A 34-year-old man comes to the office to reestablish routine healthcare. The patient has a 9-year history of asthma, for which he uses an inhaler containing a combination of both inhaled corticosteroid (ICS) and long-acting beta agonist (LABA) as needed. For the past 2 years, he has been using this combination inhaler about 3 times per week. His asthma symptoms wake him from sleep approximately once every week. The patient has seasonal allergies to ragweed, but he has no other medical conditions and takes no other medications. He demonstrates excellent inhaler technique in the office, with good synchronization and breath holding. The patient does not use tobacco, alcohol, or illicit drugs. Family history is significant for asthma in his grandfather. Vital signs are normal. Lung auscultation indicates normal breath sounds without wheezing. Heart sounds are normal. Which of the following is the most appropriate next step in management of this patient?

Question

A 34-year-old man comes to the office to reestablish routine healthcare.  The patient has a 9-year history of asthma, for which he uses an inhaler containing a combination of both inhaled corticosteroid (ICS) and long-acting beta agonist (LABA) as needed.  For the past 2 years, he has been using this combination inhaler about 3 times per week.  His asthma symptoms wake him from sleep approximately once every week.  The patient has seasonal allergies to ragweed, but he has no other medical conditions and takes no other medications.  He demonstrates excellent inhaler technique in the office, with good synchronization and breath holding.  The patient does not use tobacco, alcohol, or illicit drugs.  Family history is significant for asthma in his grandfather.  Vital signs are normal.  Lung auscultation indicates normal breath sounds without wheezing.  Heart sounds are normal.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d302_b6db_bc81_7df3480265f7_MD0003_00 This patient has persistent asthma, diagnosed when any of the following criteria are present during the week: Nocturnal waking with asthma on any night (often the earliest indicator of poor disease control) Symptoms requiring reliever inhaler use on most days Reduced FEV₁ (while the patient is taking bronchodilator therapy) Many patients may be falsely reassured that their asthma is well controlled because their symptoms do not interfere with daily life and are alleviated with acute reliever therapy alone. Therefore, they may self-treat intermittently despite having persistent asthma, which leads to chronic undermedication and poor long-term control. Undertreatment of persistent asthma is associated with greater lung function decline and a higher likelihood of severe acute exacerbations (Choice C). Patients with persistent asthma should be treated with a scheduled combination inhaler that contains both an inhaled corticosteroid (ICS) and a long-acting fast-onset beta agonist (formoterol preferred). Clinical response should be reassessed using validated tools, such as the Asthma Control Test questionnaire. If the asthma remains uncontrolled (eg, persistent nocturnal awakenings), the next step would be to increase the dose of the ICS component. (Choice A) Long-acting antimuscarinic agents (eg, tiotropium) are indicated for step-up therapy in patients with poorly controlled persistent asthma despite scheduled high-dose ICS-formoterol. (Choice B) Short courses of oral prednisone are indicated in acute asthma exacerbations (eg, wheezing) and cases of poorly controlled symptoms. Chronic use of oral prednisone is not recommended due to significant adverse effects (eg, glucose intolerance, osteopenia, adrenal suppression). (Choice D) Allergy desensitization is an adjunctive controller treatment that can benefit a minority of patients with asthma and rhinitis driven by a specific aeroallergen (eg, immunotherapy with house dust mite proteins). It is less effective for patients, such as this one, who have seasonal allergies but experience persistent asthma symptoms. Immunotherapy is not a substitute for optimization of inhaled ICS-beta agonist therapy; in the absence of appropriate asthma control, allergen challenge may cause asthma to worsen. Educational objective: Persistent asthma is treated with a step-up in asthma therapy involving scheduled inhaled corticosteroids and long-acting (fast-onset) beta agonists.

A 34-Year-Old Man Comes to the Office to Reestablish Routine