What is the best course of action for a patient with shortness of breath (SOB), wheezing, and dry cough for 3 days, currently on Advair (fluticasone-salmeterol) and Albuterol (salbutamol)?

From the Guidelines

The best course of action for a patient experiencing shortness of breath, wheezing, and dry cough for 3 days while already on Advair and Albuterol is to seek medical attention promptly, as these symptoms suggest an asthma exacerbation that isn't being adequately controlled by current medications. In the meantime, the patient should use their Albuterol rescue inhaler as prescribed (typically 2 puffs every 4-6 hours as needed) and continue their regular Advair dosing 1. If symptoms are severe (marked difficulty breathing, inability to speak in full sentences, or bluish lips), emergency care should be sought immediately. Upon medical evaluation, the provider may prescribe a short course of oral corticosteroids such as prednisone (typically 40-60mg daily for 5-7 days) to reduce airway inflammation 1. The healthcare provider might also temporarily increase the frequency of Albuterol use or add a nebulizer treatment. These interventions work by addressing the underlying inflammation causing airway narrowing and by relaxing the bronchial smooth muscles to improve airflow. Following the acute episode, the patient's maintenance therapy with Advair may need adjustment in dosage or frequency, or an additional controller medication might be added to prevent future exacerbations, considering the latest guidelines for asthma management 1.

Some key considerations for managing asthma exacerbations include:

• Ensuring adherence to the current treatment plan and assessing the need for adjustments 1
• Considering the addition of other long-term control medications to inhaled corticosteroids, such as long-acting beta2-agonists or leukotriene modifiers 1
• Evaluating the patient's response to treatment and adjusting the plan as needed to achieve optimal control 1
• Discussing the treatment options with the patient and involving them in the decision-making process to ensure the best choice for their individual needs 1

From the FDA Drug Label

The use of strong cytochrome P450 3A4 (CYP3A4) inhibitors (e.g., ritonavir, atazanavir, clarithromycin, indinavir, itraconazole, nefazodone, nelfinavir, saquinavir, ketoconazole, telithromycin) with AIRDUO RESPICLICK is not recommended because increased systemic corticosteroid and increased cardiovascular adverse effects may occur [see Drug Interactions (7.1) and Clinical Pharmacology (12.3)].

1. 9 Paradoxical Bronchospasm and Upper Airway Symptoms As with other inhaled medicines, AIRDUO RESPICLICK can produce paradoxical bronchospasm, which may be life‑threatening If paradoxical bronchospasm occurs following dosing with inhaled fluticasone propionate/salmeterol medicines, it should be treated immediately with an inhaled, short-acting bronchodilator; inhaled fluticasone propionate/salmeterol medicines should be discontinued immediately; and alternative therapy should be instituted

The patient is experiencing shortness of breath (SOB), wheezing, and dry cough for 3 days while on Advair (fluticasone-salmeterol) and Albuterol (salbutamol).

• The patient should continue to use Albuterol as needed for acute symptoms.
• The patient should be monitored for any signs of paradoxical bronchospasm and upper airway symptoms.
• Consider alternative therapy if symptoms persist or worsen 2.
• No changes to the current medication regimen can be recommended based on the provided information.

From the Research

Patient Presentation

The patient presents with shortness of breath (SOB), wheezing, and dry cough for 3 days, and is currently on Advair (fluticasone-salmeterol) and Albuterol (salbutamol).

Current Treatment

• The patient is already on Advair, which is a combination of fluticasone propionate and salmeterol, as seen in studies 3, 4, 5, 6.
• Albuterol is being used as a rescue medication.

Treatment Efficacy

• A study comparing fluticasone propionate/salmeterol (FSC) with ipratropium bromide/albuterol (IB/ALB) in patients with COPD found that FSC increased FEV(1)AUC(0-6h) significantly in both reversible and non-reversible patients 3.
• Another study comparing FSC with budesonide/formoterol in patients with asthma found that FSC had a lower odds ratio for exacerbations requiring oral steroids, although it did not reach statistical significance 4.
• A study comparing generic and brand-name fluticasone-salmeterol found that they had similar effectiveness and safety outcomes in patients with COPD 5.
• A meta-analysis of studies on the efficacy and safety of FSC compared to fluticasone propionate monotherapy in children with asthma found that FSC was associated with a greater reduction in asthma exacerbations 6.

Potential Next Steps

• Consider adjusting the dose of Advair or adding another medication to the treatment regimen if the patient's symptoms are not well-controlled.
• Monitor the patient's lung function and symptoms closely to determine the effectiveness of the current treatment.
• Consider switching to a generic version of fluticasone-salmeterol if cost is a concern, as studies have shown similar effectiveness and safety outcomes 5.

Key Considerations

• The patient's reversibility status may not be predictive of the magnitude of reduction in symptom scores, as seen in study 3.
• The use of FSC has been shown to be effective in reducing asthma exacerbations in both adults and children, as seen in studies 3, 4, 6.
• The safety profile of FSC is similar to that of other treatments, with no significant differences in adverse events observed in studies 4, 5, 6.