Is initiating fluticasone (fluticasone) 100 micrograms, two puffs, twice daily, via inhalation, and continuing albuterol (albuterol) hydrofluoroalkane (HFA) 90 micrograms, two puffs, as needed, an effective plan for managing mild persistent asthma in a 22-year-old transgender male with increased shortness of breath and wheezing?

From the Guidelines

Yes, this is a good treatment plan for A.V., a 22-year-old transgender male with worsening mild persistent asthma. The plan appropriately addresses his increased symptoms by stepping up therapy with fluticasone 100 mcg inhaled corticosteroid (ICS) twice daily while maintaining albuterol as rescue medication, which is in line with the recommendations from the expert panel report 3 (EPR-3) guidelines for the diagnosis and management of asthma 1. This approach follows standard asthma management guidelines for patients with inadequate control on rescue medication alone, as also supported by the National Asthma Education and Prevention Program (NAEPP) guidelines 1.

The plan correctly addresses his allergic rhinitis with fluticasone nasal spray and loratadine as needed, which will help manage symptoms exacerbated by his new exposure to cat allergens. The provider appropriately maintained his gender-affirming hormone therapy while planning to monitor for potential side effects. The plan includes practical components like providing a spacer device and asthma action plan, which improve medication delivery and patient self-management, as recommended by guidelines for optimal asthma control 1.

Key points to consider in this plan include:

• The use of inhaled corticosteroids (ICS) as the most effective long-term control medication for asthma, reducing airway inflammation and hyperresponsiveness 1.
• The importance of monitoring and adjusting treatment based on symptoms and rescue medication use, with the goal of achieving and maintaining asthma control 1.
• The role of patient education, including the use of spacer devices and asthma action plans, in improving outcomes and quality of life for patients with asthma 1.

Overall, the treatment plan for A.V. is consistent with current guidelines and recommendations for the management of mild persistent asthma and allergic rhinitis, prioritizing morbidity, mortality, and quality of life outcomes.

From the Research

Assessment of the Plan

• The patient's symptoms and history suggest a need for step-up therapy in managing mild persistent asthma, as indicated by increased shortness of breath, wheezing, and frequent use of the albuterol rescue inhaler 2.
• The decision to start fluticasone 100 mcg 1 puff BID (ICS) is supported by studies showing that inhaled corticosteroid therapy is the most effective anti-inflammatory treatment for asthma, and combination treatment with both ICS and LABA provides greater asthma control than increasing the ICS dose alone 2.
• Providing a written action plan, as done in this case, has been shown to improve patient adherence to medications and other recommendations, and to enhance asthma control, as demonstrated in studies such as 3 and 4.
• The plan to continue albuterol HFA 90 mcg 2 puffs PRN and to reassess control in 4 weeks is consistent with standard asthma management guidelines.
• Discussion of allergen avoidance and strategies for minimizing cat exposure is also appropriate, given the patient's recent move in with a roommate who owns a cat.

Considerations for Asthma Management

• The use of a spacer and an asthma action plan can help improve adherence and control, as seen in studies such as 3 and 4.
• Regular follow-up and monitoring of symptoms, as planned in this case, are crucial for adjusting the treatment plan as needed and ensuring optimal asthma control.
• Patient education on proper inhaler technique, medication use, and recognition of worsening symptoms is essential for effective self-management.

Relevance of Provided Studies

• Studies 2, 3, and 4 provide relevant evidence for the management of asthma, including the use of inhaled corticosteroids, combination therapy, and written action plans.
• Studies 5 and 6 are not directly relevant to the management of asthma in this patient, as they pertain to multiple sclerosis and type 2 diabetes, respectively.