What treatment is recommended for a 17-year-old patient with poorly controlled asthma, indicated by an Asthma Control Test (ACT) score of 13?

Treatment for a 17-Year-Old with Poorly Controlled Asthma (ACT Score of 13)

This 17-year-old with an ACT score of 13 requires immediate step-up therapy with a medium-dose inhaled corticosteroid (ICS) plus long-acting beta-agonist (LABA) combination, and should be considered for a short course of oral corticosteroids if symptoms are severe.

Assessment of Asthma Control

An Asthma Control Test (ACT) score of 13 indicates very poorly controlled asthma according to established guidelines 1. The ACT is a validated questionnaire where scores ≤15 represent very poorly controlled asthma, 16-19 represent not well controlled asthma, and ≥20 represent well controlled asthma 2.

Based on the National Asthma Education and Prevention Program (NAEPP) guidelines, this patient falls into the "very poorly controlled" category, which is characterized by:

• Symptoms throughout the day
• Frequent nighttime awakenings (≥4 times/week)
• Extreme limitation of normal activities
• Need for rescue medication (SABA) several times per day
• FEV1 or peak flow <60% of predicted/personal best 1

Treatment Recommendations

Immediate Actions:

1. Consider a short course of oral systemic corticosteroids (typically 1-2 mg/kg/day, not exceeding 60 mg/day) to quickly gain control of symptoms 1, 3

2. Step up to medium-dose ICS plus LABA combination therapy 1, 3

   • Options include:
     • Fluticasone/salmeterol (Wixela Inhub 250/50)
     • Budesonide/formoterol
     • Mometasone/formoterol

3. Ensure proper inhaler technique and adherence before assuming treatment failure 3

Follow-up Plan:

• Reevaluate in 2 weeks to assess response to therapy 1
• If symptoms persist, consider stepping up to high-dose ICS plus LABA 1

Rationale for Treatment Choice

The NAEPP guidelines specifically recommend stepping up 1-2 steps and considering a short course of oral corticosteroids for patients with very poorly controlled asthma 1. For a 17-year-old with an ACT score of 13, this approach addresses both the immediate need for symptom control and the underlying inflammation.

ICS-LABA combinations are preferred over increasing ICS dose alone because:

1. They target both inflammation (ICS) and bronchoconstriction (LABA)
2. Studies show better outcomes with combination therapy than with doubling ICS dose 3, 4
3. They improve lung function and reduce exacerbation risk more effectively 5

Important Cautions

• Never use LABA monotherapy for asthma due to increased risk of asthma-related death (FDA black box warning) 3, 6
• Monitor for potential steroid side effects including growth suppression, increased blood pressure, and adrenal suppression 3
• Prevent oral candidiasis by instructing the patient to rinse mouth after ICS use 3

Referral Considerations

This patient should be referred to an asthma specialist because:

1. They have very poorly controlled asthma (ACT ≤15)
2. They require step 4 care or higher
3. They may need additional testing to identify triggers or comorbidities 1, 3

Additional Management Components

• Create a written asthma action plan detailing medications and environmental control strategies 1
• Identify and address potential triggers such as allergens, irritants, or comorbidities (GERD, rhinosinusitis) 3
• Educate the patient about the dual nature of asthma (inflammation and bronchoconstriction) and the importance of controller medications even when symptoms improve 3
• Implement adherence strategies such as linking inhaler use to daily activities and setting phone reminders 3

By following this approach, the goal is to achieve asthma control characterized by minimal symptoms, no activity limitations, and reduced risk of exacerbations, which will improve this patient's quality of life and reduce morbidity and mortality risk.