Management of Worsening Asthma Despite Current Treatment
For a patient with worsening asthma symptoms despite treatment with albuterol and fluticasone, the next step should be adding a long-acting beta2-agonist (LABA) such as salmeterol to the treatment regimen, preferably as a combination inhaler with fluticasone. 1
Assessment of Current Control
Before escalating therapy, quickly assess:
- Medication adherence and inhaler technique
- Frequency of rescue inhaler (albuterol) use - using more than twice weekly indicates inadequate control
- Severity of symptoms (nighttime awakenings, activity limitations)
- Peak expiratory flow measurements compared to the patient's baseline
Treatment Escalation Algorithm
Step 1: Add a Long-Acting Beta2-Agonist (LABA)
- Combine fluticasone with salmeterol in a single inhaler (preferred approach)
- This combination is more effective than increasing the dose of fluticasone alone 1, 2
- Clinical trials have shown that patients treated with fluticasone/salmeterol have significantly greater improvements in FEV1 compared to either medication alone 2
- Patients on combination therapy have fewer withdrawals due to worsening asthma (1% vs 11% on fluticasone alone) 2
Step 2: If symptoms persist after adding LABA
- Increase the dose of inhaled corticosteroid (fluticasone) to medium-dose range while continuing LABA 1
- Consider adding a leukotriene modifier (e.g., montelukast) or theophylline to the current regimen 1
Step 3: For continued symptoms despite Step 2
- Increase to high-dose inhaled corticosteroid plus LABA
- Consider adding oral corticosteroids (e.g., prednisone)
- Referral to a specialist is strongly recommended at this point 1
Important Safety Considerations
- Never use LABAs as monotherapy - they must always be combined with inhaled corticosteroids due to safety concerns 1
- Monitor for potential side effects of increased corticosteroid dosing
- Preclinical studies have shown cardiac arrhythmias and sudden death when beta-agonists and methylxanthines are administered concurrently 2
Follow-up Recommendations
- Schedule follow-up within 1-4 weeks after initiating step-up therapy to assess symptom control 1
- Consider hospital referral for patients with:
- Life-threatening features
- Features of severe attack that persist after initial treatment
- Peak expiratory flow <33% of predicted after nebulization 3
Evidence Supporting This Approach
The combination of fluticasone and salmeterol has been shown to be significantly more effective than either agent alone in multiple clinical trials. In one study, patients treated with fluticasone/salmeterol had greater increases in morning peak expiratory flow (66.5 L/min) compared to fluticasone alone (43.0 L/min) 4. Another study demonstrated that patients on combination therapy had only a 2% withdrawal rate due to worsening asthma compared to 25% for salmeterol alone 5.
The simplified strategy using a combination inhaler for both maintenance and relief therapy has been shown to be feasible, safe, and at least as effective as separate inhalers 6.
Remember that this treatment escalation approach is designed to improve mortality and morbidity outcomes by achieving better asthma control and preventing severe exacerbations that could lead to hospitalization or death.