What is the recommended treatment for cough variant asthma after an upper respiratory infection (URI), specifically regarding the use of fluticasone (Flovent) inhaler?

Treatment of Cough Variant Asthma After URI with Fluticasone

For cough variant asthma following an upper respiratory infection, inhaled corticosteroids such as fluticasone (Flovent) should be used as first-line treatment, with a typical starting dose of 100-250 mcg twice daily for adults.

Understanding Cough Variant Asthma Post-URI

Cough variant asthma (CVA) is characterized by chronic cough as the predominant or sole symptom, with underlying airway hyperresponsiveness. Upper respiratory infections (URIs) are common triggers for CVA, as they can induce temporary bronchial hyperresponsiveness that persists after other URI symptoms have resolved.

Treatment Algorithm

First-Line Treatment:

• Inhaled corticosteroids (ICS): Fluticasone propionate (Flovent)
  • Starting dose: 100-250 mcg twice daily 1
  • Duration: Complete resolution may require up to 8 weeks of treatment 1

If response is incomplete after 2-4 weeks:

1. Step-up options:
   • Increase fluticasone dose 1
   • Add a leukotriene receptor antagonist (e.g., montelukast) 1
   • Consider short-term oral corticosteroids for severe symptoms (prednisone 40 mg daily for 5-10 days) 1

Monitoring and Follow-up:

• Assess response after 2-4 weeks
• If cough persists despite treatment, consider:
  • Checking inhaler technique
  • Evaluating for steroid-induced cough (may need to switch ICS formulation) 1
  • Assessing for other causes (e.g., GERD, upper airway disease) 1

Evidence for Fluticasone in CVA

Fluticasone is particularly effective for CVA because:

1. Anti-inflammatory effects: Reduces eosinophilic airway inflammation associated with CVA 2
2. Early intervention benefit: Early treatment with ICS may prevent progression to classic asthma with wheezing 3
3. Demonstrated efficacy: Studies show significant improvement in cough symptoms, pulmonary function, and airway inflammation 2

Important Considerations

• Potential for inhaler-induced cough: Some patients may experience cough from the inhaler itself, particularly with certain formulations. If this occurs, consider switching to a different ICS preparation 1

• Duration of therapy: Maintenance therapy is important as discontinuation can lead to symptom recurrence. Studies show that stopping anti-inflammatory therapy may not be advisable in patients with CVA 2

• Combination therapy: For patients with inadequate response to ICS alone, the combination of fluticasone with a long-acting beta-agonist (salmeterol) provides further improvements in cough symptoms, pulmonary function, and airway inflammation 2

• Safety profile: Long-term use of fluticasone at appropriate doses (100-200 mcg/day) has been shown to be safe in studies, with minimal side effects 4

By following this treatment approach with fluticasone as the cornerstone therapy, most patients with cough variant asthma following URI should experience significant improvement in symptoms and reduced risk of progression to classic asthma.