What is the next step in managing asthma that is worsening despite treatment with inhaled corticosteroids and umeclidinium (Umeclidinium), and a history of allergy to ibuprofen (Ibuprofen), in a patient with chronic rhinosinusitis and nasal polyps (teardrop cystic structures on turbinates)?

From the Guidelines

For asthma worsening despite current therapy, I recommend adding a leukotriene receptor antagonist like montelukast 10mg daily and considering a biologic therapy evaluation, as the most recent evidence from 1 suggests that patients with persistent symptoms of rhinosinusitis despite appropriate treatment should be of special concern. Your symptoms suggest allergic asthma with upper airway involvement. The teardrop cystic structures on turbinates likely represent nasal polyps, which often accompany chronic rhinosinusitis and can worsen asthma control. Given your ibuprofen allergy, you may have aspirin-exacerbated respiratory disease (AERD), a triad of asthma, nasal polyps, and NSAID sensitivity. For immediate improvement, continue your inhaled steroids but ensure proper technique, add intranasal steroids like fluticasone 50mcg 1-2 sprays per nostril daily for rhinosinusitis, as recommended by 1 for the treatment of allergic rhinitis, and consider a short course of oral prednisone (40mg daily for 5 days) to regain control. Some key points to consider in the management of your condition include:

• The importance of proper inhaler technique and adherence to inhaled corticosteroids, as emphasized in 1
• The potential benefits of adding a long-acting inhaled beta2-agonist to a low-to-medium dose of inhaled corticosteroids, as suggested in 1
• The need for simultaneous treatment of upper and lower airway inflammation for optimal asthma control, as implied by the presence of chronic rhinosinusitis and nasal polyps Schedule an appointment with an allergist or pulmonologist for skin testing and evaluation for biologics like dupilumab or anti-IgE therapy, which target the underlying inflammatory pathways and can dramatically improve both asthma and nasal symptoms. It is also crucial to monitor for signs of emergency or severe disease, such as those listed in 1, including periorbital oedema, displaced globe, double vision, and severe unilateral or bilateral frontal headache, and to seek immediate medical attention if any of these symptoms occur.

From the FDA Drug Label

SINGULAIR is prescribed for the treatment of asthma, the prevention of exercise-induced asthma, and allergic rhinitis: Asthma. SINGULAIR should be used for the long-term management of asthma in adults and children ages 12 months and older. SINGULAIR is used to help control the symptoms of allergic rhinitis (sneezing, stuffy nose, runny nose, itching of the nose)

The patient has asthma worsening despite inhaled steroids and umeclidinium, and also has allergic rhinitis and chronic rhinosinusitis.

• Montelukast may be considered as an add-on therapy for the patient's asthma.
• The patient is allergic to ibuprofen, which is a non-steroidal anti-inflammatory drug (NSAID), and the label advises to avoid aspirin or other NSAIDs while taking montelukast if asthma is made worse by these medications.
• There is no direct information in the label about cilantro or small teardrop cystic structures on turbinates. The patient's doctor should be consulted to determine the best course of treatment, considering the patient's specific condition and medical history 2.

From the Research

Asthma Worsening Despite Treatment

• Asthma worsening despite inhaled steroids and umeclidinium, and cilantro, allergic to ibuprofen, chronic rhinosinusitis and small teardrop cystic structures on turbinates is a complex condition that requires a comprehensive approach to management 3.
• The presence of chronic rhinosinusitis is a significant comorbidity that can contribute to asthma worsening, and its treatment is essential to improve asthma control 3, 4.
• Inhaled corticosteroids are a cornerstone of asthma treatment, but their effectiveness can be limited in some patients, and alternative treatments such as long-acting muscarinic antagonists and leukotriene receptor antagonists may be necessary 5.

Treatment of Chronic Rhinosinusitis

• Corticosteroid nasal irrigations have been shown to be more effective than simple sprays in treating chronic rhinosinusitis after sinus surgery, with improvements in nasal blockage, radiology, and endoscopic assessments 4.
• The use of nasal irrigation with corticosteroids can reduce inflammation and improve symptoms in patients with chronic rhinosinusitis, and may be a useful adjunct to other treatments for asthma and rhinosinusitis 4.

Management of Asthma

• A stepwise approach to asthma management is recommended, with treatment tailored to the individual patient's needs and response to therapy 5.
• The use of single maintenance and reliever therapy, which combines an inhaled corticosteroid and long-acting beta-agonist, can be effective in reducing severe exacerbations and improving asthma control 5.
• Biologic agents may be considered for patients with severe allergic and eosinophilic asthma who have not responded to other treatments 5.

Allergies and Asthma

• Allergies, such as an allergy to ibuprofen, can contribute to asthma worsening and should be identified and managed as part of a comprehensive approach to asthma treatment 3.
• The presence of small teardrop cystic structures on turbinates may be related to allergic rhinitis or other conditions, and further evaluation and treatment may be necessary to improve symptoms and asthma control 3.