What is the most appropriate pharmacological regimen for a 29-year-old woman with episodic coughing and wheezing, occurring approximately twice a week, nocturnal symptoms about 3 times per month, no diagnosis of asthma, and Forced Expiratory Volume in 1 second (FEV-1) at 82% of predicted?

Mild Persistent Asthma: Initiate Low-Dose Inhaled Corticosteroid as Controller Therapy

This patient meets criteria for mild persistent asthma and should be started on a low-dose inhaled corticosteroid (ICS) as first-line controller therapy, with a short-acting beta-agonist (SABA) as needed for symptom relief. 1

Clinical Classification

This patient's presentation clearly indicates mild persistent asthma based on:

• Symptom frequency: Twice weekly daytime symptoms 1
• Nocturnal awakenings: 3 times per month (more than 2 per month indicates persistent disease) 1
• Lung function: FEV1 82% of predicted (>80% but with symptoms) 1
• Clinical features: Episodic coughing and wheezing consistent with variable airflow obstruction 1

The diagnosis of asthma incorporates episodic symptoms of airflow obstruction (cough, wheezing, chest tightness) that are variable, intermittent, and worse at night, combined with objective measures of lung function. 1 When cough is the predominant symptom, this is referred to as cough variant asthma. 1

Recommended Pharmacological Regimen

Primary Controller Therapy

Initiate low-dose inhaled corticosteroid as the cornerstone of treatment:

• Fluticasone propionate 100 mcg twice daily OR equivalent low-dose ICS 2, 3
• Budesonide 200-400 mcg once daily is also appropriate 4
• ICS should be started immediately as anti-inflammatory therapy reduces airway inflammation, airway hyperresponsiveness, symptoms, and improves lung function 3, 5

The evidence strongly supports starting ICS even in patients with infrequent symptoms. A landmark analysis of 7,138 patients with mild asthma demonstrated that low-dose budesonide reduced severe asthma-related events by 46-52% across all symptom frequency subgroups, including those with symptoms only 0-1 days per week (HR 0.54,95% CI 0.34-0.86). 4 This challenges the outdated criterion of waiting until symptoms occur more than 2 days per week before initiating ICS. 4

Rescue Therapy

Short-acting beta-agonist (albuterol/salbutamol) as needed:

• Albuterol 200-400 mcg via metered-dose inhaler with spacer for acute symptom relief 6
• Use as needed for episodic symptoms 7, 8
• Important caveat: Albuterol is NOT appropriate as monotherapy for chronic cough without confirmed bronchospasm and should not be used empirically without establishing reversible airflow obstruction 7, 8

Critical Management Principles

Why ICS First-Line is Essential

Management of cough variant asthma should follow national asthma guidelines, with ICS as the foundation of therapy. 1 The British Thoracic Society explicitly recommends that eosinophilic bronchitis and atopic cough respond to inhaled corticosteroids. 1

• ICS relieves cough and decreases bronchial hyperresponsiveness in 90% of patients with cough variant asthma 5
• Treatment prevents progression to classic asthma with wheezing and dyspnea 5
• Benefits include reduced exacerbations, improved lung function, and better symptom control regardless of baseline symptom frequency 4

What NOT to Do

Avoid these common pitfalls:

• Do not use SABA monotherapy: The American College of Chest Physicians explicitly states that albuterol is not recommended for chronic cough not due to confirmed asthma (Grade D recommendation) 7
• Do not delay ICS initiation: Waiting for symptoms to worsen before starting anti-inflammatory therapy exposes patients to unnecessary risk of severe exacerbations and lung function decline 4
• Do not start with systemic corticosteroids: Reserve oral prednisolone for severe or refractory cases unresponsive to inhaled therapy 1, 9
• Do not add long-acting beta-agonists (LABA) at this stage: At step 3 of asthma management, there is no evidence for LABA use in cough variant asthma; leukotriene receptor antagonists are preferred if escalation is needed 1

Diagnostic Confirmation Steps

Before finalizing treatment, ensure proper diagnostic workup:

• Spirometry with bronchodilator reversibility testing: Look for ≥12% and ≥200 mL increase in FEV1 after SABA 1
• Consider bronchial challenge testing if diagnosis remains uncertain despite normal spirometry 1
• Exclude alternative diagnoses: Rule out GERD, post-nasal drip, ACE inhibitor-induced cough, vocal cord dysfunction 1
• Chest radiograph: Should be performed in all patients with chronic cough to exclude other pathology 1

Follow-Up and Monitoring

• Reassess at 4-8 weeks after initiating ICS therapy 1
• Repeat spirometry to document improvement (>7% increase in FEV1 may be considered significant) 1
• Demonstrate and check inhaler technique at each visit 1
• Monitor for symptom control: Aim for symptom-free days and minimal SABA use 4
• Consider step-down therapy after 6-12 months of disease stability 1

If symptoms persist despite adequate ICS therapy for 2 weeks, consider a trial of prednisolone 30 mg/day for 2 weeks to assess for corticosteroid-responsive cough, though this should be reserved for cases where the diagnosis remains uncertain. 1, 10