What are the recommended take-home medications for a patient with a history of bronchial asthma who has experienced an acute exacerbation?

Take-Home Medications for Acute Asthma Exacerbation

All patients discharged after an acute asthma exacerbation should receive oral prednisone 40-60 mg daily for 5-10 days (no taper needed), a short-acting beta-agonist inhaler (albuterol), and either initiation or continuation of inhaled corticosteroids. 1, 2, 3

Essential Discharge Medications

Oral Corticosteroids (Primary Anti-Inflammatory)

• Prednisone 40-60 mg daily for 5-10 days is the cornerstone of discharge therapy 1, 2, 3
• No tapering is required for courses under 10-14 days, especially if the patient is concurrently taking inhaled corticosteroids 1, 3
• Oral administration is equally effective as intravenous methylprednisolone but less invasive 1, 3
• Early systemic corticosteroid administration speeds resolution of airflow obstruction and reduces post-ED relapse rates 1
• For patients at high risk of non-adherence, consider intramuscular depot corticosteroid injection as an alternative 2

Short-Acting Beta-Agonist (Rescue Bronchodilator)

• Albuterol MDI with spacer device should be provided for symptom relief 1, 4, 3
• Patients should use 2-4 puffs every 4-6 hours as needed for symptom control 1
• MDI with spacer is equally effective to nebulizer therapy and more portable 1
• Critical pitfall: Verify proper inhaler technique before discharge, as improper technique is a common cause of treatment failure 2, 3

Inhaled Corticosteroids (Long-Term Controller)

• All patients should either initiate or continue inhaled corticosteroids at discharge 2, 3
• Patients not previously on ICS should start immediately upon discharge 2
• For those already on ICS, continue or intensify the dose based on severity 1, 4
• ICS-LABA combination therapy is preferred for moderate-to-severe asthma to achieve synergistic anti-inflammatory effects 5

Additional Considerations for Specific Scenarios

Severe Exacerbations

• For patients with severe airflow obstruction (PEF <40% predicted), consider adding ipratropium bromide 0.5 mg via nebulizer or 8 puffs via MDI to the discharge regimen 1, 4, 3
• The combination of beta-agonist and anticholinergic reduces hospitalizations, particularly in severe cases 1

High-Risk Patients

• Patients requiring frequent systemic corticosteroids (>2 bursts per year) should be referred to an asthma specialist for consideration of step-up therapy or biologic agents 2
• Those with history of near-fatal asthma, multiple ED visits, or ICU admissions require more intensive follow-up 1, 6

Critical Discharge Instructions

Written Asthma Action Plan

• Every patient must receive a written asthma action plan that specifies when to increase medications and when to seek emergency care 1, 4, 7
• Peak flow-based plans are particularly useful for patients with difficulty perceiving airflow obstruction or history of severe exacerbations 1

Monitoring and Follow-Up

• Patients should monitor peak expiratory flow daily and recognize early signs of worsening 2
• Follow-up should be scheduled within 2-4 weeks after discharge 5
• Patients should be instructed to seek medical attention if short-acting bronchodilators are needed more frequently than usual 8

Medications to Avoid

Antibiotics

• Antibiotics are NOT routinely recommended for asthma exacerbations, as viruses are the most common trigger 1, 3
• Reserve antibiotics only for cases with strong evidence of bacterial infection (pneumonia or sinusitis) 1

Leukotriene Modifiers

• Montelukast is NOT indicated for reversal of bronchospasm in acute asthma attacks and should not be used as rescue medication 8
• It can be continued during exacerbations if already part of maintenance therapy, but should not be initiated as take-home therapy for acute management 8

Sedatives

• Never prescribe sedatives of any kind to patients recovering from acute asthma exacerbations 3

Common Pitfalls to Avoid

• Do not delay or omit systemic corticosteroids in moderate-to-severe exacerbations 4, 3
• Do not taper short courses of oral steroids (<10-14 days) 1, 3
• Do not discharge patients without verifying proper inhaler technique 2, 3
• Do not substitute SABA monotherapy for ICS-containing maintenance therapy, as this increases exacerbation risk and asthma-related deaths 4
• Do not abruptly substitute montelukast or other medications for inhaled or oral corticosteroids 8