What is the best course of treatment for a patient with poorly controlled asthma, presenting with persistent wheezing, coughing up mucus, and worsening symptoms over the past month?

Management of Poorly Controlled Asthma

For this patient with very poorly controlled asthma, I recommend initiating a short course of oral prednisone immediately, followed by stepping up to a combination inhaled corticosteroid-long acting beta agonist (ICS-LABA) therapy, with consideration of adding a long-acting muscarinic antagonist if symptoms persist. 1, 2

Assessment of Asthma Control

This patient presents with clear signs of very poorly controlled asthma:

• Wheezing throughout the day, worse in morning and at night
• Symptoms worsening with physical activity
• Productive cough with mucus
• Progressive worsening over a month
• Symptoms not responding to current treatment

Based on the EPR-3 guidelines, these symptoms classify as "very poorly controlled" asthma with:

• Symptoms throughout the day
• Frequent nighttime awakenings
• Limitation of activities
• Need for rescue medication several times daily 1

Immediate Management

1. Short course of oral prednisone (as you've planned)

   • Typically 40-60mg daily for 5-7 days
   • No need to taper for short courses less than 10 days

2. Chest X-ray and spirometry (as you've planned)

   • Essential to rule out complications like pneumonia
   • Spirometry will help assess severity and response to treatment

Step-Up Therapy Approach

After the acute exacerbation is controlled with prednisone, implement a step-up in controller therapy:

1. If patient is currently on low-dose ICS:

   • Step up to medium-to-high dose ICS plus LABA combination therapy
   • Options include fluticasone/salmeterol (Wixela Inhub) 3

2. If patient is already on ICS-LABA combination:

   • Increase to higher dose ICS-LABA
   • Consider adding a long-acting muscarinic antagonist (LAMA)

3. For ongoing relief:

   • Short-acting beta-agonist (SABA) as needed for breakthrough symptoms
   • Consider switching to single maintenance and reliever therapy (SMART) with budesonide-formoterol for both maintenance and as-needed relief 4

Follow-Up Plan

1. Short-term follow-up (1-2 weeks):

   • Assess response to prednisone and stepped-up therapy
   • Review spirometry results
   • Confirm proper inhaler technique

2. Medium-term follow-up (4-6 weeks):

   • Assess control using validated tools (ACT or ACQ)
   • Adjust therapy based on control level
   • Consider referral to specialist if still poorly controlled

Addressing Contributing Factors

1. Identify and address triggers:

   • Environmental allergens
   • Occupational exposures
   • Respiratory infections

2. Manage comorbidities that may worsen asthma:

   • Gastroesophageal reflux disease
   • Chronic sinusitis
   • Obesity
   • Anxiety/depression

Important Considerations

• Do not initiate immunotherapy if asthma remains uncontrolled, as this increases risk of severe reactions 1

• Assess adherence to current medications before assuming treatment failure

• Check inhaler technique as improper use is a common cause of treatment failure

• Consider referral to an asthma specialist if the patient:

  • Required ≥2 bursts of oral corticosteroids in the past year
  • Has had an exacerbation requiring hospitalization
  • Requires step 4 care or higher
  • Does not respond to the stepped-up therapy 1

Caution

If symptoms do not improve with the above approach, or if the patient shows signs of respiratory distress (inability to speak in sentences, cyanosis, altered mental status), immediate emergency evaluation is required for possible hospitalization and more intensive therapy 2.