What is the best management approach for a patient with asthma who experiences more than 6 respiratory illnesses per year and only uses their inhaler when symptomatic?

Management of Poorly Controlled Asthma with Frequent Respiratory Illnesses

This 30-year-old patient requires immediate initiation of daily inhaled corticosteroid (ICS) therapy, as using a rescue inhaler only when sick represents inadequate treatment and places her at ongoing risk for exacerbations and progressive airway remodeling. 1

Classification and Treatment Indication

This patient has persistent asthma, not intermittent asthma, based on the frequency of respiratory illnesses requiring inhaler use (>6 times per year). 2

Daily long-term controller therapy is indicated when any of the following criteria are met: 2

• Symptomatic treatment required >2 days per week for >4 weeks
• ≥2 exacerbations requiring systemic corticosteroids within 6 months
• Frequent interruptions of sleep or daily activities

The pattern of needing treatment during respiratory illnesses more than 6 times yearly clearly meets these thresholds for persistent asthma requiring daily controller medication. 1

Recommended Treatment Approach

Initial Controller Therapy

Start low-dose inhaled corticosteroid (ICS) as the foundation of treatment. 1 This is the preferred first-line controller medication for persistent asthma in adults. 2

For patients aged 12 years and older with mild persistent asthma, two evidence-based options exist: 2

• Low-dose ICS daily plus as-needed short-acting beta-agonist (SABA)
• As-needed combination ICS-formoterol (for patients who may have adherence challenges with daily therapy)

Rescue Medication Strategy

Continue short-acting beta-agonist (albuterol/salbutamol) for acute symptom relief, but emphasize this should not be the sole therapy. 1

Critical teaching point: If SABA use exceeds 2-3 times daily or symptoms remain inadequately controlled, treatment must be stepped up. 1

Essential Management Components

Peak Flow Monitoring and Self-Management Plan

Provide a peak expiratory flow (PEF) meter and teach proper technique. 2 The patient should: 2

• Monitor PEF regularly to track asthma control
• Know specific PEF values at which to increase treatment
• Know when to call their doctor
• Know when to seek emergency care

Develop a written asthma action plan that specifies: 2, 1

• Daily controller medication regimen
• When and how to use rescue medication
• Signs of worsening asthma
• Specific actions to take during exacerbations

Inhaler Technique Verification

Check and document proper inhaler technique at every visit, as poor technique is a common cause of treatment failure. 2 If the patient cannot use a metered-dose inhaler (MDI) properly, add a large volume spacer device or consider alternative delivery devices. 1

Addressing the Root Problem

Why Current Approach Is Inadequate

Using rescue medication only during illness represents reactive rather than preventive management, which: 1

• Fails to control underlying airway inflammation
• Increases risk of severe exacerbations
• May lead to progressive airway remodeling
• Results in preventable morbidity

The dissociation between symptoms and inflammation means that waiting until symptoms appear to treat asthma misses the opportunity to prevent exacerbations. 3

Follow-Up Schedule

Schedule follow-up within 1-4 weeks after initiating controller therapy to: 2

• Assess response to treatment
• Verify adherence and proper technique
• Adjust therapy if needed

Ongoing monitoring intervals should be 1-6 months depending on control level, with closer follow-up for newly initiated therapy. 2

Stepping Up Therapy If Needed

If asthma remains uncontrolled on low-dose ICS after 3 months of adequate adherence and proper technique: 2, 1

• Add long-acting beta-agonist (LABA) to ICS (combination inhaler such as fluticasone-salmeterol)
• Consider increasing ICS dose
• Evaluate for alternative diagnoses or comorbidities

Common Pitfalls to Avoid

Do not accept SABA-only treatment as adequate for this patient—this is the most critical error to correct. 1

Do not assume respiratory illnesses are separate from asthma—these likely represent asthma exacerbations triggered by viral infections, which daily ICS can help prevent. 2

Do not delay referral to a specialist if the patient experiences life-threatening exacerbations, requires frequent oral corticosteroids, or remains uncontrolled despite appropriate step-up therapy. 4, 5

Ensure the patient understands this is chronic disease management, not just treatment of acute episodes, and that daily controller medication is necessary even when feeling well. 6