A 21-year-old man with asthma comes to the office for follow-up. His asthma symptoms are not adequately controlled with albuterol as needed, and a daily inhaled therapy was added at the previous visit. The patient says he feels much better and has been using his rescue inhaler less frequently. He has no other medical conditions. The patient does not use tobacco or illicit drugs and drinks one or two 12-oz cans of beer daily. He received childhood vaccinations but has refused the flu and pneumococcal vaccines. Vital signs are within normal limits, and lungs are clear to auscultation. White mucosal plaques that can be easily scraped off using a tongue depressor are present in the oropharynx. The remainder of the physical examination shows no abnormalities. Which of the following measures would have been most effective in preventing this patient's abnormal oropharyngeal findings?

Question

A 21-year-old man with asthma comes to the office for follow-up.  His asthma symptoms are not adequately controlled with albuterol as needed, and a daily inhaled therapy was added at the previous visit.  The patient says he feels much better and has been using his rescue inhaler less frequently.  He has no other medical conditions.  The patient does not use tobacco or illicit drugs and drinks one or two 12-oz cans of beer daily.  He received childhood vaccinations but has refused the flu and pneumococcal vaccines.  Vital signs are within normal limits, and lungs are clear to auscultation.  White mucosal plaques that can be easily scraped off using a tongue depressor are present in the oropharynx.  The remainder of the physical examination shows no abnormalities.  Which of the following measures would have been most effective in preventing this patient's abnormal oropharyngeal findings?

Quizplus · Accepted Answer

Patients with intermittent asthma may be managed with an as-needed, short-acting beta-agonist alone; however, persistent symptoms or severe disease necessitates the addition of long-term controller medications. Inhaled glucocorticoids are recommended for all such patients and have been shown to improve symptoms, reduce the need for short-acting bronchodilators, and lower the risk of serious exacerbations and associated hospitalization. Low-dose inhaled glucocorticoids are well tolerated and rarely cause systemic adverse effects. However, poor inhalation technique can cause much of the medication to deposit on the oral mucous membranes, where it is ineffective and can lead to oropharyngeal candidiasis (OPC) (evidenced by white plaques that are easily scraped off). Patients can avoid this complication by using a spacer and rinsing the mouth after inhalation. Dysphonia unrelated to OPC can also occur with inhaled glucocorticoids due to myopathy of laryngeal muscles and mucosal irritation. (Choice A) Excessive alcohol intake may increase the risk of developing OPC; however, this patient's intake of 1 or 2 beers per day is within acceptable limits and is an unlikely contributing factor. (Choice B) Diphtheria (due to Corynebacterium diphtheriae) is a serious infection that typically presents with pharyngitis and gray oropharyngeal pseudomembranes; it can be prevented with vaccination. However, there is no vaccine to prevent OPC. (Choice D) Patients with chronically elevated blood glucose levels have increased risk of developing OPC; however, there is no evidence that this patient has poorly controlled diabetes mellitus. (Choice E) Prophylactic antibiotics are not indicated for OPC and, in fact, are likely to increase the risk of developing OPC by altering the normal oropharyngeal bacterial flora. Prophylactic antifungals are also not indicated for OPC. (Choice F) Vitamin A deficiency can impair cell-mediated immunity and create higher susceptibility to OPC. However, patients with vitamin A deficiency typically have drying and thickening of the skin and ocular conjunctivae. Improper administration of inhaled glucocorticoids is far more likely in this patient. Educational objective: Improper administration of inhaled glucocorticoids for the treatment of asthma can lead to adverse effects, including oropharyngeal candidiasis and dysphonia. Using a spacer during administration and rinsing the mouth after each use can help prevent these adverse effects.

A 21-Year-Old Man with Asthma Comes to the Office for Follow-Up