What is the recommended continuation of management for a patient with moderate persistent asthma and impaired lung function not fully responding to medium-dose inhaled corticosteroids and albuterol (salbutamol)?

From the Guidelines

For a patient with moderate persistent asthma not responding adequately to medium-dose inhaled corticosteroids (ICS) and albuterol, the recommended approach is to step up therapy by adding a long-acting beta-agonist (LABA) to the current ICS regimen, as supported by the most recent and highest quality study 1. This is typically done by switching to a combination inhaler such as fluticasone/salmeterol (Advair), budesonide/formoterol (Symbicort), or mometasone/formoterol (Dulera). The patient should continue using the combination inhaler as maintenance therapy (typically twice daily) while keeping albuterol as a rescue medication for breakthrough symptoms. If this step-up doesn't provide adequate control within 2-4 weeks, consider increasing to high-dose ICS/LABA combination. Additionally, adding a long-acting muscarinic antagonist (LAMA) such as tiotropium (Spiriva Respimat, 2.5 mcg, two inhalations once daily) can provide further bronchodilation, as suggested by previous studies 1. This stepped approach targets both airway inflammation (with ICS) and bronchoconstriction (with LABA/LAMA) through different mechanisms. The patient should also be assessed for proper inhaler technique, medication adherence, environmental triggers, and comorbidities like allergic rhinitis or GERD that might be contributing to poor asthma control, as emphasized in various guidelines 1. Regular follow-up every 1-3 months is essential until asthma control improves. Key considerations include the importance of inhaled corticosteroids as the most potent and consistently effective long-term control medication for asthma 1, and the role of LABAs in providing long-term control of symptoms when added to inhaled corticosteroid therapy 1. The use of oral systemic corticosteroids may be necessary for moderate to severe asthma exacerbations, but high doses of inhaled corticosteroids are preferable due to fewer systemic effects 1. Overall, the management strategy should prioritize the patient's quality of life, morbidity, and mortality outcomes, with a focus on achieving and maintaining asthma control through a stepped approach to therapy.

From the Research

Asthma Management

The patient in question has moderate persistent asthma with impaired lung function, not fully responding to medium-dose inhaled corticosteroids and albuterol. Based on the provided evidence, the recommended continuation of management is as follows:

• The use of oral corticosteroids, such as prednisone, is a common approach for managing acute asthma exacerbations 2.
• However, the overuse of oral corticosteroids and underuse of inhaled corticosteroids is a concern, and optimizing inhaler therapy may reduce the need for oral corticosteroids 3.
• Inhaled corticosteroids are the preferred long-term maintenance drug therapy for mild persistent asthma and are essential for optimal management of moderate and severe persistent asthma 4.
• The early use of inhaled corticosteroids in the emergency department treatment of acute asthma may be beneficial in reducing hospital admissions and improving lung function 2.

Treatment Options

The following treatment options are considered:

• Oral prednisone 40 to 60 mg daily for 5 to 7 days: This is a common approach for managing acute asthma exacerbations, but the overuse of oral corticosteroids is a concern 3.
• Doubling the dose of the inhaled corticosteroid: This may be considered, but the evidence suggests that optimizing inhaler therapy and ensuring proper inhaler technique is crucial before increasing the dose 3.
• Use of albuterol inhaler every 3 to 4 hours for 5 to 7 days: This is a common approach for managing acute asthma symptoms, but the patient's response to treatment should be closely monitored 2.
• Antibiotic therapy: There is no evidence to suggest that antibiotic therapy is necessary in this case, as the patient's symptoms are consistent with an asthma exacerbation rather than a bacterial infection.

Key Considerations

• Inhaler technique and adherence: Ensuring proper inhaler technique and adherence to inhaled corticosteroid therapy is crucial for optimal management of asthma 4, 3.
• Monitoring and follow-up: Close monitoring of the patient's response to treatment and follow-up appointments are necessary to adjust the treatment plan as needed 2.