What pharmacologic management should be added for a 10-year-old boy with persistent intermittent asthma, who uses a short-acting Beta (β)-agonist inhaler, and has normotension and clear lungs?

From the Guidelines

The recommended pharmacologic management for this 10-year-old boy with asthma should include an inhaled corticosteroid (option A). This patient has demonstrated a pattern of increasing reliance on his short-acting β2-agonist inhaler, from twice monthly to three times weekly, indicating that his asthma is progressing from intermittent to persistent. According to asthma management guidelines, when a patient requires rescue medication more than twice weekly, it's appropriate to add a daily controller medication 1. Inhaled corticosteroids are the preferred first-line controller therapy for persistent asthma because they effectively reduce airway inflammation, decrease bronchial hyperresponsiveness, and prevent exacerbations. They work by suppressing inflammatory cell recruitment and activation, reducing cytokine production, and inhibiting inflammatory mediator release.

Some key points to consider in the management of this patient's asthma include:

• The importance of daily controller medication to achieve and maintain control of persistent asthma 1
• The role of inhaled corticosteroids in reducing airway inflammation and preventing exacerbations 1
• The need for regular follow-up appointments to monitor response to therapy and adjust the treatment plan as needed 1
• The potential benefits and risks of other medications, such as leukotriene receptor antagonists and long-acting β2-agonists, which may be considered as alternative or adjunctive therapies 1

In terms of specific medication options, inhaled corticosteroids such as fluticasone, budesonide, and beclomethasone are commonly used and effective treatments for persistent asthma 1. The medication should be taken daily as prescribed, even when symptoms are not present, while continuing the short-acting β2-agonist as needed for breakthrough symptoms.

It's also important to note that the patient's response to therapy should be monitored carefully, and adjustments to the treatment plan should be made as needed 1. This may involve stepping up or stepping down therapy, or considering alternative medications or treatment approaches. By working closely with the patient and their family, and by following established guidelines and evidence-based recommendations, it's possible to develop an effective treatment plan that improves symptoms, reduces exacerbations, and enhances overall quality of life 1.

From the Research

Asthma Management

The patient's asthma management should include a pharmacologic approach to control symptoms and prevent exacerbations. Based on the provided evidence, the following options are considered:

• Inhaled Corticosteroid: This is a recommended treatment for asthma, as it reduces inflammation and improves lung function 2, 3, 4. Inhaled corticosteroids are the most potent and effective therapy for treating asthma, and they are recommended as the first-line treatment for patients with persistent asthma.
• Leukotriene Receptor Antagonist: This can be used as an add-on therapy to inhaled corticosteroids for patients whose asthma is not controlled by inhaled corticosteroids alone 5. However, the evidence suggests that the combination of inhaled corticosteroids and long-acting beta2-agonists is more effective in achieving asthma control.
• Long-Acting Beta2-Agonist: This can be used in combination with inhaled corticosteroids to improve lung function and reduce symptoms 5, 3, 4. The combination of inhaled corticosteroids and long-acting beta2-agonists is effective in achieving asthma control and is recommended for patients with moderate to severe asthma.
• Mast Cell Stabilizer: There is no evidence to support the use of mast cell stabilizers as a first-line treatment for asthma.
• Methylxanthine: There is no evidence to support the use of methylxanthines as a first-line treatment for asthma.

Recommended Treatment

Based on the evidence, the recommended treatment for this patient would be to add an inhaled corticosteroid to their current treatment regimen, as they are already using a short-acting beta2-agonist inhaler 2, 3, 4. This will help to reduce inflammation and improve lung function, and is a recommended treatment for patients with persistent asthma. If the patient's asthma is not controlled with inhaled corticosteroids alone, a long-acting beta2-agonist can be added to the treatment regimen 5, 3, 4.