For an 18-year-old patient with persistent cough needing albuterol more frequently, should an oral steroid or inhaled steroid be added next?

Treatment for 18-Year-Old with Persistent Cough Requiring Frequent Albuterol

For an 18-year-old with persistent cough requiring increasingly frequent albuterol use, inhaled corticosteroids should be added as the next best treatment option rather than oral steroids. 1

Rationale for Inhaled Corticosteroids as First-Line

The American College of Chest Physicians (ACCP) guidelines clearly recommend that patients with cough due to asthma should initially be treated with a standard antiasthmatic regimen of inhaled bronchodilators and inhaled corticosteroids (Grade A recommendation with substantial net benefit) 1. This approach provides effective control while minimizing systemic side effects.

Treatment Algorithm:

1. Initial therapy: Add inhaled corticosteroid to current albuterol regimen

   • Complete resolution of cough may require up to 8 weeks of treatment with inhaled corticosteroids 1
   • Partial improvement is often achieved after 1 week of inhaled bronchodilator therapy

2. If inadequate response after 2-4 weeks:

   • Check inhaler technique
   • Assess compliance
   • Consider increasing inhaled corticosteroid dose

3. For severe or refractory cough:

   • Consider short course of oral steroids (prednisone 40 mg daily for 1 week) 1
   • Follow with maintenance inhaled corticosteroid therapy

Potential Pitfalls and Considerations

When using inhaled corticosteroids:

• Some inhaled steroids may actually induce or exacerbate cough due to components in the aerosol 1
• If cough worsens with inhaled steroids, consider:
  • Switching to a different inhaled steroid formulation (e.g., triamcinolone acetonide instead of beclomethasone dipropionate)
  • Checking proper inhaler technique
  • Evaluating for other etiologies like gastroesophageal reflux disease

When to consider oral steroids:

• Reserve for cough that is severe or only partially responsive to inhaled corticosteroids 1
• Should not be first-line therapy due to potential systemic side effects
• Can be used as a diagnostic trial (prednisone 30 mg daily for 1-2 weeks) to confirm cough variant asthma 2

Evidence Supporting This Approach

Research shows that inhaled corticosteroid therapy after a diagnostic trial of oral steroids is effective for long-term control of cough variant asthma 2. In a study with a mean follow-up period of 28 months, patients with cough variant asthma remained free of debilitating cough with maintenance inhaled steroid therapy 2.

The British Thoracic Society guidelines also support that for chronic persistent asthma, regular nebulized bronchodilator treatment should only be undertaken after formal evaluation of its benefit and where treatment with a hand-held inhaler at appropriate doses has failed 1.

Special Considerations for This 18-Year-Old Patient

• The increasing need for albuterol suggests inadequate control of underlying inflammation
• Adding an inhaled corticosteroid addresses the inflammatory component while minimizing systemic side effects
• Regular use of inhaled corticosteroids can help prevent the development of bronchodilator subsensitivity that can occur with frequent albuterol use 3
• If the patient shows features of more severe disease (cannot complete sentences, respiratory rate >25/min, heart rate >110/min, PEF <50% best), then oral steroids would be appropriate in addition to inhaled therapy 1

By starting with inhaled corticosteroids, you provide effective anti-inflammatory treatment while avoiding the potential adverse effects of systemic steroids, which should be reserved for more severe presentations or when inhaled therapy fails.