What is the most appropriate medication to initiate now for a 30-year-old woman with intermittent asthma triggered by dust and perfumes, mild expiratory wheeze, and reversible bronchospasm on spirometry?

Initial Treatment for Intermittent Asthma

For this 30-year-old woman with intermittent asthma (recurrent attacks only with specific triggers, normal examination between episodes), inhaled salbutamol (short-acting beta-agonist) as needed is the most appropriate initial therapy. 1, 2

Classification and Rationale

This patient has intermittent asthma based on:

• Symptoms only with specific exposures (dust, perfumes) 1
• Normal physical examination except during symptomatic episodes 1
• No mention of daily symptoms, nighttime awakenings, or frequent SABA use 3

According to the NAEPP stepwise approach, Step 1 (intermittent asthma) requires only as-needed short-acting beta-agonist therapy with no daily controller medication. 1, 2

Why Each Option Is or Isn't Appropriate

Option B: Inhaled Salbutamol (CORRECT)

• Short-acting beta-agonists are the preferred and only medication needed for intermittent asthma 1, 2
• Salbutamol provides rapid reversal of airflow obstruction and prompt symptom relief 1
• Should be used as needed for symptom relief, ideally less than twice weekly 1, 4
• Has excellent safety profile with extensive data supporting use 1, 5

Option C: Inhaled Budesonide (INCORRECT at this stage)

• Inhaled corticosteroids are reserved for Step 2 (mild persistent asthma) and above 1
• Only indicated when symptoms occur more than twice weekly, nighttime awakenings more than twice monthly, or SABA use exceeds twice weekly 1, 3
• This patient's intermittent, trigger-specific symptoms do not meet criteria for daily controller therapy 1, 2

Option D: Montelukast (INCORRECT at this stage)

• Leukotriene receptor antagonists are alternative (not preferred) therapy for mild persistent asthma (Step 2), not intermittent asthma 1
• No role in intermittent asthma where only as-needed bronchodilator is indicated 1, 2

Option A: Inhaled Tiotropium (INCORRECT)

• Long-acting anticholinergics have no established role in Step 1 intermittent asthma 1
• Reserved for more severe, persistent asthma as add-on therapy 1

Critical Monitoring Parameters

If SABA use increases to more than twice weekly (excluding exercise prophylaxis), this signals inadequate control and need to step up to Step 2 with daily low-dose inhaled corticosteroid. 1, 3

Additional red flags requiring treatment intensification include:

• Nighttime awakenings more than twice monthly 3
• Any limitation of daily activities 1
• Need for oral corticosteroids 1

Common Pitfalls to Avoid

Do not initiate daily controller therapy (ICS, LTRA, or LABA) in truly intermittent asthma—this represents overtreatment and exposes patients to unnecessary medication burden and potential side effects. 1, 2

Do not prescribe LABA (like formoterol) as monotherapy or initial therapy—LABAs are never appropriate as first-line treatment and significantly increase mortality risk when used without concurrent ICS. 1, 3

Ensure patient receives education on:

• Proper inhaler technique 1
• Environmental trigger avoidance (dust, perfumes) 1
• When to seek urgent care (severe symptoms unresponsive to SABA) 1
• Self-monitoring to recognize if asthma control deteriorates 1, 2