What is the next step for a patient experiencing shortness of breath (SOB), phlegm, and wheezing despite being on Albuterol Sulfate (Albuterol) HFA inhalation 108 mcg/actuation and Alvesco (Ciclesonide) 160 mcg/actuation, both administered as aerosol solutions twice daily (BID)?

From the Guidelines

I recommend adding a long-acting beta-agonist (LABA) such as salmeterol or formoterol to the patient's current regimen of albuterol (rescue inhaler) and Alvesco (ciclesonide, an inhaled corticosteroid). The patient is experiencing persistent symptoms of shortness of breath, phlegm, and wheezing despite using both a rescue inhaler and an inhaled corticosteroid, indicating that their asthma is not adequately controlled. A combination inhaler containing both an inhaled corticosteroid and a LABA (such as Advair, Symbicort, or Breo) could replace the Alvesco, providing both anti-inflammatory effects and long-acting bronchodilation. The patient should continue using albuterol as needed for acute symptoms.

According to the guidelines outlined in 1, long-acting beta-agonists are used in combination with inhaled corticosteroids for long-term control and prevention of symptoms in moderate or severe persistent asthma. The addition of a LABA to the patient's current regimen is supported by the National Asthma Education and Prevention Program (NAEPP) guidelines, as stated in 1, which recommend a medium-dose inhaled corticosteroid plus a long-acting inhaled beta agonist as the preferred treatment for step 4 asthma management.

Some key points to consider when adding a LABA to the patient's regimen include:

• Proper inhaler technique should be assessed, as improper use can lead to suboptimal medication delivery.
• If symptoms persist despite these changes, further evaluation may be needed to rule out other conditions contributing to respiratory symptoms, such as allergies, GERD, or sinusitis.
• The patient should be monitored for any potential side effects or interactions with other medications.
• The use of a LABA in combination with an inhaled corticosteroid has been shown to improve asthma control and reduce the risk of exacerbations, as noted in 1 and 1.

Overall, the addition of a LABA to the patient's current regimen is a reasonable step to take in managing their asthma, given the persistent symptoms they are experiencing despite using a rescue inhaler and an inhaled corticosteroid. This approach is supported by the guidelines and evidence-based recommendations outlined in 1, 1, 1, and 1.

From the FDA Drug Label

If your symptoms do not improve or get worse, call your healthcare provider. Your healthcare provider may prescribe a rescue inhaler for emergency relief of sudden asthma attacks Call your healthcare provider if you have: • an asthma attack that does not respond to your rescue inhaler or • you need more of your rescue inhaler than usual.

The patient is still experiencing shortness of breath (sob), phlegm, and wheezing.

• The Albuterol Sulfate HFA Inhalation and Alvesco Inhalation are being used as prescribed.
• The patient should call their healthcare provider as their symptoms have not improved.
• The healthcare provider may need to adjust the treatment plan or prescribe additional medication to control the patient's asthma symptoms 2.

From the Research

Patient Symptoms and Medications

• The patient is experiencing shortness of breath (sob), phlegm, and wheezing despite being on two medications:
  • Albuterol Sulfate HFA Inhalation 108 (90 Base) MCG/ACT, and
  • Alvesco Inhalation 160 MCG/ACT.
• Both medications are aerosol solutions to be taken twice a day (BID).

Treatment Options for COPD

• According to 3, the combination of long-acting muscarinic antagonists (LAMAs) and long-acting beta-agonists (LABAs) is thought to leverage different pathways to induce bronchodilation using submaximal drug doses, increasing the benefits and minimizing receptor-specific side effects.
• 4 provides an overview of four fixed-dose combinations of a LAMA with a LABA, all indicated as maintenance bronchodilator treatment to relieve symptoms in adult patients with COPD.
• 5 compares the benefits and harms of LAMA+LABA versus LABA+ICS for treatment of people with stable COPD, finding that LAMA+LABA probably holds similar benefits to LABA+ICS for exacerbations and quality of life.

Diagnosis and Evaluation of Chronic Dyspnea

• 6 suggests that a detailed history and physical examination should begin the workup for chronic dyspnea, with results driving testing, including first-line tests such as spirometry and pulse oximetry.
• 7 discusses the use of bronchial provocation tests to detect underlying airway hyper-responsiveness in patients with normal spirometry, which may be relevant for diagnosing asthma or other conditions contributing to the patient's symptoms.

Potential Next Steps

• Consider evaluating the patient's response to the current medications and adjusting the treatment plan as needed, potentially incorporating a LAMA+LABA combination as recommended by 5.
• Further diagnostic testing, such as bronchial provocation tests or pulmonary function tests, may be necessary to determine the underlying cause of the patient's symptoms, as suggested by 6 and 7.