A 28-year-old primigravid woman at 20 weeks gestation comes to the office for asthma follow-up. Her asthma has been managed with combination mometasone-formoterol for relief as needed. She has never been hospitalized for asthma. Prior to pregnancy, the patient used a reliever inhaler no more than 1 or 2 times per month. However, over the past 2 months, she has used her inhaler several days per week. The patient also reports occasionally awakening at night with cough and wheezing. She denies any specific asthma triggers and does not own any pets.
Temperature is 36.7 C (98 F), blood pressure is 110/70 mm Hg, pulse is 84/min, and respirations are 16/min. Pulse oximetry is 96% on room air. The patient is not in acute distress and is breathing comfortably. Lung examination demonstrates good air entry with scattered expiratory wheezing bilaterally.
Results of spirometry are as follows:
Which of the following is the most appropriate pharmacotherapy?

Question

A 28-year-old primigravid woman at 20 weeks gestation comes to the office for asthma follow-up.  Her asthma has been managed with combination mometasone-formoterol for relief as needed.  She has never been hospitalized for asthma.  Prior to pregnancy, the patient used a reliever inhaler no more than 1 or 2 times per month.  However, over the past 2 months, she has used her inhaler several days per week.  The patient also reports occasionally awakening at night with cough and wheezing.  She denies any specific asthma triggers and does not own any pets.
Temperature is 36.7 C (98 F), blood pressure is 110/70 mm Hg, pulse is 84/min, and respirations are 16/min.  Pulse oximetry is 96% on room air.  The patient is not in acute distress and is breathing comfortably.  Lung examination demonstrates good air entry with scattered expiratory wheezing bilaterally.
Results of spirometry are as follows:
 Which of the following is the most appropriate pharmacotherapy?

Quizplus · Accepted Answer

11ec193a_98d3_882a_853d_6f1235a80830_MD0002_00 Asthma is the most common pulmonary disorder encountered during pregnancy. Most pregnant women experience a change in their asthma control, with disease severity improving in one-third but worsening in another third. The benefits of treating asthma during pregnancy greatly outweighs potential adverse medication effects. Poorly controlled asthma is associated with increased perinatal complications (eg, preterm delivery, low birth weight, fetal hypoxia) and maternal morbidity. The approach to asthma in pregnant women is similar to treatment in nonpregnant adults. Management includes objective pulmonary function testing, symptoms scoring with validated tools (eg, Asthma Control Test), avoiding asthma triggers, and patient education. Pharmacotherapy is intensified until symptoms are adequately controlled. This patient has persistent asthma (nighttime awakenings, symptoms most days), and her therapy should be stepped up according to established guidelines. stepped up The patient's combination inhaled corticosteroid and long-acting beta-agonist (ICS/LABA) should now be taken on a scheduled basis to achieve control. Formoterol is a LABA with fast-onset kinetics (<5 min), so ICS-formoterol inhalers can be used as an acute reliever as well. (Choice A) Tiotropium is the only long-acting muscarinic antagonist approved for pregnant women who continue to have uncontrolled asthma despite scheduled high-dose scheduled ICS and beta-agonist. (Choice B) The patient's worsening asthma should be addressed as soon as possible, and intensification of pharmacotherapy is an important part of establishing control. Poorly controlled asthma carries a greater risk of poor maternal-fetal outcomes. (Choice C) Oral prednisone would be appropriate for an acute exacerbation, even during pregnancy. However, this patient is not in significant acute distress. (Choice E) Salmeterol, a slower-onset LABA (15 to 30 min) with a relatively slow onset of action, is not preferred as an acute reliever. In addition, controlling asthma by scheduling the patient's existing ICS/LABA regimen, rather than changing the inhaler formulation, places less of a burden on her. Educational objective: Asthma treatment for pregnant and nonpregnant adults is approached in a similar way. Excellent asthma control reduces the risk of negative maternal and fetal outcomes, and an inhaled corticosteroid with a beta-agonist should be included at every step. __________

A 28-Year-Old Primigravid Woman at 20 Weeks Gestation Comes to the Office