42-year-old baker with wheezing worse on workdays
A 42-year-old woman with allergic rhinitis reports 3 months of cough, chest tightness, and wheezing that wake her 3 nights each week. She uses her albuterol inhaler several times most days. Symptoms are noticeably worse during weekday shifts at a commercial bakery and improve on weekends. She has had two prednisone bursts in the past year. Temperature is 36.8 C, blood pressure 124/76 mm Hg, pulse 82/min, and oxygen saturation 98% on room air. Spirometry shows FEV1 78% of predicted with a 16% increase after bronchodilator. Which of the following is the most appropriate next step in management?
See the answer and explanation below:
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View on AmazonThe Correct Answer
D
Explanation
Clinical Pearl:
In adults with asthma that is frequent, nocturnal, and exacerbation-prone, inhaled corticosteroid-containing therapy is essential; for moderate persistent disease, ICS-formoterol used as both controller and reliever reduces severe exacerbations and treats symptoms promptly. Improvement away from work should prompt evaluation and mitigation of occupational triggers.
Explanation:
This patient has uncontrolled moderate persistent asthma with likely occupational exposure, based on frequent daytime symptoms, nighttime awakening, repeated steroid bursts, reversible airflow obstruction, and clear worsening at the bakery. Current GINA-based management favors an inhaled corticosteroid-containing regimen rather than SABA-only treatment, and for patients with this symptom burden, ICS-formoterol used as both maintenance and reliever therapy is an evidence-based choice that lowers exacerbation risk while improving daily control. Continuing albuterol alone leaves airway inflammation untreated and is no longer appropriate. Tiotropium can be added in selected patients with persistent symptoms despite adequate ICS-LABA therapy, but it is not preferred monotherapy. Using low-dose inhaled corticosteroid only when symptoms occur is generally insufficient for someone with this level of impairment and recent exacerbation history. Chronic oral prednisone carries substantial toxicity and is reserved for severe refractory disease after optimized inhaled therapy and specialist evaluation.
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