A 36-year-old woman comes to the office due to episodic shortness of breath and cough productive of a trace amount of whitish sputum, occurring once or twice a week for the last 6 months. Symptoms seem worse when it is hot and humid and at night, but they do not disturb her sleep. Medical history is significant for allergic rhinitis, gastroesophageal reflux disease, and obesity. Medications include cetirizine, intranasal fluticasone, and pantoprazole. The patient smoked a pack of cigarettes daily at age 18-25. She feels well today and has no respiratory complaints.
Vital signs are within normal limits. BMI is 32 kg/m². Examination of the nasal passages shows boggy, edematous turbinates and no polyps. Pulmonary auscultation demonstrates clear breath sounds bilaterally with no wheezing. The remainder of the examination is normal.
The patient returns to the clinic for pulmonary function tests several days later, reporting that "my allergies and breathing are acting up again." Spirometry data are as follows:
Which of the following inhaled medication regimens would be most appropriate for initial management of this patient's condition?

Question

A 36-year-old woman comes to the office due to episodic shortness of breath and cough productive of a trace amount of whitish sputum, occurring once or twice a week for the last 6 months. Symptoms seem worse when it is hot and humid and at night, but they do not disturb her sleep. Medical history is significant for allergic rhinitis, gastroesophageal reflux disease, and obesity. Medications include cetirizine, intranasal fluticasone, and pantoprazole. The patient smoked a pack of cigarettes daily at age 18-25. She feels well today and has no respiratory complaints.
Vital signs are within normal limits. BMI is 32 kg/m². Examination of the nasal passages shows boggy, edematous turbinates and no polyps. Pulmonary auscultation demonstrates clear breath sounds bilaterally with no wheezing. The remainder of the examination is normal.
The patient returns to the clinic for pulmonary function tests several days later, reporting that "my allergies and breathing are acting up again." Spirometry data are as follows:

Which of the following inhaled medication regimens would be most appropriate for initial management of this patient's condition?

Quizplus · Accepted Answer

11ec193a_98d1_da75_853d_29a21f06eef8_MD0002_00 This patient has intermittent asthma symptoms (less than daily, no waking, normal postbronchodilator FEV₁). Guidelines recommend treatment with an inhaled corticosteroid (ICS) (eg, budesonide) plus formoterol as needed. This strategy addresses leukocyte-induced bronchoconstriction as the central pathophysiology of asthma: ₁ ICSs target leukocytes and should be included at every step of asthma, even for patients with intermittent symptoms.Formoterol targets bronchoconstriction and is the preferred long-acting beta agonist (LABA) because it has fast-onset kinetics (<5 min) and is therefore effective for acute relief. ICSs target leukocytes and should be included at every step of asthma, even for patients with intermittent symptoms. ICSs target leukocytes and should be included at every step of asthma, even for patients with intermittent symptoms. Formoterol targets bronchoconstriction and is the preferred long-acting beta agonist (LABA) because it has fast-onset kinetics (<5 min) and is therefore effective for acute relief. Formoterol targets bronchoconstriction and is the preferred long-acting beta agonist (LABA) because it has fast-onset kinetics (<5 min) and is therefore effective for acute relief. Short-acting beta agonists (SABAs) (eg, albuterol) are an alternative to formoterol in patients with very infrequent intermittent symptoms, but ICSs should be taken when a SABA is used. SABA monotherapy increases the risk for future exacerbation, probably because the underlying airway inflammation is not addressed. Frequent SABA use also down-regulates airway beta-2receptors, which dampens bronchodilator responsiveness over time. (Choice A) As-needed ICSs (eg, budesonide) reduce airway inflammation but do not provide acute relief of bronchoconstriction. A fast-onset LABA (eg, formoterol) or SABA is recommended with ICS for intermittent asthma. (Choice C) Short-acting antimuscarinic agents (eg, ipratropium) are used to maximize bronchodilation during acute exacerbations of asthma and chronic obstructive pulmonary disease (COPD). However, they are not efficacious or recommended as monotherapy for intermittent asthma. (Choices D and E) Long-acting antimuscarinic agents (LAMA) (eg, tiotropium) are indicated for step-up therapy in patients with uncontrolled asthma despite scheduled high-dose ICS-formoterol. LAMA monotherapy is preferred as initial treatment for most patients with COPD; combined LAMA/LABA therapy (eg, umeclidinium-vilanterol) is used for patients who have a higher symptom score and a history of frequent exacerbations (COPD Group D). Educational objective: Inhaled corticosteroids (ICSs) are recommended at every step of asthma treatment. Intermittent symptoms are treated with an ICS and a beta agonist as needed. Formoterol is a fast-onset, long-acting beta agonist that acts as an acute reliever. __________

A 36-Year-Old Woman Comes to the Office Due to Episodic