PROBLEM

Mary is a 42-year-old woman with a 3-year history of asthma. She is rarely free of wheezing, despite multiple courses of oral corticosteroids and antibiotics for acute bronchitis. For the last few weeks, she has been coughing at night and using her rescue inhaler of albuterol more frequently, sometimes twice a day. On her own, Mary doubled the dose of her inhaled corticosteroid, without much change in her symptoms. She has been reluctant to go to her physician, fearing he might recommend that she get rid of her new cat.

APPROACH

Table 1: Asthma differential diagnosis

Most physicians now understand that asthma is a chronic inflammatory airway disorder characterized by variable cough, chest tightness, breathlessness, wheezing, and airflow obstruction on spirometric testing. In patients who do not respond to usual therapy, it is important to make sure the asthma diagnosis is correct. Other diagnoses to consider are listed in Table 1.

After the diagnosis is confirmed and the patient is still not responding to treatment, the physician must determine whether or not the patient is receiving appropriate asthma treatment. Adherence to medical therapy is another factor to consider when patients are not responding. Some patients may fear the side effects of corticosteroids. Others may be put off by the expense of medications. During symptom-free periods, patients may decide that they don't need their "controller" (inhaled corticosteroid) medications. Finally, many patients do not know how to properly use their inhalers and require repeated instruction and education. All these issues need to be addressed with Mary.

In patients with difficult-to-control asthma, it is also important to identify and treat any conditions that may be exacerbating asthma, such as environmental allergies and irritants, rhinosinusitis, gastroesophageal reflux, medication use, and psychosocial factors.

MANAGEMENT

Except for those with mild intermittent asthma (symptoms on 2 days or less per week and 2 nights or less per month), most patients with asthma are best managed with inhaled corticosteroids, and patients with more severe persistent disease will require higher doses. Alternatively, strong evidence now exists supporting the addition of long-acting beta agonists (LABA), such as salmeterol (Serevent Diskus), to low-dose inhaled corticosteroid therapy. This combination may be associated with fewer side effects. (A word of caution: In 2003, preliminary findings of the Salmeterol Multi-center Asthma Research Trial comparing salmeterol versus placebo showed a small but significant increase in asthma-related deaths in the salmeterol arm. These early results prompted FDA labeling changes for the medication.) The role of leukotriene inhibitors, such as montelukast (Singulair), in asthma management is not entirely clear. They may be appropriate for patients with mild persistent asthma who cannot or will not take inhaled corticosteroids. Finally, in patients who have symptoms despite inhaled corticosteroid and LABA therapy, a 7-to 14-day course of oral corticosteroids may be necessary to suppress airway inflammation.

Omalizumab (Xolair), a monoclonal antibody that blocks circulating IgE, is a new asthma medication that is not routinely indicated for most patients with asthma. It may have a role in difficult-to-treat asthma, especially in patients with allergies. In this patient, the obvious first step is to discuss the possibility that cat dander is exacerbating her asthma. Removing the cat may relieve some of her symptoms. However, she will probably need a course of oral corticosteroids to quiet the ongoing inflammation that has been present for at least 2 weeks. Once her symptoms are controlled again, the physician should consider other allergic triggers, reinforce the importance of medical adherence, and prescribe inhaled corticosteroids and a LABA.