Case study: Your clinic days have slowed down considerably after the rush at the end of the school year. With fewer patients and your own vacation not scheduled until August, you have time to think through some of your chronic disease management plans. One of these plans is for the management of chronic asthma in your adult patients. In fact, one of these patients, a 28-year-old woman named Maria, is coming to see you in clinic this morning. You enter the exam room and greet the patient warmly.
What do you ask Maria?
You ask Maria to tell you how she is doing. She tells you that she does not feel like her recently diagnosed asthma is well-controlled on her current asthma regimen. She continues to have cough and shortness of breath; she also needs to use her short-acting bronchodilator (SABA) for shortness of breath 3-4 times a week. She tells you that she is currently breathing without difficulty, but she also required her rescue inhaler shortly after waking up this morning for shortness of breath. On physical exam, Maria is afebrile, has a heart rate of 70 beats per minute, and a respiratory rate of 18. Her blood pressure is 120/76. Her eyes are not injected, heart sounds are regular, breath sounds are clear bilaterally, and she does not have any abdominal tenderness. You look in both ears with your otoscope and do not appreciate any erythema or drainage. The patient does not have any palpable lymphadenopathy.
What do you do next?
You review Maria’s spirometry results, two chest x-rays, and a CT scan done recently after repeated bouts of pneumonia. Her pulmonary function tests (PFTs) are consistent with a diagnosis of asthma, and her chest x-rays and CT scan do not show any pulmonary processes other than the pneumonia that you treated with antibiotics several months ago. You proceed to review her medications in order to decide whether to scale up on her asthma control given that she has uncontrolled asthma and requires SABA more than twice a week. She is currently on a medium-dose inhaled corticosteroid (ICS) with a SABA for breakthrough symptoms. Before changing her dose, you review whether or not she has any issues with technique or adherence to her medications. She shows you how she takes her medication, and it is spot-on; she also tells you that she never misses a dose of her ICS. She does not have any comorbid conditions, and she does not have seasonal allergies or GERD.
What are the step-up and step-down maneuvers for managing asthma in adults?
Adults with asthma fall into two general categories: patients with intermittent symptoms or patients with chronic symptoms. Patients with intermittent symptoms are often maintained on inhaled SABA for exacerbations, although there is some controversy about this management. Management for patients with chronic asthma depends on whether patients have mild, moderate, or severe symptoms. Patients with mild symptoms can start with low-dose ICS. Alternatives may include cromolyn, theophylline, and leukotriene receptor antagonists. If patient symptoms are not well-controlled, step-up management involves either medium-dose ICS or low-dose ICS plus long-acting beta-2 agonist (LABA). Alternatives may include low-dose ICS plus one of the following: zileuton, theophylline, or leukotriene receptor antagonists. The next step up is medium-dose ICS plus LABA. Alternatives are medium-dose ICS plus one of the following: zileuton, theophylline, or leukotriene receptor antagonists. At this point, the general practitioner may want to consider a referral to a pulmonologist if the patient’s symptoms are still not controlled. Additional possibilities for patients with severe asthma involve increasing the ICS to high-dose ICS and adding oral corticosteroids for severe exacerbations. Again, consider a pulmonology referral at this point.
What is your final management plan for Maria?
For Maria, you would step up from her current medication of only a medium-dose ICS to continuing the medium-dose ICS and adding a LABA. She should continue using her SABA for symptom exacerbations.
Additional Reading:
Falk NP, Hughes SW, Rodgers BC. Medications for Chronic Asthma. Am Fam Physician. 2016;94(6):454-62.
Dr. V. Silverstein
Durham, NC
Published on 6/6/19
