MKSAP: 24-year-old woman with increasing asthma symptoms

Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 24-year-old woman is evaluated for increasing asthma symptoms. Her symptoms now require her to use her as-needed albuterol inhaler two to three times per week, and she has been waking up at night at least once a week with asthma symptoms that require her inhaler. She is still able to perform most of her daily activities, including regular exercise, if she uses albuterol for prevention. She is allergic to house dust mites, ragweed, grass, trees, and cats.

On physical examination, vital signs are normal. Pulmonary examination is normal with no wheezing. Spirometry shows an FEV1 of 85% of predicted and an FEV1/FVC ratio of 80% of predicted.

Which of the following is the most appropriate treatment?

A: Add a long-acting β2-agonist
B: Add a long-acting β2-agonist and a low-dose inhaled corticosteroid
C: Add a low-dose inhaled corticosteroid
D: Advise scheduled use of albuterol
E: Refer for allergen immunotherapy

MKSAP Answer and Critique

The correct answer is C: Add a low-dose inhaled corticosteroid.

The most appropriate treatment is to add a low-dose inhaled corticosteroid (ICS). This patient has mild persistent asthma; she has symptoms more than 2 days per week but not daily and she wakes up once a week but not nightly. The preferred therapy for this patient is a low-dose ICS added to an as-needed short-acting β2-agonist. Alternatives to ICS include a leukotriene receptor antagonist or theophylline.

Adding a long-acting β2-agonist is not recommended for patients with asthma who are not already receiving ICS therapy.

Providing combination long-acting β2-agonist and ICS therapy is not indicated at this point. Based on the Expert Panel Report 3 guidelines and an FDA black box warning, patients should be started on ICS first. Long-acting β2-agonists should be added only if medium-dose ICS therapy fails to control symptoms.

Scheduled use of albuterol is not recommended, because it might mask ongoing airway inflammation and the need to provide anti-inflammatory therapy with ICS.

Allergen immunotherapy is an option for some patients, but its benefits are mostly for those with allergic rhinitis and would not be recommended for patients with mild persistent asthma.

Key Point

  • The preferred therapy for mild persistent asthma is a low-dose inhaled corticosteroid added to an as-needed short-acting β2-agonist.

This content is excerpted from MKSAP 16 with permission from the American College of Physicians (ACP). Use is restricted in the same manner as that defined in the MKSAP 16 Digital license agreement. This material should never be used as a substitute for clinical judgment and does not represent an official position of ACP. All content is licensed to on an “AS IS” basis without any warranty of any nature. The publisher, ACP, shall not be liable for any damage or loss of any kind arising out of or resulting from use of content, regardless of whether such liability is based in tort, contract or otherwise.

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