers like pets from sleeping areas.
• If symptoms persist despite these interventions, consider adding a leukotriene modifier like montelukast (10mg daily for adults) or a long-acting muscarinic antagonist like tiotropium, as suggested by the study on chronic cough due to asthma 1. It is essential to note that asthma should be considered as a potential etiology in any patient with chronic cough, and clinical suspicion must remain high, especially in cases of cough-variant asthma (CVA) 1.

From the FDA Drug Label

What is asthma? Asthma is a continuing (chronic) inflammation of the bronchial passageways which are the tubes that carry air from outside the body to the lungs Symptoms of asthma include: coughing wheezing chest tightness shortness of breath The patient's symptoms of persistent nighttime cough and wheezing are consistent with asthma.

• Key considerations for managing asthma symptoms include:
  • Assessing the patient's current treatment plan and adherence to it
  • Evaluating the patient's environment for potential asthma triggers
  • Considering the use of medications such as bronchodilators or anti-inflammatory agents to control symptoms
  • Monitoring the patient's symptoms and adjusting the treatment plan as needed 2

From the Research

Persistent Nighttime Cough and Wheezing in Asthma Patients

• Asthma is a chronic disease characterized by inflammation and bronchoconstriction, and medications that can effectively treat both components are advantageous 3.
• A combination of inhaled corticosteroids and long-acting beta2-agonists is recommended for the treatment of persistent asthma 4, 5.
• Studies have shown that fluticasone propionate/salmeterol combination is more effective than montelukast in improving asthma control and patient satisfaction 3, 4.
• The combination of salmeterol and fluticasone propionate has been shown to be more effective than monotherapy with either drug alone in improving lung function, symptom-free days, and quality of life 4, 5.
• A systematic review of clinical studies found that fluticasone and formoterol appear to provide improved therapeutic benefits versus budesonide and salmeterol, respectively 5.
• Another study found that combination fluticasone and salmeterol was not significantly different from fixed-dose combination budesonide and formoterol in terms of lung function outcomes, symptoms, and rescue medication use 6.
• Pharmacoeconomic analyses have shown that salmeterol/fluticasone propionate is a cost-effective treatment option compared to other maintenance therapies 7.

Treatment Options

• Fluticasone propionate/salmeterol combination is a potential treatment option for patients with persistent nighttime cough and wheezing 3, 4.
• Salmeterol/fluticasone propionate administered via a single inhaler represents a cost-effective treatment option 7.
• The choice of treatment should be based on individual patient needs and medical history, and should be guided by clinical guidelines and evidence-based medicine 5, 6.