Question of the Week # 470

470) An 11-year-old with a history of asthma and seasonal allergies is currently using albuterol to manage asthma symptoms. Recently his use of albuterol has increased from 1-2 days per week to 4 times per week for several weeks, though does not experience his symptoms daily. On physical examination, you find that his vital signs are within normal limits. Auscultation of his lungs reveals mild end expiratory wheezing. Given his persistent symptoms, what change should be made to his current treatment regimen?

A. Add salmeterol twice daily

B. Add montelukast 10mg daily

C. Add fluticasone daily

D. Add formoterol + budesonide twice daily

E. Add tiotropium

11 Responses

  1. Mild Persistent Asthma. Will add fluticasone .
    R Basharat.

  2. B

  3. Correct answer l suggest C
    If rapid-acting beta2 agonists are used more than 2 days a week for symptom relief , stepping up on treatment may need be considered.

  4. E. Mid persistent asthma

  5. This is a mild persistent asthma in a child .
    To answer the question we need to remind ourselves the 4 types of asthma : Mild intermittent , Mild persistent , Moderate , Severe
    .We remind ourselves also the day time symptoms and frequency , The night time symptoms and frequency , the PFTs and the treatment .
    Having said that In a mild persistent Will add a corticosteroid inhaler or Cromolyn in Children .
    In the context of the question above the answer will be C

  6. C

  7. Intermittent versus Persistent Asthma, there is a silver line between the two. (i.e 1-2 attacks/week is Intermittent, 3 or more attacks is Persistent) Persistent Asthmatics get inhaled steroids

    Albuterol – Intermittent – less than 2 attacks in a week
    Add inhaled steroid – Persistent – more than 2 attacks in a week
    a) low dose- Mild Persistent – not daily attacks
    b) medical dose – Moderate Persistent – daily attacks
    c) high dose – Severe Persistent – continous attack

    What just happened?
    Patients symptoms switched from Intermittent to Persistent
    Fluticasone is an inhaled steroid spray (Option C) used in Persistent Asthma.

    What does a steroid do? It alters membrane structure of all cells, restoring normalcy like a referee in a boxing ring.
    Bronchial smooth muscles – become more susceptible to B-agonists
    Capillary endothelium – becomes less leaky
    Macrophages – do not release secretagogues (decrease secretions)
    Leucocytes – do not release pro-inflammatory proteins
    (reference: http://www.ncbi.nlm.nih.gov/pubmed/3026210)

    Why not use a more long acting beta- agonist, salmeterol (Option A)?
    It will not address the allergy and the mucosal edema. The over-drive proinflammatory cells are still firing.

    Ok, why not use an anticholinergic (tiotropium, Option E)? Adverse effects will be more. (Can’t see, can’t pee and can’t climb a tree?) These are not something that are necessarily needed unless we run out of options.

    Ok, why not use Montelukast (Option B)? It is the best detractor in this question. It is a Leukotriene receptor antagonist. In other words, a traffic police holding a stop sign for the pro-inflammatory cells. But how well does it address the bronchospasm compared to inhaled steroids?
    You guessed right. Inhaled steroids are better at multitasking in acute exacerbation of asthma. Montelukast are better in prevention services and adjunctive services.
    (reference: http://www.ncbi.nlm.nih.gov/pubmed/10804041)

    Hold on, why not combine a long acting beta agonist (formetorol) with a
    systemic steroid (Budesonide), which is Option D? That will be too extreme like killing a wasp or a housefly with a bazooka. Let’s keep this ooption for when we see daily symptoms or continous symptoms (that is, Moderate and Severe Persistent Asthma respectively)

    So, this patient just switched from intermittent to persistent. He is having 3-4 attacks despite using his Albuterol inhaler. He has recently gotten worse from 1-2 attacks to 3-4 attacks. He needs a low dose steroid inhaler like fluticasone added to his Albuterol inhaler.

    My answer is Option C.

    Thank you.

    • Adnan, I always love your explanations. Systematic and easy to read. Thank you!

      Just a little correction though — anticholinergic side effects are “blind as a bat, red as a beet, hot as a hare, mad as a hatter, dry as a bone” and “bowel and bladder lose their tone while the heart runs alone”.

      “Can’t see, can’t pee, can’t climb a tree” is for reactive arthritis/ Reiter’s syndrome.

  8. Adnan your explanations are unbelievable so good way to go All the best

  9. The correct answer is C

  10. C

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