What is the most appropriate pharmacotherapy for a child with intermittent nonproductive cough, rhinorrhea, watery eyes, mild dyspnea, and wheezing, with a history of eczema and environmental allergies?

From the Guidelines

The most appropriate pharmacotherapy to initiate for this 5-year-old girl is inhaled fluticasone. This child presents with symptoms consistent with mild persistent asthma, including a chronic cough occurring twice weekly during the day, wheezing on examination, and a history of atopic conditions (eczema and environmental allergies). According to the expert panel report 3 (EPR-3) guidelines for the diagnosis and management of asthma, inhaled corticosteroids are the preferred long-term control medication for initiating therapy in children with mild persistent asthma 1. The guidelines recommend considering daily long-term control therapy for children who consistently require symptomatic treatment more than 2 days per week for a period of more than 4 weeks, which applies to this patient's situation 1. Inhaled fluticasone is a suitable option for long-term control, as it is FDA-approved for children 4 years of age and older, and it can be administered via a dry powder inhaler, which is an appropriate delivery device for this age group 1. While albuterol is a short-acting beta-2 agonist that provides rapid bronchodilation, it is primarily used as a rescue medication for acute asthma symptoms, and inhaled corticosteroids like fluticasone are preferred for long-term control 1. The patient's presentation does not suggest an infection requiring antibiotics, and her symptoms are significant enough to warrant treatment rather than observation alone. Some key points to consider when initiating long-term control therapy in young children include:

• Monitoring response to therapy closely and adjusting treatment as needed 1
• Considering a step-down approach if symptoms are well-controlled for at least 3 months 1
• Weighing the potential benefits and risks of long-term control therapy, including the potential for delayed growth with inhaled corticosteroids 1
• Selecting a delivery device that is appropriate for the child's age and ability, such as a nebulizer or metered-dose inhaler with a spacer device 1. Overall, inhaled fluticasone is the most appropriate initial pharmacotherapy for this 5-year-old girl with mild persistent asthma, as it provides long-term control and can help reduce the risk of exacerbations and improve quality of life 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Patient Presentation

The patient is a 5-year-old girl with a 4-week history of nonproductive cough, runny nose, watery eyes, and mildly increased difficulty breathing. She has a history of eczema and environmental allergies.

Symptoms and Diagnosis

• The patient's symptoms include:
  • Nonproductive cough
  • Runny nose
  • Watery eyes
  • Mildly increased difficulty breathing
  • Wheezing in the right upper and lower lung fields
• The patient's history of eczema and environmental allergies suggests an allergic component to her symptoms

Appropriate Pharmacotherapy

• Based on the patient's symptoms and history, the most appropriate pharmacotherapy to initiate at this time would be an inhaled corticosteroid (ICS) such as fluticasone 2
• ICS therapy is considered the most effective anti-inflammatory treatment for asthma and is recommended as the first-line treatment for patients with persistent asthma
• The addition of a long-acting beta2-adrenergic (LABA) bronchodilator such as salmeterol to ICS therapy may be considered for patients with moderate-to-severe persistent asthma 2
• Inhaled albuterol may be used as a rescue medication to relieve acute symptoms of asthma, but it is not a suitable replacement for regular ICS therapy 3, 4

Treatment Options

• Inhaled fluticasone (B) is the most appropriate pharmacotherapy to initiate at this time
• Inhaled albuterol (A) may be used as a rescue medication, but it is not a suitable replacement for regular ICS therapy
• Inhaled racemic epinephrine (C) is not a recommended treatment for asthma
• Oral amoxicillin (D) is an antibiotic and is not indicated for the treatment of asthma
• No pharmacotherapy (E) is not a suitable option given the patient's symptoms and history