What is the recommended treatment for a patient with post-viral asthma, especially during winter and considering factors like postnasal drip (PND)?

Treatment of Post-Viral Asthma with Postnasal Drip

For post-viral asthma with postnasal drip, initiate daily low-dose inhaled corticosteroids as the primary controller medication, combined with intranasal corticosteroids to address the upper airway inflammation contributing to asthma symptoms. 1

Controller Medication Strategy

Inhaled corticosteroids (ICS) are the preferred first-line controller medication for persistent asthma symptoms following viral respiratory infections, as they improve asthma control more effectively than any other single long-term control medication when used consistently 1. For adults and children ≥12 years, this means:

• Low-dose ICS daily (e.g., fluticasone propionate 100-250 mcg, budesonide 200-400 mcg, or mometasone 200 mcg once daily) 1
• Continue this regimen throughout winter months when viral triggers are most prevalent 1
• Do not rely on increasing ICS doses only during exacerbations—this approach is less effective than consistent daily low-dose treatment 2

Addressing Postnasal Drip Component

Intranasal corticosteroids are essential for managing postnasal drip that contributes to asthma symptoms:

• Mometasone furoate, fluticasone propionate, or fluticasone furoate once daily are preferred due to negligible bioavailability and once-daily dosing 1
• These reduce upper airway inflammation that can trigger or worsen lower airway symptoms 1
• For acute post-viral rhinosinusitis symptoms, intranasal corticosteroids provide modest symptom reduction, though the effect is small 1

Important caveat: Intranasal corticosteroids have no role in treating common cold symptoms themselves, only post-viral rhinosinusitis or chronic rhinitis 1.

When Initial Treatment Is Insufficient

If symptoms remain poorly controlled on low-dose ICS alone (defined as symptoms >2 days/week, nighttime awakenings >2 times/month, or SABA use >2 days/week), escalate therapy as follows 1:

Step 1: Add a long-acting beta-agonist (LABA)

• Combination ICS/LABA is more effective than doubling the ICS dose 1, 3, 4
• Use fluticasone/salmeterol 100/50 mcg or 250/50 mcg twice daily, or fluticasone furoate/vilanterol 100/25 mcg once daily 4, 5

Step 2: Consider adding a leukotriene receptor antagonist

• Montelukast 10 mg daily can be added to ICS therapy, though it is less effective than ICS alone and substantially less effective than ICS/LABA combinations 1
• May provide additional benefit for patients with concurrent allergic rhinitis 1, 6

Rescue Medication Protocol

Short-acting beta-agonists (SABA) remain the most effective therapy for acute symptom relief 1:

• Albuterol/salbutamol 2-4 puffs as needed for symptoms 1
• Critical monitoring point: SABA use >2 days/week or >2 nights/month indicates inadequate control requiring intensification of anti-inflammatory therapy 1

Managing Acute Exacerbations

For moderate to severe exacerbations, use oral systemic corticosteroids 1:

• Prednisone 40-60 mg daily for adults (or 1-2 mg/kg/day for children, maximum 60 mg) for 5-7 days 1, 6
• Do not attempt to manage exacerbations by temporarily increasing ICS doses—evidence shows this provides no benefit over stable dosing 2

Environmental and Trigger Management

Address specific winter-related triggers:

• Viral respiratory infections are the most significant environmental factor contributing to asthma persistence and severity 1
• Influenza vaccination is recommended, though it should not be expected to reduce exacerbation frequency 1
• Identify and treat any underlying allergic triggers with standard allergy testing if symptoms persist despite optimal pharmacotherapy 6

Common Pitfalls to Avoid

• Do not use antibiotics for post-viral rhinosinusitis—there is no benefit and increased adverse events 1
• Do not use systemic corticosteroids for acute post-viral rhinosinusitis without lower airway involvement—they show minimal benefit with potential harm 1
• Do not prescribe leukotriene receptor antagonists as monotherapy when ICS are indicated—they are second-line alternatives only 1
• Do not increase ICS doses during exacerbations as a substitute for oral corticosteroids—this strategy lacks evidence of benefit 2