In a 30-year-old woman with intermittent asthma symptoms triggered by dust and perfumes and reversible bronchospasm, which medication should be initiated first?

Initial Treatment for Intermittent Asthma

For this 30-year-old woman with intermittent asthma triggered by environmental exposures, inhaled salbutamol (short-acting β2-agonist) should be initiated as first-line therapy for as-needed symptom relief. 1, 2

Rationale for Short-Acting β2-Agonist Selection

Inhaled short-acting β2-agonists are the most effective therapy for rapid reversal of airflow obstruction and prompt relief of asthmatic symptoms. 1 This patient presents with:

• Intermittent symptoms (triggered by specific exposures) 1
• Normal physical examination between episodes 1
• Reversible bronchospasm on spirometry 1

These features indicate intermittent asthma (Step 1 care), where as-needed bronchodilator therapy alone is appropriate. 1

Why Not the Other Options?

Inhaled Budesonide (Option C) - Not Yet Indicated

• Inhaled corticosteroids are the preferred controller medication for persistent asthma, not intermittent asthma. 1, 3
• The trigger to initiate inhaled corticosteroids is when short-acting β2-agonists are needed more than 2-3 times daily or symptom control is inadequate. 1
• This patient has not yet trialed as-needed bronchodilator therapy, so escalation to daily controller medication is premature. 1

Montelukast (Option D) - Second-Line Alternative

• Leukotriene receptor antagonists are an alternative, second-line treatment option for mild persistent asthma (Step 2 care), not first-line for intermittent asthma. 1
• The FDA label explicitly states: "SINGULAIR is not indicated for use in the reversal of bronchospasm in acute asthma attacks" and "patients should have appropriate short-acting inhaled β-agonist medication available." 4

Inhaled Tiotropium (Option A) - Wrong Drug Class

• Tiotropium is a long-acting anticholinergic primarily used in COPD and as add-on therapy for severe persistent asthma. 1
• It is not indicated as initial monotherapy for intermittent asthma. 1

Practical Implementation

Prescribe salbutamol metered-dose inhaler 200-400 µg (2-4 puffs) as needed for symptom relief. 1 Key counseling points include:

• Use only when symptomatic or before predictable exposures (dust, perfumes). 1, 2
• Proper inhaler technique must be demonstrated at the first visit. 1
• If requiring use more than 2 days per week (excluding pre-exercise prophylaxis), this signals inadequate control and need to escalate to daily inhaled corticosteroids. 1

Critical Monitoring Parameters

Increasing use of short-acting β2-agonists generally indicates inadequate asthma control and the need to initiate anti-inflammatory therapy. 1 Specifically, monitor for:

• Frequency of salbutamol use exceeding twice weekly. 1
• Nocturnal symptoms requiring bronchodilator use more than twice monthly. 1
• Any limitation of daily activities despite as-needed bronchodilator therapy. 1

If any of these occur, add inhaled corticosteroid up to 800 µg/day beclomethasone equivalent as the next step. 1