What is the level of asthma control and best treatment options for a patient experiencing daytime symptoms and using a rescue inhaler (inhaler containing a short-acting beta-agonist (SABA)) at least 4 times weekly?

Asthma Classification and Treatment

Classification: Mild Persistent Asthma

This patient has mild persistent asthma based on daytime symptoms and rescue inhaler use ≥4 times weekly without nighttime awakenings. 1

The classification criteria are straightforward:

• Daytime symptoms: ≥2 days per week (this patient has ≥4 days/week) 1
• SABA use: >2 days per week for symptom relief indicates inadequate control and mild persistent disease 1
• Nighttime awakenings: None in this case, which is consistent with mild persistent rather than moderate persistent asthma 1

Recommended Treatment: Step 2 Therapy

The preferred treatment is daily low-dose inhaled corticosteroid (ICS) plus as-needed short-acting beta-agonist (SABA) for quick relief. 1, 2

Primary Treatment Approach

• Initiate daily low-dose ICS as the cornerstone controller therapy 1, 2
• Continue SABA as needed for symptom relief, but frequency should decrease once ICS therapy is established 1
• The 2020 NAEPP guidelines conditionally recommend either daily low-dose ICS with as-needed SABA OR as-needed ICS and SABA used concomitantly for mild persistent asthma in patients ≥12 years 1

Critical Action Before Initiating Treatment

Before prescribing controller therapy, assess medication adherence, inhaler technique, and environmental triggers. 1, 2

This is essential because:

• Poor inhaler technique significantly reduces medication effectiveness 2
• Environmental control measures should be implemented concurrently 1
• Checking adherence prevents unnecessary treatment escalation 2

Alternative Treatment Options (If ICS Not Tolerated)

If the patient cannot tolerate ICS, alternative options include 1:

• Leukotriene receptor antagonists (LTRAs) - though note the FDA issued a black-box warning for montelukast in March 2020 1
• Cromolyn or nedocromil (limited availability) 1
• Theophylline (requires monitoring, less desirable due to adverse effect profile) 1

What NOT to Do

Do not add a long-acting beta-agonist (LABA) at this stage. 1, 3, 4

• LABAs are indicated only when asthma is not controlled on low-to-moderate dose ICS alone (Step 3 or higher) 1
• LABAs must never be used as monotherapy - the FDA has issued a black-box warning against this practice 1
• Adding LABA to mild persistent asthma represents overtreatment and unnecessary medication exposure 3, 4

Follow-Up and Monitoring

Reassess asthma control in 2-6 weeks after initiating ICS therapy. 1, 2

Evaluate:

• Frequency of daytime symptoms 1
• SABA use (should decrease to ≤2 days/week) 1
• Nighttime awakenings 1
• Interference with normal activities 1
• Peak flow measurements if previously established 1

Expected Outcomes

• Improvement in asthma control can occur within 30 minutes to 1 week of starting ICS therapy 5
• Maximum benefit may take 1 week or longer 5
• Once well-controlled for ≥3 consecutive months, consider stepping down therapy 1, 2

Common Pitfall to Avoid

The most critical error is failing to initiate controller therapy when SABA use exceeds 2 days per week. 1, 2

This pattern indicates:

• Inadequate asthma control 1
• Progression from intermittent to persistent disease 2
• Increased risk of exacerbations without anti-inflammatory therapy 1, 6
• Potential for excessive SABA use, which is associated with higher risk of fatal or near-fatal asthma 7

Instruct the patient to rinse mouth with water without swallowing after each ICS dose to reduce risk of oral candidiasis. 1, 5