What is the best treatment approach for a patient with mild persistent asthma, a past history of recurrent ocular herpes, and perennial allergic rhinitis?

From the Guidelines

For a patient with mild persistent asthma, recurrent ocular herpes, and perennial allergic rhinitis, the recommended treatment approach would be a low-dose inhaled corticosteroid (ICS) as primary controller therapy for asthma, while avoiding systemic corticosteroids due to the herpes history. A suitable option would be fluticasone propionate 88-110 mcg twice daily or beclomethasone 80-160 mcg twice daily, as supported by the expert panel report 3 (EPR-3) guidelines for the diagnosis and management of asthma 1. A short-acting beta-agonist like albuterol should be prescribed as rescue medication. For the allergic rhinitis, an intranasal corticosteroid such as fluticasone propionate nasal spray 1-2 sprays per nostril daily would be appropriate, along with a second-generation antihistamine like loratadine 10 mg daily or cetirizine 10 mg daily, as suggested by the 2017 joint task force on practice parameters for the pharmacologic treatment of seasonal allergic rhinitis 1. The patient should be advised to avoid known asthma and allergy triggers, maintain good adherence to controller medications, and have regular follow-ups to assess symptom control. This approach targets the underlying airway inflammation in asthma while managing the allergic rhinitis that can exacerbate asthma symptoms. Systemic corticosteroids are avoided because they could potentially trigger herpes recurrence, making the localized delivery of corticosteroids via inhalation and intranasal routes preferable for this patient. Additionally, patient education is essential to provide the best care for the patient with rhinitis, as emphasized in the diagnosis and management of rhinitis guidelines 1. The patient should be educated on the chronicity of rhinitis, the realistic outcome of therapy, and the importance of adherence to treatment, as well as the potential interactions between the upper and lower airways. By following this treatment approach, the patient's asthma and allergic rhinitis symptoms can be effectively managed, while minimizing the risk of herpes recurrence. It is also important to note that leukotriene modifiers, such as montelukast, may be considered as alternative therapy for mild persistent asthma, but are not preferred as first-line treatment 1. However, the most recent and highest quality study 1 supports the use of inhaled corticosteroids as the primary controller therapy for asthma, making it the recommended treatment approach for this patient.

From the FDA Drug Label

The 10-mg film-coated tablet is recommended for use in patients ≥15 years of age The 5-mg chewable tablet should be used in pediatric patients 6 to 14 years of age and the 4-mg chewable tablet should be used in pediatric patients 2 to 5 years of age. The 4-mg oral granule formulation should be used for pediatric patients 12 to 23 months of age for the treatment of asthma, or for pediatric patients 6 to 23 months of age for the treatment of perennial allergic rhinitis

The best treatment approach for a patient with mild persistent asthma, a past history of recurrent ocular herpes, and perennial allergic rhinitis is not directly stated in the provided drug label. However, based on the information provided, montelukast can be used for the treatment of asthma and perennial allergic rhinitis.

• For patients ≥15 years of age, the recommended dose is 10 mg once daily.
• For patients 6 to 14 years of age, the recommended dose is 5 mg once daily.
• For patients 2 to 5 years of age, the recommended dose is 4 mg once daily.
• For patients 12 to 23 months of age, the recommended dose is 4 mg once daily, using the oral granule formulation. However, the label does not provide information on how to manage recurrent ocular herpes in conjunction with montelukast treatment. Therefore, a conservative clinical decision would be to consult additional resources or an expert in the field to determine the best course of treatment for this patient, considering the past history of recurrent ocular herpes 2.

From the Research

Treatment Approach for Mild Persistent Asthma with Recurrent Ocular Herpes and Perennial Allergic Rhinitis

• The treatment of mild persistent asthma can be approached with continuous inhaled corticosteroid treatment, which is highly effective in children and adults 3.
• However, some patients may not adhere to continuous treatment and instead take inhaled corticosteroids intermittently, usually when symptoms increase 3.
• For patients with mild persistent asthma, the use of inhaled corticosteroids on-demand when symptoms are troublesome, rather than on a continuous basis, has been proposed as an alternative treatment approach 3.
• In terms of perennial allergic rhinitis, nasal inhalation of budesonide from a spacer has been shown to be effective in reducing nasal symptoms and improving nasal peak inspiratory flow and oral peak expiratory flow in children 4.
• The addition of montelukast to fluticasone propionate/salmeterol for control of asthma and seasonal allergic rhinitis has been studied, and it was found that adding montelukast provided no additional benefit in asthma control 5.
• Predictors of symptom recurrence after low-dose inhaled corticosteroid cessation in mild persistent asthma include age > 40 years and disease duration > 5 years 6.

Considerations for Recurrent Ocular Herpes

• There is no direct evidence in the provided studies regarding the treatment of mild persistent asthma with a past history of recurrent ocular herpes.
• However, it is essential to consider the potential interactions between asthma treatment and ocular herpes when developing a treatment plan.

Treatment Recommendations

• Based on the available evidence, a treatment approach for mild persistent asthma with perennial allergic rhinitis could include continuous or on-demand inhaled corticosteroid treatment, depending on the patient's adherence and symptom profile 3.
• For perennial allergic rhinitis, nasal inhalation of budesonide from a spacer could be considered as a treatment option 4.
• The treatment plan should be individualized, taking into account the patient's specific needs and medical history, including the history of recurrent ocular herpes.