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

Take-Home Medications After Acute Asthma Exacerbation

All patients discharged after an acute asthma exacerbation must receive oral corticosteroids (prednisone 40-60 mg daily for 5-10 days without tapering), an inhaled short-acting beta-agonist (albuterol), and should be initiated or continued on inhaled corticosteroids. 1, 2, 3

Essential Discharge Medications

Oral Corticosteroids - Non-Negotiable

• Prednisone 40-60 mg daily for 5-10 days is mandatory for all moderate-to-severe exacerbations 1, 2, 3
• No tapering is necessary for courses less than 10 days, especially if the patient is concurrently taking inhaled corticosteroids 2, 3
• For patients at high risk of non-adherence, consider intramuscular depot corticosteroid injection (such as methylprednisolone acetate) at discharge as an alternative to oral agents 2, 3
• Pediatric dosing: 1-2 mg/kg/day (maximum 60 mg/day) for 3-10 days 1, 2

Short-Acting Beta-Agonist (Rescue Inhaler)

• Albuterol metered-dose inhaler (MDI) with spacer: 2-4 puffs every 4-6 hours as needed 1, 2, 4
• Patients must be instructed to have this available at all times for acute symptom relief 1, 5
• Verify proper inhaler technique before discharge - improper technique is a common cause of treatment failure 2, 3

Inhaled Corticosteroids - Critical for Prevention

• All patients should be initiated on or continued with inhaled corticosteroids immediately at discharge 2, 3, 4
• For patients not already receiving ICS, start immediately to prevent relapse 2, 3
• For patients already on ICS, continue or increase the dose based on severity 1, 2
• Low-dose ICS is the preferred option for mild persistent asthma 1

Additional Controller Medications to Consider

ICS-LABA Combination Therapy

• For patients with moderate-to-severe asthma or those requiring Step 3+ treatment, prescribe ICS-LABA combination inhalers 1, 2, 6
• This combination demonstrates synergistic anti-inflammatory and bronchodilator effects, achieving efficacy equivalent to or better than doubling the ICS dose 6, 7
• Examples include fluticasone/salmeterol or budesonide/formoterol 7

Leukotriene Receptor Antagonists

• Consider adding montelukast for patients with persistent symptoms despite ICS therapy 1, 6
• Montelukast is NOT for acute exacerbations - it should only be used as maintenance therapy 5
• Patients must be counseled about neuropsychiatric side effects (agitation, depression, suicidal thinking) and instructed to notify their prescriber if these occur 5

Mandatory Discharge Components Beyond Medications

Written Asthma Action Plan

• Every patient must receive a written asthma action plan before discharge 1, 3, 4
• The plan should specify when to increase medications, when to start oral corticosteroids, and when to seek emergency care 1, 3

Peak Flow Meter and Education

• Provide a peak flow meter and teach patients to monitor PEF daily 3
• Instruct patients to recognize early signs of worsening (PEF <80% of personal best, increased rescue inhaler use) 1, 3
• Patients should seek medical care if using more than one canister of SABA per month 1

Follow-Up Arrangements

• Schedule follow-up within 1 week with primary care and within 4 weeks with a specialist 2, 4
• For patients requiring frequent courses of systemic corticosteroids (>2 bursts per year), refer to an asthma specialist 3

Critical Discharge Criteria - Do Not Discharge Until Met

• PEF ≥70% of predicted or personal best 1, 2, 3, 4
• Symptoms minimal or absent 1, 2, 3, 4
• Oxygen saturation stable on room air 2, 3, 4
• Patient stable for 30-60 minutes after last bronchodilator dose 2, 3, 4

Common Pitfalls to Avoid

• Never discharge without oral corticosteroids - airway inflammation persists for days to weeks after an acute attack 8
• Never prescribe antibiotics routinely unless there is strong evidence of bacterial infection (pneumonia or sinusitis) 1, 2, 4
• Do not rely on SABA alone - all patients need anti-inflammatory therapy 1, 2
• Avoid unnecessarily high steroid doses or prolonged tapers for short courses 2, 3
• Never substitute montelukast for inhaled corticosteroids - it is not indicated for acute treatment 5