Management of Moderate Persistent Asthma: Adding to Albuterol
For a patient with moderate persistent asthma who is currently only on albuterol, inhaled corticosteroids (ICS) should be added as the preferred controller medication.
Rationale for Adding Inhaled Corticosteroids
Inhaled corticosteroids are the most consistently effective long-term control medication for persistent asthma at all steps of care 1. They are superior to other controller medications for several important reasons:
- ICS reduce airway hyperresponsiveness and inhibit inflammatory cell migration and activation
- ICS improve asthma control more effectively than leukotriene receptor antagonists (LTRAs) or any other single long-term control medication in both children and adults 1
- ICS reduce both impairment and risk of exacerbations 1
Stepwise Approach for Moderate Persistent Asthma
According to the National Asthma Education and Prevention Program (NAEPP) guidelines, the treatment of moderate persistent asthma requires:
Step 3 care: Low-dose inhaled corticosteroid plus a long-acting beta agonist (LABA) OR medium-dose inhaled corticosteroid 1
Alternative therapies (not preferred): Low-dose inhaled corticosteroid plus either a leukotriene receptor antagonist, theophylline, or zileuton 1
Why Not Montelukast or Theophylline?
While montelukast (Singulair) and theophylline are listed as alternative options in the guidelines, they are not preferred therapies for moderate persistent asthma:
Montelukast: LTRAs are alternative, but not preferred, therapy for mild persistent asthma (Step 2). When used as adjunctive therapy with ICS, they are not the preferred option compared to LABAs for patients 12 years and older 1
Theophylline: Sustained-release theophylline is only used as an alternative (not preferred) therapy for mild persistent asthma (Step 2) or as adjunctive therapy with ICS. It requires monitoring of serum theophylline concentration, which adds complexity to treatment 1
Evidence Supporting ICS as First-Line Add-On Therapy
The evidence strongly supports ICS as the cornerstone of asthma management:
- ICS are the only currently available asthma therapy that effectively suppress the underlying inflammation in asthmatic airways 2
- ICS not only control symptoms and improve lung function but also prevent exacerbations and may reduce asthma mortality 2
- Regular use of SABA alone (like albuterol) without addressing the underlying inflammation leaves patients at risk for severe exacerbations 3
Implementation Considerations
When adding an ICS to albuterol therapy:
- Begin with a low-dose ICS for mild persistent asthma, advancing to medium-dose for moderate persistent asthma 4
- Monitor for symptom improvement with a goal of reducing symptoms to ≤2 days/week 4
- Schedule follow-up in 2-6 weeks to assess response to therapy 4
- Consider increasing the dose or adding another medication if control is not achieved
Potential Side Effects and Monitoring
- Local side effects: Cough, dysphonia, and oral thrush can be mitigated by using a spacer and rinsing the mouth after inhalation 4
- Systemic effects: At higher doses, potential for adrenal suppression, osteoporosis, and skin thinning; at low-to-medium doses, possible transient suppression of growth velocity in children 4
Warning Signs for Treatment Adjustment
Increasing use of albuterol (more than 2 days per week) for symptom relief generally indicates inadequate control and the need to step up treatment 1. This may mean:
- Increasing the dose of ICS
- Adding a LABA if the patient is already on an appropriate dose of ICS
- Ensuring proper inhaler technique and medication adherence
In conclusion, for a patient with moderate persistent asthma currently on albuterol only, adding an inhaled corticosteroid is the most appropriate next step in management to improve symptoms, reduce exacerbations, and optimize long-term outcomes.