What is the preferred treatment for a 14-year-old patient with a history of episodic wheezing, currently using albuterol (short-acting beta-agonist) as needed, who experiences nighttime wheezing and has required urgent care visits and short courses of oral corticosteroids?

From the Guidelines

The preferred treatment for this 14-year-old patient with persistent asthma is to add a daily low-dose inhaled corticosteroid (ICS) such as fluticasone (44-110 mcg twice daily), budesonide (180-360 mcg twice daily), or beclomethasone (40-80 mcg twice daily) while continuing albuterol as needed for rescue therapy. The patient should be instructed to use proper inhaler technique and may benefit from a spacer device. The nighttime symptoms, need for urgent care visits, and requirement for oral corticosteroids indicate that the patient's asthma is not well-controlled with as-needed albuterol alone and has progressed beyond mild intermittent asthma. Daily controller medication is necessary to reduce airway inflammation, prevent exacerbations, and improve quality of life. Inhaled corticosteroids work by reducing inflammation in the airways, decreasing bronchial hyperresponsiveness, and preventing asthma symptoms 1.

Key Considerations

• The patient's symptoms and history of urgent care visits and oral corticosteroid use suggest a need for daily controller medication to manage persistent asthma.
• Inhaled corticosteroids are the preferred long-term control medication for asthma, as they reduce airway inflammation and prevent symptoms 1.
• The patient should be educated about asthma triggers, develop an asthma action plan, and receive annual influenza vaccination to prevent exacerbations.
• Follow-up in 4-6 weeks is necessary to assess response to therapy and consider step-up therapy if symptoms persist.

Treatment Options

• Low-dose inhaled corticosteroid (ICS) such as fluticasone, budesonide, or beclomethasone
• Continue albuterol as needed for rescue therapy
• Consider adding a long-acting beta-agonist (LABA) if symptoms persist despite ICS therapy 1
• Educate the patient on proper inhaler technique and consider a spacer device to improve medication delivery.

From the FDA Drug Label

Use of background ICS was not required in SMART. The increased risk of asthma-related death is considered a class effect of LABA monotherapy. 5. 2 Deterioration of Disease and Acute Episodes Wixela Inhub® should not be initiated in patients during rapidly deteriorating or potentially life-threatening episodes of asthma or COPD. Increasing use of inhaled, short-acting beta2-agonists is a marker of deteriorating asthma. In this situation, the patient requires immediate reevaluation with reassessment of the treatment regimen, giving special consideration to the possible need for replacing the current strength of Wixela Inhub with a higher strength, adding additional ICS, or initiating systemic corticosteroids.

The preferred treatment for this patient is to add a low-dose inhaled corticosteroid for daily use along with an as-needed short-acting beta-agonist. This approach is supported by the need to reassess the treatment regimen in patients with deteriorating asthma, considering the addition of ICS to reduce inflammation and prevent further exacerbations 2.

From the Research

Treatment Options for Asthma

The patient's history of episodic wheezing, nighttime wheezing, and requirement for urgent care visits and short courses of oral corticosteroids indicates a need for a more comprehensive treatment plan. The current management with albuterol as needed may not be sufficient to control the patient's symptoms.

Preferred Treatment

Based on the evidence, the preferred treatment for this patient would be to:

• Add a low-dose inhaled corticosteroid for daily use along with an as-needed short-acting beta-agonist 3, 4, 5, 6
• Consider adding a long-acting beta-agonist to the treatment plan if the patient's symptoms are not well-controlled on inhaled corticosteroids alone 3, 4, 6
• Use a combination inhaler containing an inhaled corticosteroid and a long-acting beta-agonist, or an inhaled corticosteroid and a short-acting beta-agonist, as an anti-inflammatory reliever therapy 5, 7

Key Points to Consider

• Inhaled corticosteroids are effective in reducing the risk of asthma exacerbations and improving lung function 3, 4, 5, 6
• Long-acting beta-agonists can be added to inhaled corticosteroids to improve symptom control and reduce the risk of exacerbations 3, 4, 6
• Anti-inflammatory reliever therapy, such as budesonide/formoterol or budesonide/albuterol, can be used to reduce exacerbations and improve symptom control 5, 7
• Treatment should be tailored to the individual patient's needs and preferences 4, 7