What is the next step for a 33-year-old patient with asthma, currently taking Advair (fluticasone-salmeterol) twice daily and using albuterol and Duoneb (ipratropium-albuterol) as needed, with increased rescue inhaler use to approximately three times daily over the past month?

From the Guidelines

This patient's asthma appears to be poorly controlled, as evidenced by the frequent use of rescue medication (albuterol 3 times daily), and I recommend stepping up therapy by adding a long-acting muscarinic antagonist (LAMA) such as tiotropium (Spiriva Respimat) 2.5 mcg, 2 inhalations once daily, as suggested by the guidelines for managing asthma 1. The patient should continue Advair twice daily as maintenance therapy. Additionally, I suggest optimizing inhaler technique and adherence to the current regimen, as emphasized in the expert panel report 3 (EPR-3) guidelines for the diagnosis and management of asthma 1. The patient should keep using albuterol and DuoNebs as needed for breakthrough symptoms, but the goal is to reduce this need. A short course of oral corticosteroids (prednisone 40mg daily for 5 days) may be considered if symptoms are particularly troublesome now. According to asthma management guidelines, frequent use of rescue medication (more than twice weekly) indicates poor control and warrants therapy adjustment, as outlined in the EPR-3 guidelines 1. Adding a LAMA provides a different bronchodilation mechanism than the long-acting beta-agonist in Advair, potentially offering complementary benefits. The patient should return for follow-up in 4-6 weeks to assess response to the adjusted treatment plan, and should track rescue inhaler use to gauge improvement. Some key points to consider in managing this patient's asthma include:

• Assessing control and stepping up therapy if needed, while also considering the potential to step down medication if asthma is well controlled for at least 3 months 1
• Optimizing inhaler technique and adherence to the current regimen, as well as identifying and avoiding environmental exposures that worsen the patient's asthma 1
• Using a written asthma action plan to guide adjustments to medication and seeking medical care as appropriate 1

From the FDA Drug Label

ADVAIR HFA is used for asthma as follows: o ADVAIR HFA is a prescription medicine used to control symptoms of asthma and to prevent symptoms such as wheezing in adults and adolescents aged 12 years and older.

Call your healthcare provider or get medical care right away if: o your breathing problems get worse. o you need to use your rescue inhaler more often than usual o your rescue inhaler does not work as well to relieve your symptoms. o you need to use 4 or more inhalations of your rescue inhaler in 24 hours for 2 or more days in a row.

The patient is using her rescue inhaler about 3 times/day, which is more often than usual. According to the label, this is a sign that her asthma is not well-controlled. The patient should call her healthcare provider or get medical care right away to reassess her treatment plan. 2

From the Research

Asthma Control and Treatment

• The patient's current treatment regimen includes Advair BID, and albuterol and Duonebs as needed, with a reported use of the rescue inhaler about 3 times/day for the past month 3.
• According to the American Family Physician, asthma severity and level of control should be assessed at diagnosis and evaluated at subsequent visits using validated tools such as the Asthma Control Test or the asthma APGAR tools 3.
• The patient's frequent use of the rescue inhaler may indicate inadequately controlled symptoms, suggesting the need for a reassessment of their treatment plan.

Treatment Options and Guidelines

• The Global Initiative for Asthma (GINA) guidelines recommend that all asthma patients be treated with inhaled corticosteroids taken daily or as needed, and that treatment be escalated or de-escalated based on symptom control 4.
• Combination therapy with an inhaled corticosteroid and a long-acting β2-agonist in a single inhaler is the mainstay of asthma management, and switching from one combination to another may improve asthma control and peripheral airway/alveolar inflammation 5.
• Biologic agents may be considered for patients with severe allergic and eosinophilic asthma, and the choice of biologic should be guided by factors such as asthma severity, phenotype, age, biomarkers, treatment goals, and patient preference 6.

Assessing Asthma Control

• The Asthma Control Questionnaire (ACQ) is a validated tool for measuring asthma control, with a score of 0 indicating totally controlled asthma and a score of 6 indicating severely uncontrolled asthma 7.
• A cut-point of 0.75 on the ACQ can be used to identify patients with well-controlled asthma, while a cut-point of 1.50 can be used to identify patients with inadequately controlled asthma 7.
• The patient's reported use of the rescue inhaler and other symptoms should be evaluated in the context of their overall asthma control, using tools such as the ACQ to guide treatment decisions 3, 7.