What is the best course of treatment for a 47-year-old female patient with persistent cough, intermittent shortness of breath, and gastrointestinal symptoms, including rectal bleeding and constipation, who has a history of steroid allergy and is currently using an albuterol (salbutamol) inhaler for asthma management?

Management of Persistent Cough with Suspected Steroid Allergy in Asthma

Given your documented reactions to both Advair (rash and facial swelling) and prednisone (abdominal rash), you should be treated with a leukotriene receptor antagonist (montelukast 10 mg daily) combined with optimized albuterol therapy, while avoiding all corticosteroid formulations until formal allergy evaluation can be completed. 1

Immediate Respiratory Management

Primary Diagnosis: Post-Bronchitis Persistent Cough

Your 2-week cough following emergency room treatment for bronchitis fits the classic pattern of postinfectious cough, which typically persists for 3-8 weeks after the initial respiratory infection resolves 2. Key features supporting this diagnosis include:

• Clear to white sputum production (non-purulent, excluding bacterial infection) 2
• No fever (ruling out ongoing infection) 2
• Throat fullness sensation (consistent with upper airway inflammation) 2
• Intermittent shortness of breath with coughing (typical of postinfectious bronchial hyperresponsiveness) 3

Steroid Allergy Considerations

Your reactions to both Advair and prednisone represent a critical safety concern that fundamentally changes your treatment approach:

• Facial swelling with Advair suggests possible angioedema, a serious hypersensitivity reaction 3
• Rash development with both inhaled and oral steroids indicates a pattern of steroid hypersensitivity 3
• All corticosteroid formulations should be avoided until you can undergo formal allergy evaluation 3

Recommended Treatment Algorithm

Step 1: Optimize Current Bronchodilator Therapy

Continue albuterol inhaler with proper technique verification 3, 4. The albuterol action lasts up to 6 hours, and you should use 2 puffs every 4-6 hours as needed, not exceeding recommended frequency 4. Common pitfall: inadequate inhaler technique is a leading cause of treatment failure 1.

Step 2: Add Leukotriene Receptor Antagonist (Critical for Steroid-Allergic Patients)

Start montelukast 10 mg orally once daily 1. This is your most important intervention because:

• Leukotriene inhibitors are specifically recommended by the American College of Chest Physicians as an alternative to systemic corticosteroids in patients with asthmatic cough who cannot tolerate steroids 1
• Provides anti-inflammatory effects through a different pathway than corticosteroids 1
• Complete resolution may require up to 8 weeks of treatment 1
• Most patients show at least partial improvement within 1 week 1

Step 3: Add Inhaled Ipratropium Bromide

Initiate ipratropium bromide 2-3 puffs (17-34 mcg per puff) four times daily 2. This anticholinergic bronchodilator has the strongest evidence for attenuating postinfectious cough and works through a mechanism completely independent of steroids 2. Expected response time is 1-2 weeks 2.

Step 4: Treat Upper Airway Component

Your "throat fullness" and occasional clear nasal drainage when bending over suggest upper airway cough syndrome (previously called postnasal drip) 2. Add a first-generation antihistamine-decongestant combination (such as brompheniramine/pseudoephedrine or chlorpheniramine/phenylephrine) plus an intranasal corticosteroid spray 2.

Important caveat: Given your steroid allergy history, you may need to avoid the intranasal corticosteroid component initially and rely solely on the antihistamine-decongestant combination 2. Response typically occurs within days to 1-2 weeks 2.

Step 5: Consider GERD Empiric Treatment

Even without typical heartburn symptoms, gastroesophageal reflux can cause persistent cough 2. If cough persists after 2-3 weeks of the above treatments, initiate high-dose PPI therapy (omeprazole 40 mg twice daily) with dietary modifications 2. "Silent GERD" is common in chronic cough patients, and response may require 2 weeks to several months 2.

Critical Red Flags Requiring Urgent Re-evaluation

Gastrointestinal Concerns

Your report of bright red blood followed by maroon-to-black stool requires immediate gastroenterology evaluation 2. This color progression suggests:

• Bright red blood: likely lower GI source (hemorrhoids, anal fissure, or lower colon)
• Maroon-to-black transition: possible upper GI bleeding or slower lower GI bleeding

You need colonoscopy referral as requested, but also consider upper endoscopy given the stool color changes. The right lower quadrant pain episode, though resolved, combined with constipation and rectal bleeding, warrants complete GI evaluation separate from your respiratory issues.

Respiratory Red Flags

Seek immediate medical attention if you develop 2:

• Hemoptysis (blood in cough)
• Fever (suggesting bacterial superinfection)
• Worsening shortness of breath at rest
• Chest pain
• Weight loss or night sweats

What NOT to Do

Do not retry any corticosteroid formulations (inhaled, oral, or systemic) without first consulting an allergist for formal evaluation 1. This includes:

• No inhaled corticosteroids (fluticasone, budesonide, beclomethasone, etc.)
• No oral prednisone or methylprednisolone
• No combination inhalers containing corticosteroids (Advair, Symbicort, Breo, etc.)

Do not use antibiotics for your persistent cough, as the American College of Chest Physicians explicitly states that antibiotics have no role in postinfectious cough unless there is clear evidence of bacterial sinusitis or early pertussis infection 2. Your clear-to-white sputum, absence of fever, and clinical presentation exclude bacterial infection 2.

Expected Timeline and Follow-up

• Week 1-2: Expect partial improvement with ipratropium and antihistamine-decongestant combination 2
• Week 2-4: Montelukast should begin showing anti-inflammatory effects 1
• Week 8: Complete resolution of asthma-related cough may require this full duration of optimized treatment 3, 1

If cough persists beyond 8 weeks, you need chest X-ray and systematic re-evaluation for alternative diagnoses 2. Chronic cough is frequently multifactorial, and you may need to continue effective therapies while adding additional interventions rather than stopping and switching 2.

Allergy Evaluation Priority

Schedule formal allergy/immunology consultation to evaluate your steroid reactions 3. This will help determine:

• Whether you have true steroid allergy versus reaction to specific formulation components
• If desensitization protocols might be possible in the future
• Alternative anti-inflammatory strategies for long-term asthma control