What prescription should be given for a patient with a known diagnosis of asthma?

Asthma Prescription Management

For a patient with known asthma, prescribe inhaled corticosteroids (ICS) as the cornerstone of long-term control therapy for all persistent asthma, combined with a short-acting beta-agonist (SABA) for quick relief. 1

Stepwise Treatment Algorithm Based on Severity

Step 1: Mild Intermittent Asthma

• No daily medication required 1
• Quick-relief: Short-acting inhaled beta-agonist (albuterol/salbutamol) as needed 1
• Use 2 puffs via spacer, repeat 10-20 times if no nebulizer available 1

Step 2: Mild Persistent Asthma

• Preferred daily medication: Low-dose inhaled corticosteroids 1
• Alternative options (not preferred): Cromolyn, leukotriene modifiers (montelukast/zafirlukast), or nedocromil 1
• Quick-relief: Short-acting beta-agonist as needed 1

Step 3: Moderate Persistent Asthma

• Preferred: Low-to-medium dose ICS + long-acting beta-agonist (LABA) 1
• Alternative for children <5 years: Medium-dose ICS alone 1
• Quick-relief: Short-acting beta-agonist as needed 1

Step 4-5: Severe Persistent Asthma

• High-dose ICS + LABA 1
• Consider adding omalizumab (anti-IgE) for patients ≥12 years with allergen sensitivity requiring step 5-6 care 1
• If needed: Add oral corticosteroids 1
• Quick-relief: Short-acting beta-agonist as needed; oral steroids may be required 1

Acute Exacerbation Management

Mild Exacerbation (PEF >50% predicted, normal speech, pulse <110, respirations <25)

• Nebulized salbutamol 5 mg or terbutaline 10 mg 1
• If PEF 50-75% after 15-30 minutes: Give prednisolone 30-60 mg 1, 2
• If PEF >75%: Step up usual treatment 1
• Follow-up within 48 hours 1

Moderate-Severe Exacerbation (PEF <50%, can't complete sentences, pulse >110, respirations >25)

• Oxygen 40-60% to maintain SpO2 >92% 1
• Nebulized salbutamol 5 mg or terbutaline 10 mg with oxygen-driven nebulizer 1
• Prednisolone 30-60 mg orally (preferred route) 1, 2
• Alternative if vomiting/severe: IV hydrocortisone 200 mg, then 200 mg every 6 hours 1, 2
• Add ipratropium 0.5 mg to nebulizer if not improving after 15-30 minutes 1
• Monitor response 15-30 minutes after treatment 1

Systemic Corticosteroid Dosing for Exacerbations

Adults:

• 40-60 mg prednisone daily for 5-10 days without tapering 2
• Continue until PEF reaches 70% of predicted or personal best 2
• Oral route equally effective as IV and strongly preferred 2

Children:

• 1-2 mg/kg/day prednisone (maximum 60 mg/day) in 2 divided doses for 3-10 days 2
• No tapering needed for courses <7-10 days, especially if on inhaled corticosteroids 2

Monitoring Beta-Agonist Use

Critical pitfall: If using more than one canister of short-acting beta-agonist per month, increase daily long-term control therapy immediately 1. This indicates inadequate asthma control and increased risk of exacerbation 1.

Essential Concurrent Management

Comorbidity Treatment

• Allergic rhinitis: Intranasal corticosteroids, antihistamines, consider immunotherapy 1
• GERD: Avoid heavy meals/caffeine/alcohol within 3 hours of sleep, elevate head of bed 6-8 inches, proton pump inhibitors 1
• Obstructive sleep apnea: Consider in overweight/obese patients with poorly controlled asthma; treat with CPAP 1

Patient Education Requirements

• Written asthma action plan detailing when to increase medications, when to call physician, when to seek emergency care 1
• Peak flow meter with instructions on target values 1
• Proper inhaler technique verification at every visit 1

Critical Pitfalls to Avoid

• Never underuse corticosteroids in persistent asthma—this is the most effective anti-inflammatory medication and reduces exacerbations more effectively than any other single agent 1
• Never delay systemic corticosteroids in moderate-severe exacerbations; anti-inflammatory effects take 6-12 hours to manifest 2, 3
• Never use sedating medications during acute exacerbations—absolutely contraindicated as they worsen respiratory function 4
• Never discharge from hospital until PEF >75% predicted, diurnal variability <25%, and nocturnal symptoms resolved 2
• Never rely solely on clinical impression for severity assessment—always measure PEF or FEV1 objectively 1