From the Guidelines
For a 32-year-old patient with moderate persistent asthma experiencing symptoms despite medium-dose inhaled corticosteroids (ICS) and as-needed albuterol, the recommended management is to step up therapy by adding a long-acting beta-agonist (LABA) to the current ICS regimen. This approach is supported by the most recent and highest quality evidence, which suggests that adding a LABA to a low-to-medium dose of ICS is the most effective treatment for moderate persistent asthma 1. The patient's symptoms, including nocturnal cough and decreased peak flow to 80-90% of personal best, indicate suboptimal control and necessitate this step-up approach.
Key Considerations
- The addition of a LABA to the current ICS regimen can be accomplished by switching to a combination inhaler such as fluticasone/salmeterol (Advair), budesonide/formoterol (Symbicort), or mometasone/formoterol (Dulera) 1.
- The patient should continue using albuterol as a rescue medication when needed.
- The treatment plan should include a review of inhaler technique, assessment of adherence, and identification of potential triggers or comorbidities that may be worsening asthma control.
- Adding a LABA provides bronchodilation throughout the day and night while the ICS addresses the underlying inflammation, making this combination therapy more effective than simply increasing the ICS dose alone 1.
Next Steps
- The patient should be reassessed in 2-4 weeks to evaluate response to the adjusted therapy.
- Instructions should be given to seek medical attention if symptoms worsen or fail to improve.
- Consideration should be given to consulting an asthma specialist if the patient's symptoms persist or worsen despite the step-up in therapy 1.
From the Research
Management of Moderate Persistent Asthma
The patient in question has moderate persistent asthma, currently managed with medium dose Inhaled Corticosteroids (ICS) and Albuterol as needed. Given the symptoms, including nocturnal cough and decreased peak flow to 80-90% of personal best, the following management options are recommended:
- Addition of a Long-Acting Beta-Agonist (LABA): Studies have shown that adding a LABA to ICS is preferred in patients with moderate persistent asthma, as it provides better asthma control and reduces exacerbation risks 2.
- Combination of ICS and LABA in a Single Inhaler: Using a combination product, such as budesonide/formoterol or fluticasone/salmeterol, is preferred for convenience and avoids the risk of LABA monotherapy 2, 3.
- Single-Inhaler Combination Therapy for Maintenance and Relief: The budesonide/formoterol combination can be used for both maintenance and reliever components of asthma treatment, which has been shown to improve asthma outcomes and reduce treatment costs 3.
- Assessment of Treatment Outcomes: Treatment outcomes, including lung function, symptom-free days, use of rescue medications, and asthma exacerbations, should be regularly assessed to determine the effectiveness of the treatment regimen 4, 5.
Key Considerations
- The combination of ICS and LABA has been shown to be more effective than doubling or quadrupling the dose of ICS alone in achieving better asthma control and reducing exacerbation risks 2.
- Formoterol has been shown to have a rapid onset of bronchodilator effect and can be used for both maintenance and reliever components of asthma treatment 6.
- The choice of ICS and LABA should be based on individual patient needs and response to treatment, as well as consideration of potential side effects and tolerability profiles 5.