What is the best course of treatment for a patient with asthma, experiencing shortness of breath (SOB), wheezing, cough with watery and mucoid phlegm, and chest tightness, who has lost their Dulera (mometasone and formoterol) inhaler and has been symptomatic for 6 days, with symptoms occurring 3-5 times a day and every night, and is currently tachycardic?

Immediate Management of Acute Asthma Exacerbation with Lost Controller Medication

This patient requires immediate reinitiation of combination inhaled corticosteroid/long-acting beta-agonist therapy (Dulera replacement) plus a short course of oral corticosteroids given the 6-day interruption in controller therapy with daily and nocturnal symptoms, along with tachycardia indicating acute exacerbation. 1

Immediate Actions

Assess Severity and Provide Acute Treatment

• Administer albuterol 2-4 puffs via metered-dose inhaler with spacer immediately to address current bronchospasm and wheezing 1
• Measure peak expiratory flow (PEF) before and 15-30 minutes after bronchodilator administration to objectively assess severity and response 1
• The tachycardia in clinic indicates significant physiologic stress and supports classification as an acute exacerbation requiring systemic corticosteroids 1, 2

Initiate Systemic Corticosteroids

Start oral prednisone 40-60 mg daily for 5-7 days given the prolonged interruption in controller therapy and current daily/nocturnal symptoms 1, 3

• A short course of systemic corticosteroids is indicated when asthma "frequently interrupts sleep or normal daily activities" 1
• Lower doses (40-50 mg) are as effective as higher doses for acute exacerbations 3
• No taper is necessary after short courses of 5-10 days 1
• While short courses carry risks including bone density loss, hypertension, and GI effects, the immediate need to regain control outweighs these concerns 4

Controller Medication Replacement

Restart Dulera (Mometasone/Formoterol) Immediately

Prescribe Dulera 200 mcg/5 mcg, 2 inhalations twice daily to replace the lost inhaler 5, 6

• Mometasone/formoterol combination is highly effective for patients with persistent asthma requiring daily controller therapy 5
• The 6-day interruption in inhaled corticosteroid therapy has allowed airway inflammation to worsen, explaining the current symptom pattern 1
• This dosage is appropriate for moderate persistent asthma (symptoms 3-5 times daily and nightly) 1

Optimize Rescue Medication Use

• Continue albuterol as needed for symptom relief, but if requiring more than 2 times per week after controller reinitiation, this indicates inadequate control 1
• Provide clear instructions that albuterol treats symptoms but does not address underlying inflammation 1

Monitoring and Follow-Up

Immediate Monitoring (First 48-72 Hours)

Schedule follow-up within 48 hours to assess response to systemic corticosteroids and controller reinitiation 7

• Instruct patient to monitor PEF twice daily and record values 7, 2
• Seek immediate care if PEF drops below 50% of predicted/best, inability to complete sentences, or worsening shortness of breath 1, 7
• Monitor for resolution of tachycardia as indicator of improving control 2

Short-Term Follow-Up (1-2 Weeks)

• Reassess after completing oral corticosteroid course to ensure symptoms have stabilized 1
• Verify proper inhaler technique with Dulera to ensure adequate drug delivery 1
• Confirm adherence to twice-daily dosing schedule 1

Long-Term Management (1-3 Months)

Once well-controlled for at least 3 months (minimal symptoms, PEF >75% predicted, diurnal variability <25%, no nocturnal symptoms), consider step-down by reducing ICS dose by 25-50% 1

• Patient currently meets criteria for Step 3-4 therapy given symptom frequency 1
• Do not attempt step-down until sustained control is achieved 1

Critical Pitfalls to Avoid

Do Not Delay Controller Reinitiation

• The single most important intervention is immediate replacement of the lost Dulera - the 6-day gap has caused loss of anti-inflammatory control 1, 5
• Relying on albuterol alone perpetuates the inflammatory cycle and increases exacerbation risk 1

Do Not Undertreat the Current Exacerbation

• Daily and nocturnal symptoms for 7 days with tachycardia warrant systemic corticosteroids, not just inhaler reinitiation 1
• Attempting to regain control with inhaled therapy alone will take too long and risks further deterioration 1

Ensure Medication Access

• Provide emergency prescription or samples to prevent another interruption in controller therapy 1
• Discuss barriers to medication access and develop contingency plan 1
• Consider providing backup inhaler for work/home 1

Patient Education Priorities

• Explain that controller medication (Dulera) must be taken twice daily even when feeling well to prevent inflammation 1
• Clarify that albuterol is for symptom relief only and frequent use (>2x/week) indicates poor control 1
• Emphasize that stopping controller therapy, even briefly, allows inflammation to return within days 1, 5
• Provide written asthma action plan with specific PEF thresholds for seeking care 8