What changes should be made to his current regimen?

A 54-year-old male with a long history of mild persistent asthma on daily fluticasone therapy has been using his albuterol inhaler every day for the past month, and presents requesting a refill.

What changes should be made to his current regimen?
A . Add ciclesonide to current regimen
B . Add salmeterol to current regimen
C . Discontinue fluticasone and instead use salmeterol
D . Add cromolyn to current regimen
E . Discontinue fluticasone and add ipratropium to current regimen

Answer: B


Add salmeterol to the current regimen. This patient had mild persistent asthma but was using his albuterol daily, which indicates that a step up in therapy is warranted. The preferred first line treatment regimen for moderate persistent asthma are low to medium dose inhaled corticosteroids plus a long acting beta2 agonist, as well as a short acting beta2 agonist as needed. A is incorrect. Ciclesonide is an inhaled corticosteroid. The patient in the case is already using fluticasone, so adding ciclesonide would be therapeutic duplication. C is incorrect. Long-acting beta2 agonists should only be used as adjunctive therapy in patients who are currently receiving but not adequately controlled on an inhaled corticosteroid. These medications should not be used as monotherapy, due to an increased risk of asthma related deaths. D is incorrect. Cromolyn prevents the release of vasoactive mediators from mast cell and is primarily used for exercise-induced asthma, it is not indicated as an alternative agent in patients with moderate persistent asthma. E is incorrect. Ipratropium is a short-acting anticholinergic, which is often used in COPD or in asthma exacerbations. It is not indicated for maintenance treatment of moderate persistent asthma.

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