What is the appropriate management for a 21-year-old patient with moderate persistent asthma, using an albuterol (Albuterol) inhaler since childhood, experiencing increased symptoms due to dust storms, with daytime symptoms occurring twice a week or less, nighttime symptoms occurring once every 2 weeks, and a peak expiratory flow (PEF) of greater than 60% but less than 80% of predicted?

From the Guidelines

I strongly recommend initiating a daily inhaled corticosteroid (ICS) such as fluticasone 110-220 mcg twice daily, along with albuterol 90 mcg 2 puffs as needed for rescue, for this 21-year-old patient with moderate persistent asthma. Based on the assessment, this patient has moderate persistent asthma, characterized by daytime symptoms twice weekly or less, nighttime symptoms once every two weeks, and PEF 60-80% of predicted. This classification requires daily controller medication, not just rescue therapy. The ICS will reduce airway inflammation, preventing symptoms and exacerbations, while albuterol provides quick relief during acute symptoms 1.

Key Considerations

• The patient should use a spacer with her inhalers for optimal medication delivery and rinse her mouth after ICS use to prevent oral thrush.
• Environmental modifications like using air purifiers during dust storms and keeping windows closed may help reduce triggers.
• If symptoms persist despite adherence to this regimen, we may need to consider stepping up therapy to a combination ICS/long-acting beta-agonist, as recommended by the NAEPP EPR-2 guidelines for moderate persistent asthma 1.
• Regular follow-up is essential to assess symptom control and medication effectiveness, with adjustments made as needed to achieve optimal asthma control 1.

Management Priorities

• Reduce airway inflammation and prevent symptoms and exacerbations with daily ICS therapy.
• Provide quick relief during acute symptoms with albuterol as needed.
• Monitor and adjust therapy as needed to achieve optimal asthma control and minimize the risk of exacerbations.
• Consider stepping up therapy to a combination ICS/long-acting beta-agonist if symptoms persist despite adherence to the initial regimen 1.

From the FDA Drug Label

The use of albuterol sulfate inhalation solution can be continued as medically indicated to control recurring bouts of bronchospasm During this time most patients gain optimum benefit from regular use of the inhalation solution. If a previously effective dosage regimen fails to provide the usual relief, medical advice should be sought immediately, as this is often a sign of seriously worsening asthma that would require reassessment of therapy. The patient's symptoms suggest that their current treatment regimen may not be adequately controlling their asthma, as they are experiencing increased symptoms due to dust storms.

• Key considerations:
  • The patient's daytime symptoms occur twice a week or less, and nighttime symptoms occur once every 2 weeks.
  • The patient's PEF is greater than 60% but less than 80% of predicted.
• Management decision: The patient should seek medical advice, as their previously effective dosage regimen is failing to provide the usual relief, which may indicate seriously worsening asthma that requires reassessment of therapy 2.

From the Research

Asthma Management

The patient's symptoms and peak expiratory flow (PEF) indicate moderate persistent asthma. According to the studies, the following management options can be considered:

• Combination therapy with an inhaled corticosteroid (ICS) and a long-acting beta2-adrenergic (LABA) bronchodilator, such as fluticasone propionate/salmeterol 3 or fluticasone propionate/formoterol 4, can provide greater asthma control and reduce the frequency of exacerbations.
• The use of a combination inhaler, such as Advair or Symbicort, can improve patient adherence and reduce morbidity 3, 5.
• The patient's current symptoms and PEF suggest that a step-up in therapy may be necessary, and the addition of an ICS/LABA combination could be considered 6.

Treatment Options

Some possible treatment options for the patient include:

• Fluticasone propionate/salmeterol (Advair) 3
• Fluticasone propionate/formoterol (a combination inhaler) 4
• Budesonide/formoterol (Symbicort) 5
• A novel multidose dry powder inhaler containing fluticasone propionate and salmeterol 6

As-Needed Treatment

The patient may also benefit from an "as-needed" inhaled corticosteroid strategy, which involves taking ICSs whenever they take their reliever inhaler, to empower patients to adjust their ICS intake in response to symptom fluctuation 7.