What is the best treatment approach for an exacerbation of moderate persistent asthma with an upper respiratory tract infection?

From the Guidelines

The best treatment approach for an exacerbation of moderate persistent asthma with an upper respiratory tract infection involves intensifying the asthma medication regimen while addressing the infection. This approach is based on the most recent and highest quality evidence available, which prioritizes the reduction of morbidity, mortality, and improvement of quality of life as outcomes 1.

Key Components of Treatment

• Increase the frequency of short-acting beta-agonist (SABA) use, such as albuterol, to 2-4 puffs every 4-6 hours as needed for symptom relief.
• Add a short course of oral corticosteroids, such as prednisone 40-60mg daily for 5-7 days, to reduce airway inflammation.
• Continue regular controller medications, which typically include an inhaled corticosteroid (ICS) combined with a long-acting beta-agonist (LABA).
• For the upper respiratory infection, recommend adequate hydration, rest, and acetaminophen or NSAIDs for fever or pain.
• Antibiotics are generally not indicated unless there is evidence of bacterial infection.
• Peak flow monitoring should be performed regularly during the exacerbation, with values below 50-60% of personal best indicating severe exacerbation requiring immediate medical attention.

Rationale

This approach works by addressing both the increased airway inflammation triggered by the viral infection and the underlying asthma pathophysiology, preventing further deterioration and promoting faster recovery. The use of oral corticosteroids and continued use of ICS and LABA are supported by guidelines that emphasize the importance of controlling inflammation and preventing exacerbations in asthma management 1.

Considerations

• The choice of treatment should be individualized based on the patient's history, severity of symptoms, and response to previous treatments.
• Regular follow-up and monitoring are crucial to adjust the treatment plan as needed and to prevent future exacerbations.
• Patient education on proper inhaler technique, medication adherence, and recognition of worsening symptoms is essential for effective management of asthma exacerbations.

From the FDA Drug Label

Reduction in asthma symptoms and use of rescue VENTOLIN Inhalation Aerosol and improvement in morning and evening PEF also occurred within the first day of treatment with fluticasone propionate and salmeterol inhalation powder, and continued to improve over the 12 weeks of therapy in both trials. In Trials 4 and 5, fluticasone propionate and salmeterol inhalation powder was non-inferior to fluticasone propionate in terms of time to first serious asthma-related events based on the pre-specified risk margins, with estimated hazard ratios of 1.03 (95% CI: 0.64,1.66) and 1.29 (95% CI: 0.73,2. 27), respectively. Effect on Exacerbation Trials 4 and 5 included time to first exacerbation as a secondary endpoint, where exacerbation was defined as a deterioration of asthma requiring the use of systemic corticosteroids for at least 3 days or an in-patient hospitalization or emergency department visit due to asthma that required systemic corticosteroids. In Trials 4 and 5, the hazard ratio for the time to first asthma exacerbation for fluticasone propionate and salmeterol inhalation powder relative to fluticasone propionate inhalation powder was 0.79 (95% CI: 0.70,0.89) and 0.86 (95% CI: 0.73,1.

The best treatment approach for an exacerbation of moderate persistent asthma with an upper respiratory tract infection is to use fluticasone propionate and salmeterol inhalation powder, as it has been shown to be non-inferior to fluticasone propionate in terms of time to first serious asthma-related events and has a lower hazard ratio for time to first asthma exacerbation. Key points include:

• Reduction in asthma symptoms: Fluticasone propionate and salmeterol inhalation powder reduces asthma symptoms and improves lung function.
• Non-inferiority: Fluticasone propionate and salmeterol inhalation powder is non-inferior to fluticasone propionate in terms of serious asthma-related events.
• Lower exacerbation risk: Fluticasone propionate and salmeterol inhalation powder has a lower hazard ratio for time to first asthma exacerbation compared to fluticasone propionate inhalation powder 2.

From the Research

Treatment Approach

The treatment approach for an exacerbation of moderate persistent asthma with an upper respiratory tract infection involves several options, including:

• The use of systemic corticosteroids, such as prednisolone, to reduce inflammation and improve symptoms 3, 4
• The addition of a leukotriene receptor antagonist, such as pranlukast, to systemic corticosteroids to reduce the cumulative dose of corticosteroids and improve symptoms 3
• The use of combination therapy with inhaled corticosteroids and long-acting beta2-agonists, such as fluticasone propionate and salmeterol, to reduce the frequency and severity of exacerbations 5, 6
• The use of low-dose inhaled corticosteroids, such as fluticasone propionate, as a first-line maintenance therapy for persistent asthma 7

Key Findings

Key findings from the studies include:

• The combination of a leukotriene receptor antagonist and systemic corticosteroids may be more effective than systemic corticosteroids alone in reducing the cumulative dose of corticosteroids and improving symptoms 3
• Combination therapy with inhaled corticosteroids and long-acting beta2-agonists may provide protection against asthma exacerbations temporally associated with upper respiratory tract infections 5
• Low-dose inhaled corticosteroids may be more effective than leukotriene modifiers as a first-line maintenance therapy for persistent asthma 7
• A short high-dose course of corticosteroids may be effective in treating exacerbations of asthma, with a minimum dose of 0.6 mg prednisolone/kg body weight for a period up to two weeks 4

Treatment Considerations

Treatment considerations for an exacerbation of moderate persistent asthma with an upper respiratory tract infection include:

• The need for prompt treatment with systemic corticosteroids to reduce inflammation and improve symptoms
• The potential benefits of adding a leukotriene receptor antagonist to systemic corticosteroids to reduce the cumulative dose of corticosteroids and improve symptoms
• The importance of using combination therapy with inhaled corticosteroids and long-acting beta2-agonists to reduce the frequency and severity of exacerbations
• The need for individualized treatment approaches based on the severity of symptoms and the patient's response to treatment 3, 5, 6, 7, 4