Inhaled Corticosteroid (Option B)
For this 27-year-old woman with mild persistent asthma (symptoms 2-3 times per week without severe exacerbations), the most appropriate management is initiating a low-dose inhaled corticosteroid such as fluticasone 100-250 μg/day or budesonide 200-400 μg/day, administered twice daily. 1, 2
Why Inhaled Corticosteroids Are First-Line
Inhaled corticosteroids are the most effective single long-term controller medication for persistent asthma, demonstrating superior outcomes compared to leukotriene modifiers, theophylline, or other alternatives in improving symptom control, reducing exacerbations, and preventing lung function decline. 1, 2, 3
This patient meets criteria for mild persistent asthma based on symptom frequency of 2-3 times per week, which mandates daily anti-inflammatory controller therapy rather than as-needed bronchodilator use alone. 1, 4
Low-dose ICS reduce severe asthma-related events (hospitalizations, emergency treatment) with a hazard ratio of 0.54-0.60 across all symptom frequency subgroups, including patients with symptoms as infrequent as 0-1 days per week. 5
Why the Other Options Are Incorrect
Salbutamol (Option C) is a short-acting beta-agonist appropriate only for intermittent asthma or as rescue therapy. Using SABA more than 2 days per week for symptom relief indicates inadequate control and the need to initiate anti-inflammatory therapy, not continue with bronchodilator monotherapy. 2, 6
Salmeterol (Option D), a long-acting beta-agonist, should never be used as monotherapy for asthma due to increased risk of severe exacerbations and asthma-related deaths. LABAs must always be combined with ICS. 1, 2, 6
Ipratropium bromide (Option A) is an anticholinergic bronchodilator with no role in chronic asthma management as a controller medication. It is reserved for acute exacerbations or COPD management. 7
Practical Implementation
Start with low-dose ICS: Fluticasone propionate 100-250 μg/day, budesonide 200-400 μg/day, or beclomethasone 200-500 μg/day, divided into twice-daily dosing. 1, 2, 7
Add a spacer device with metered-dose inhalers to increase lung deposition and reduce oropharyngeal side effects like thrush. 1, 2
Provide as-needed SABA (salbutamol) for quick symptom relief alongside the daily ICS controller. 2, 6
Reassess in 2-6 weeks to evaluate treatment response, checking symptom control, SABA use frequency, and spirometry if available. 2, 7
When to Step Up Therapy
If asthma remains uncontrolled after 2-6 weeks on low-dose ICS (persistent symptoms >2 days/week, nighttime awakenings >2 nights/month, or frequent SABA use), the preferred step-up is adding a LABA to low-dose ICS rather than increasing ICS dose alone, as this provides greater improvement in lung function and symptom control. 1, 2
Common Pitfall to Avoid
Do not delay initiating ICS in persistent asthma. The conventional criterion of "symptoms on more than 2 days per week" as a threshold for starting ICS lacks strong evidence—patients with even less frequent symptoms benefit from ICS in reducing severe exacerbations and preventing lung function decline. 5 This patient's 2-3 times weekly symptoms clearly warrant controller therapy.