Treatment Options for Worsening Asthma Control During Allergy Season

Assessment of Current Control

The American Academy of Family Physicians supports the assessment of asthma control, which is considered inadequate if the Asthma Control Test score is less than 20, indicating poorly controlled asthma 3
Using a reliever medication such as albuterol more than twice a week signals the need for treatment intensification, according to the American Academy of Family Physicians 3, 4
Seasonal allergic triggers can contribute to poor asthma control, as evidenced by reduced exercise tolerance and increased cough frequency during allergy season 1

The American Academy of Family Physicians recommends adding a leukotriene receptor antagonist (LTRA) such as montelukast to the current ICS/LABA combination for patients requiring additional control beyond Step 3 care 1, 2
LTRAs are particularly effective for allergic asthma and can attenuate allergen-induced bronchoconstriction, as supported by the Journal of Allergy and Clinical Immunology 2
Adding an LTRA addresses the seasonal allergic component without requiring dose escalation of corticosteroids, which is recommended by the Journal of Allergy and Clinical Immunology 1

The American Academy of Family Physicians supports verifying proper inhaler technique before stepping up therapy, as poor technique is a common cause of apparent treatment failure 1
Assessing medication adherence is crucial to ensure the patient is actually taking the prescribed medication, as recommended by the Journal of Allergy and Clinical Immunology 1

Implementing multiple allergen avoidance strategies during spring allergy season is essential, as single interventions are rarely sufficient, according to the Journal of Allergy and Clinical Immunology 1
Keeping windows closed during high pollen counts, using HEPA filters, and showering after outdoor exposure can help reduce allergen exposure, as recommended by the Journal of Allergy and Clinical Immunology 1

The American Academy of Family Physicians recommends never discontinuing the ICS component when adding adjunctive therapy, as LABAs without ICS significantly increase mortality risk 2, 3
The American Academy of Family Physicians advises against increasing ICS dose to high levels as the first step, since the dose-response curve for ICS is relatively flat beyond moderate doses, with high doses providing minimal additional benefit but substantially increasing systemic side effects 3

Reassessing the patient in 2-4 weeks after adding LTRA is crucial to evaluate improvement in Asthma Control Test score, reduction in reliever medication use, and improvement in exercise tolerance, as recommended by the American Academy of Family Physicians 3, 4
If control remains inadequate after optimizing Step 4 therapy, considering referral to an asthma specialist for evaluation of Step 5 options is recommended by the Journal of Allergy and Clinical Immunology and the American Academy of Family Physicians 1, 5