Asthma Treatment Plan Adjustment for Lilly Madison
Lilly's asthma treatment should be stepped up to medium-dose ICS plus LABA combination therapy due to her not well-controlled asthma symptoms and recent exacerbations. 1
Assessment of Current Control Status
Lilly's asthma is currently not well-controlled based on the following criteria:
- Using albuterol 3-4 days/week over past 2 months, increasing to daily use in the past week
- Nighttime awakening once weekly
- Morning peak flows at 75% of personal best (300 L/min vs. 400 L/min)
- Recent hospitalization and ED visit requiring oral corticosteroids
- Symptoms with exposure to triggers (father's workshop) and with exercise
- Oral thrush present, indicating possible issues with inhaler technique
Treatment Recommendations
Step 1: Adjust Controller Medication
- Increase from low-dose fluticasone to medium-dose ICS plus LABA combination therapy (fluticasone/salmeterol) 1, 2
- Recommended dose: Fluticasone/salmeterol 250/50 mcg, 1 inhalation twice daily 3
- Discontinue separate fluticasone MDI once combination therapy is started
Step 2: Address Inhaler Technique
- Evaluate and correct inhaler technique to prevent recurrence of oral thrush
- Instruct Lilly to rinse her mouth after each use of inhaled corticosteroid 3
- Consider using a spacer device with her MDI to improve medication delivery 1
Step 3: Environmental Control Measures
- Minimize exposure to triggers in father's workshop (wood dust)
- Recommend wearing an N95 mask if she must visit the workshop
- Consider allergen testing to identify other potential triggers (including cat dander) 1
Step 4: Medication Adjustment
- Discontinue propranolol for migraine prophylaxis as beta-blockers can worsen asthma symptoms
- Consult with neurologist for alternative migraine prophylaxis options
Step 5: Create Written Asthma Action Plan
- Provide a clear written asthma action plan with specific instructions for:
- Daily controller medications
- When to use rescue inhaler
- Signs of worsening asthma requiring medical attention
- Peak flow monitoring with specific thresholds for action 4
Monitoring Plan
- Schedule follow-up in 2-4 weeks to assess response to treatment changes 2
- Monitor peak flow measurements daily, with goal of maintaining >80% of personal best
- Track frequency of albuterol use, with goal of reducing to <2 days/week
- Monitor for nighttime symptoms, with goal of elimination
Rationale for Treatment Changes
The EPR-3 guidelines recommend stepping up therapy when asthma is not well-controlled 1. Lilly meets criteria for not well-controlled asthma based on:
- Albuterol use >2 days/week
- Nighttime awakenings 1-3x/week
- Peak flow 60-80% of personal best
- Recent exacerbations requiring oral corticosteroids
The combination of ICS plus LABA is more effective than increasing the dose of ICS alone for patients with moderate persistent asthma 2. The presence of oral thrush indicates either poor inhaler technique or excessive ICS dose, which needs to be addressed through proper technique education.
Common Pitfalls to Avoid
Continuing beta-blocker therapy: Propranolol can worsen asthma symptoms and should be discontinued with appropriate alternative migraine therapy.
Inadequate environmental control: Failure to address occupational exposures (wood dust in father's workshop) can lead to persistent symptoms despite medication adjustments.
Poor inhaler technique: The presence of oral thrush suggests improper technique. Ensure Lilly rinses her mouth after each use of inhaled corticosteroids.
Inadequate follow-up: Close monitoring is essential after stepping up therapy to ensure improvement and adjust as needed.
Overlooking comorbidities: Address potential allergic triggers, including the two cats at home, which may contribute to persistent symptoms.