A 16-year-old boy comes to the office for follow-up after having been seen in the emergency department 5 days ago due to an acute asthma exacerbation. Two weeks ago, he developed a cough and rhinorrhea. The rhinorrhea resolved after a few days, but the cough worsened and he began wheezing, prompting his visit to the emergency department. In the emergency department, his temperature was 36.7 C (98 F), respirations were 24/min, pulse oximetry was 94% on room air, and pulmonary examination revealed scattered expiratory wheezes with slightly diminished breath sounds in all fields. The patient received 2 doses of nebulized albuterol and 60 mg of oral prednisone, after which he felt considerably better and had a normal lung examination; he was then discharged home on an additional 60 mg of prednisone daily for the next 4 days. Today he feels well and his cardiopulmonary examination is normal. Prior to this illness, he had been treated at home for the last several years with intermittent albuterol. Which of the following is the most appropriate next step in management of this patient?

Question

A 16-year-old boy comes to the office for follow-up after having been seen in the emergency department 5 days ago due to an acute asthma exacerbation.  Two weeks ago, he developed a cough and rhinorrhea.  The rhinorrhea resolved after a few days, but the cough worsened and he began wheezing, prompting his visit to the emergency department.  In the emergency department, his temperature was 36.7 C (98 F), respirations were 24/min, pulse oximetry was 94% on room air, and pulmonary examination revealed scattered expiratory wheezes with slightly diminished breath sounds in all fields.  The patient received 2 doses of nebulized albuterol and 60 mg of oral prednisone, after which he felt considerably better and had a normal lung examination; he was then discharged home on an additional 60 mg of prednisone daily for the next 4 days.  Today he feels well and his cardiopulmonary examination is normal.  Prior to this illness, he had been treated at home for the last several years with intermittent albuterol.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c075_83a8_8f63_f3a4569da00d_MD0005_00 Oral glucocorticoids (GCs) are the standard of care for treatment of acute asthma exacerbations refractory to bronchodilator therapy. GCs help alleviate airway inflammation and airflow obstruction. However, the duration of therapy should be as short as possible due to potential adverse effects. Exogenous GCs suppress endogenous cortisol production through negative feedback on the hypothalamic-pituitary-adrenal (HPA) axis. This suppression of the HPA axis may lead to adrenal insufficiency on discontinuation of glucocorticoids depending on the dose and duration of therapy. HPA axis suppression is more likely with prolonged (>3 weeks) GC usage, especially at higher doses or with evening administration. In these cases, a gradual taper of GCs is indicated to allow for the return of adequate endogenous cortisol production (Choice B). suppression of the HPA axis By contrast, short-term (<3 weeks) use of GCs is unlikely to cause significant suppression of the HPA axis, and GCs can be stopped abruptly with minimal risk of significant adrenal insufficiency. This patient has had only a 5-day course of systemic GCs and may safely discontinue without tapering. (Choices C and E) A lengthy taper of >1 month may be required for patients with very prolonged GC therapy (eg, >1 year). Alternate-day GC dosing may be associated with decreased suppression of the HPA axis and reduce the need for tapering. This patient has an acute asthma exacerbation that is now resolved; he requires neither additional treatment with GCs nor a taper of medication. (Choice D) Extending the high-dose GC regimen could be considered for a patient whose symptoms have improved but not resolved after an initial 5-day course; a taper would still not be indicated for a patient with 10 days of therapy. This patient's acute asthma exacerbation is resolved; therefore, he does not require additional GC therapy. Educational objective: Glucocorticoid administration for <3 weeks does not typically cause significant suppression of the hypothalamic-pituitary-adrenal axis and can be stopped abruptly with minimal risk of adrenal insufficiency. References: Glucocorticoid therapy and adrenal suppression. (http://www.ncbi.nlm.nih.gov/pubmed/25905379)

A 16-Year-Old Boy Comes to the Office for Follow-Up After