What treatment can be given to a patient with recurrent asthma attacks in the past month?

Management of Recurrent Asthma Attacks

For a patient with recurrent asthma attacks in the past month, immediately initiate or step up daily inhaled corticosteroid (ICS) therapy, as this patient has persistent asthma requiring long-term controller medication to prevent future exacerbations and reduce mortality risk. 1

Immediate Assessment and Classification

This patient's recurrent attacks within the past month indicate persistent asthma, not intermittent disease, which fundamentally changes the treatment approach 1:

• Patients with ≥2 exacerbations requiring urgent care in the past year should be treated as having persistent asthma, even if daily symptoms appear minimal 1
• Recurrent attacks signal inadequate disease control and increased risk for severe exacerbations, hospitalization, and asthma-related death 1

Primary Treatment: Daily Controller Medication

First-Line Therapy: Inhaled Corticosteroids

Inhaled corticosteroids are the most consistently effective anti-inflammatory therapy and must be prescribed as daily maintenance treatment 1:

• ICS improve asthma control more effectively than any other single long-term control medication when used consistently 1
• They directly address the underlying chronic airway inflammation that causes recurrent attacks 2, 3
• Low-dose ICS is appropriate for mild persistent asthma; medium-dose for moderate persistent disease 1

Add-On Therapy if ICS Alone is Insufficient

If the patient remains uncontrolled on ICS monotherapy, add a long-acting beta-agonist (LABA) in combination with ICS 1:

• ICS-LABA combination therapy is more effective than doubling the ICS dose for moderate persistent asthma 1, 4
• Never prescribe LABA as monotherapy—this increases exacerbation risk and mortality 1, 2
• The combination demonstrates synergistic anti-inflammatory and bronchodilator effects 5

Alternative Controller Options

Leukotriene receptor antagonists (e.g., montelukast) are second-line alternatives for patients who cannot or will not use ICS 1, 6:

• Easier to use with high compliance rates (once-daily oral tablet) 1
• Less effective than ICS but can provide good symptom control in many patients 1, 4
• Can be added to ICS as adjunctive therapy, though ICS-LABA combination is preferred for patients ≥12 years 1

Rescue Medication

Prescribe short-acting beta-agonist (SABA) for acute symptom relief only 1, 7:

• Albuterol (salbutamol) 2.5 mg via nebulizer or 2 puffs via metered-dose inhaler as needed 1, 7
• SABA use >2 days/week indicates inadequate control and need to step up controller therapy 1
• Increasing SABA use is a red flag for impending severe exacerbation 1

Oral Corticosteroid Burst for Current Exacerbation

If the patient is currently experiencing an exacerbation, prescribe prednisolone 30-60 mg daily for 1-3 weeks 1:

• Oral steroids rapidly establish control during acute worsening 1
• Short courses are effective for patients whose asthma frequently interrupts daily activities 1
• This does not replace the need for daily ICS maintenance therapy 1

Critical Follow-Up and Monitoring

Schedule follow-up every 2-4 weeks initially, then every 1-3 months once controlled 5, 8:

• Assess control using validated tools (Asthma Control Test, ACQ, or ATAQ) 1
• Verify proper inhaler technique at every visit—incorrect technique is a common cause of treatment failure 5
• Monitor for warning signs of poor control: nighttime awakenings, activity limitation, increased SABA use 1

High-Risk Features Requiring Urgent Attention

Refer immediately to emergency care if any life-threatening features present 1:

• Cannot complete sentences in one breath 1
• Respiratory rate ≥25/min, heart rate ≥110/min 1
• Peak flow <50% predicted or personal best 1
• Silent chest, cyanosis, confusion, or exhaustion 1

Common Pitfalls to Avoid

• Do not rely on SABA alone—this patient needs daily controller medication to prevent recurrent attacks 1
• Do not prescribe LABA without ICS—monotherapy with LABA increases mortality risk 1, 2
• Do not delay stepping up therapy in patients with recurrent exacerbations—they are at high risk for severe attacks 1
• Do not prescribe antibiotics unless bacterial infection is confirmed—they are not helpful for asthma exacerbations 1
• Do not use sedatives—these are contraindicated in acute asthma 1

Stepwise Treatment Algorithm

For patients with recurrent attacks (≥2 exacerbations in past year) 1:

1. Start at Step 3: Daily low-dose ICS-LABA combination therapy 1
2. Add oral corticosteroid burst if currently symptomatic: prednisolone 30-60 mg for 1-3 weeks 1
3. Provide SABA for rescue use only 1, 7
4. Reassess in 2-4 weeks: If not well-controlled, step up to medium-dose ICS-LABA 1
5. If controlled for ≥3 months, consider stepping down therapy gradually 1