Optimal Medication Change for Poorly Controlled Moderate Persistent Asthma

Rationale for This Recommendation

The American Academy of Family Physicians recommends stepping up therapy for patients with poorly controlled asthma, as seen in this patient with an ACT score of 14 despite being on appropriate step 3 therapy with Symbicort (budesonide/formoterol combination ICS/LABA) 1, 2

The American Academy of Allergy, Asthma, and Immunology guidelines state that LABAs should not be discontinued when stepping up therapy in patients already on combination therapy, making Option 2 (Switching to Flovent alone) inappropriate 3, 4, 5
The American Academy of Allergy, Asthma, and Immunology guidelines also state that nebulizers offer no therapeutic advantage over properly used MDIs with spacers for stable asthma management, making Option 3 (Switching to nebulized albuterol) ineffective 3, 1
The American Academy of Family Physicians recommends against using oral corticosteroids for chronic poor control, instead suggesting adjustment of maintenance therapy, making Option 4 (Adding prednisone 40 mg daily for 5 days) unnecessary 3, 5

The Journal of Allergy and Clinical Immunology recommends assessing for factors contributing to poor control, including verifying proper inhaler technique, confirming medication adherence, identifying and addressing environmental triggers, and considering adding intranasal corticosteroids for concurrent allergic rhinitis 6, 7, 4

The American Academy of Family Physicians recommends reassessing asthma control in 2-4 weeks and tracking the number of as-needed Symbicort inhalations used daily, with more than 8 additional inhalations per day signaling the need for further step-up 1
The American Academy of Family Physicians also recommends considering stepping down therapy if the patient is well-controlled for at least 3 months 1, 2