What is the best addition to the treatment regimen for a 12-year-old male with mild persistent asthma, low-grade fever, runny nose, cough, and yellowish phlegm, currently using Symbicort (budesonide/formoterol) and albuterol?

From the Guidelines

The best addition to this 12-year-old's treatment regimen is not a long-acting macrolide agent or increasing the budesonide frequency, but rather continuing the current Symbicort and albuterol regimen while considering a 5-7 day course of an appropriate antibiotic such as azithromycin, as the yellowish phlegm combined with fever and respiratory symptoms suggests a bacterial respiratory infection, likely secondary to an initial viral upper respiratory infection, as suggested by 1. The patient's current symptoms, including low-grade fever, runny nose, cough, and yellowish phlegm, are indicative of a respiratory infection, which can exacerbate asthma symptoms.

• The patient's peak flow of 300 L per minute, which is 73% of their personal best, indicates that their asthma is not well-controlled, and they may require additional treatment to manage their symptoms.
• Increasing the frequency of budesonide to every four hours up to 10 times a day may not be necessary, as the patient is already using Symbicort, which contains budesonide, and increasing the dose may not provide additional benefits, as noted in 1.
• Adding a long-acting macrolide agent may not be the best option, as the patient's symptoms are more indicative of a bacterial respiratory infection, which would require targeted antibiotic treatment, as suggested by 1.
• A 7-day course of Zithromax (azithromycin) may be considered, as it is an appropriate antibiotic for treating bacterial respiratory infections, and the patient's symptoms suggest a bacterial infection, as noted in 1. The patient should continue to use their Symbicort and albuterol as prescribed, and their parents should monitor their symptoms closely, watching for signs of worsening asthma, such as increased wheezing, shortness of breath, or decreased response to albuterol, as respiratory infections can trigger exacerbations in asthmatic children, as suggested by 1.

From the FDA Drug Label

The efficacy of SINGULAIR in pediatric patients 6 to 14 years of age was demonstrated in one 8-week, double-blind, placebo-controlled trial in 336 patients (201 treated with SINGULAIR and 135 treated with placebo) using an inhaled β-agonist on an “as-needed” basis SINGULAIR, one 5-mg chewable tablet daily at bedtime, significantly decreased the percent of days asthma exacerbations occurred (SINGULAIR 20.6% vs placebo 25.7%, p≤0. 05). Separate trials in adults evaluated the ability of SINGULAIR to add to the clinical effect of inhaled corticosteroids and to allow inhaled corticosteroid tapering when used concomitantly

The best addition to the treatment regimen for a 12-year-old male with mild persistent asthma, low-grade fever, runny nose, cough, and yellowish phlegm, currently using Symbicort (budesonide/formoterol) and albuterol, would be to add a leukotriene receptor antagonist, such as montelukast (SINGULAIR), to the existing treatment regimen. This is because montelukast has been shown to be effective in reducing asthma exacerbations and improving symptoms in pediatric patients with asthma, including those already using inhaled corticosteroids 2.

• Key benefits of adding montelukast:
  • Reduces asthma exacerbations
  • Improves symptoms
  • Can be used concomitantly with inhaled corticosteroids
• Recommended dosage: one 5-mg chewable tablet daily at bedtime 2

From the Research

Treatment Options for Mild Persistent Asthma

The patient is currently using Symbicort (budesonide/formoterol) and albuterol, and the question is what would be the best addition to the treatment regimen. The options considered are:

• Adding a long-acting muscarinic agent
• Increasing the budesonide dose and frequency to every four hours up to 10 times a day
• A seven-day course of Zithromax

Analysis of Options

• Adding a long-acting muscarinic agent: There is no direct evidence in the provided studies to support the addition of a long-acting muscarinic agent to the treatment regimen for mild persistent asthma.
• Increasing the budesonide dose and frequency: Studies have shown that the use of budesonide/formoterol in a single inhaler can be effective for maintenance and reliever therapy 3, 4. However, increasing the dose and frequency of budesonide may not be necessary, as the patient is already using Symbicort.
• A seven-day course of Zithromax: There is no evidence in the provided studies to support the use of Zithromax for the treatment of mild persistent asthma.

Recommended Approach

Based on the available evidence, the recommended approach would be to continue the current treatment regimen with Symbicort and albuterol, and consider adjusting the dose or frequency of Symbicort as needed to control symptoms 3, 5. The use of a single inhaler for both maintenance and reliever therapy has been shown to be effective in reducing exacerbations and improving asthma control 3, 4.

Key Considerations

• The patient's peak flow is 300 L per minute, which is 73% of their personal best, indicating some degree of airway obstruction.
• The patient is already using a combination inhaler (Symbicort) that contains a long-acting beta2-agonist (formoterol) and an inhaled corticosteroid (budesonide).
• The evidence suggests that the use of a single inhaler for both maintenance and reliever therapy can be effective in reducing exacerbations and improving asthma control 3, 4.

Some key points to consider when making a decision:

• The patient's symptoms and peak flow should be closely monitored to determine the effectiveness of the current treatment regimen.
• Adjustments to the dose or frequency of Symbicort may be necessary to control symptoms and prevent exacerbations.
• The use of a single inhaler for both maintenance and reliever therapy can simplify treatment and improve adherence.