Treatment for Mild Persistent Asthma with History of Ocular Herpes Simplex
For a patient with mild persistent asthma and a history of ocular herpes simplex, leukotriene receptor antagonists (montelukast or zafirlukast) should be used as the preferred first-line controller therapy instead of inhaled corticosteroids, given the risk of reactivating herpetic eye disease with corticosteroid use. 1
Why Avoid Inhaled Corticosteroids in This Patient
- Corticosteroids, even when inhaled, can theoretically increase the risk of herpes simplex reactivation, particularly concerning for ocular herpes which can lead to corneal scarring and vision loss 1
- While inhaled corticosteroids (ICS) are typically the preferred first-line therapy for mild persistent asthma, the presence of ocular herpes simplex history represents a relative contraindication that warrants alternative therapy 1, 2
Recommended Treatment Algorithm
First-Line Controller Therapy
- Montelukast 10 mg once daily (for patients ≥15 years) or zafirlukast 20 mg twice daily (for patients ≥12 years) 1
- These leukotriene receptor antagonists are appropriate alternative therapies for mild persistent asthma in patients unable or unwilling to use ICS 1, 2
- Advantages include ease of use, high compliance rates, and good symptom control in many patients 1, 2
Quick-Relief Therapy
- Short-acting beta-agonist (SABA) as needed: albuterol 2-4 puffs every 4 hours for symptoms 2, 3
- SABA should be prescribed as-needed only, not on a regular schedule 2
Critical Monitoring Parameters
Signs of Inadequate Control (Requiring Step-Up)
- SABA use >2 days per week for symptom relief (excluding exercise prevention) indicates inadequate control and need to intensify therapy 1, 2, 4
- Nighttime awakenings >3-4 times per month 4
- Any limitation of normal activities 4
Follow-Up Schedule
- Schedule visits at 2-6 week intervals when initiating therapy 4
- Perform spirometry at initial assessment, after treatment stabilization, and at least every 1-2 years 4
Important Safety Considerations
Leukotriene Receptor Antagonist Warning
- The FDA has issued a black box warning for neuropsychiatric events including suicidal thoughts associated with leukotriene antagonists 2
- Counsel patients and families to monitor for mood changes, depression, or suicidal ideation 2
Common Pitfalls to Avoid
- Never use long-acting beta-agonists (LABAs) as monotherapy - they must be combined with ICS, which this patient should avoid 1, 2
- Do not use oral SABA - less potent, slower onset, and more side effects than inhaled 2
- Regular SABA use (≥4 times daily) reduces duration of action without affecting potency 2
If Leukotriene Antagonists Fail
Step-Up Options (Use with Caution)
If asthma remains uncontrolled on leukotriene receptor antagonists alone:
- Consider low-dose ICS with ophthalmology consultation to assess current ocular herpes status and risk of reactivation 1, 2
- Alternative: Cromolyn sodium (less effective but no corticosteroid risk) 1
- If ICS must be used, start with the lowest effective dose (e.g., fluticasone 100 mcg twice daily) and maintain close ophthalmology follow-up 2, 5
When to Consider ICS Despite History
- If the ocular herpes simplex was remote (>5 years) and patient has had no recurrences, the risk-benefit may favor ICS use with ophthalmology clearance 1
- The benefit of preventing severe asthma exacerbations (which may require systemic corticosteroids) may outweigh the theoretical risk of low-dose ICS in select cases 1, 6