Home Regular Therapy in PracticeCase Study: Deirdre

Deirdre

35
Female
Non-smoker

Baseline characteristics and patient history

Past mild asthma diagnosis at 6 years of age
Currently experiencing worsening of her asthma:
- Moderate exercise limitations despite SABA use pre-exercise
- Night-time symptoms once/twice per fortnight
Has previously been well-controlled; the patient’s adherence to her controller inhaler is excellent and she perceives her asthma as being well controlled
She uses her SABA inhaler for instant relief when she experiences shortness of breath, wheeze and chest tightness. She has recently been using SABA as a reliever approximately twice a week
FEV₁ 70% predicted, ACT score 17, BMI within normal range, slight wheeze on examination
Normal chest X-ray, no clinical signs of respiratory infection. No recent exposure to allergens

Current treatment

Daily low-dose ICS/LABA with as-needed SABA as a reliever, stepped up from daily low-dose ICS plus as-needed SABA in her teenage years.

Q1: What severity of asthma would you diagnose Deirdre with?

Mild

Moderate

Severe

Likely incorrect

Deirdre is symptomatic weekly with at least 3-4 nocturnal awakenings per month and limitation in her activity. Her asthma is poorly controlled on low-dose ICS/LABA monotherapy plus as-needed SABA as demonstrated by her ACT score and she has moderate airway obstruction with an FEV₁ of 70%.¹

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Potentially correct

Moderate asthma has been defined as asthma that is well controlled with low or medium dose ICS/LABA.¹

Deirdre is symptomatic weekly with at least 3-4 nocturnal awakenings per month, limitation in her activity and wheeze on examination. Her asthma is poorly controlled on low-dose ICS/LABA plus as-needed SABA as demonstrated by her ACT score and she has moderate airway obstruction with an FEV₁ of 70% despite excellent adherence to her treatment. Asthma control should be assessed after treatment with medium-dose ICS/LABA to definitively diagnose asthma severity.

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Possibly correct, although other options may be more likely

Deirdre cannot be classified as having severe asthma. It has not been demonstrated that her asthma will remain uncontrolled on step-up to medium or high-dose ICS/LABA maintenance therapy. Her symptoms are not occurring daily, and her lung function parameters are not low enough to suggest a diagnosis of severe asthma.¹

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Q2: Given Deirdre’s history, which treatment goal is best prioritized?

Symptom control

Exacerbation reduction

Correct

For many patients in primary care, improving symptom control is a good approach to reduce future risk of exacerbations; however, some patients may continue to experience exacerbations despite having well-controlled symptoms.¹

Continue

Correct, but other options may be more appropriate

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Q3: What would be your treatment recommendation as an alternative to Deirdre’s current regimen?

Step-up to daily maintenance medium-dose ICS/LABA with SABA as a reliever

Switch to ICS/formoterol as maintenance and reliever

Medium-dose ICS or low-dose ICS/LTRA + ICS/formoterol as a reliever

Correct

Deirdre is currently being treated for moderate asthma according to Step 3 of the GINA 2022 treatment Track 2.¹ She has been noted to have excellent adherence to her treatment regimen and has been trained in using a separate inhaler for both controller and reliever medication since childhood.

With these factors in mind, stepping the patient up to daily maintenance medium-dose ICS/LABA with as-needed SABA as a reliever could be an appropriate recommendation.

Correct, but other options may be more appropriate

According to the GINA 2022 recommendations, a switch to low or medium-dose ICS/formoterol is a valid choice.¹ However, in this case the patient is familiar with using separate controller and reliever inhalers and has had excellent adherence to her current treatment regimen. Recommendation of a combination medium-dose ICS/LABA maintenance therapy with as-needed SABA as a reliever may be more appropriate for this patient and will not require further training on inhaler administration.

Likely incorrect

These options are not appropriate step-up therapy for this patient according to the GINA recommendations for treatment of asthma in adults and adolescents.¹

Abbreviations

ACT, Asthma Control Test; BMI, body mass index; FEV₁, forced expiratory volume in 1 second; GINA, Global Initiative for Asthma; ICS, inhaled corticosteroid; LABA, long-acting β₂-agonist; LTRA, leukotriene receptor antagonist; SABA, short-acting β₂-agonist.

Reference

1. Global Initiative for Asthma 2022 Report. Global Strategy for asthma management and prevention. Available from: https://ginasthma.org/gina-reports/. Accessed 15 March 2023

NX-GBL-ASU-WCNT-220003 | March 2023