Moderate Persistent Asthma Step-Up
A 58-year-old woman has wheezing and breathlessness most days during allergy season, limiting her activities several times a week, plus nocturnal waking twice weekly. She uses loratadine and antihistamine eye drops only. Examination shows conjunctival injection and expiratory wheeze. Chest radiograph is normal. FEV1 is 74% of predicted and rises 18% after bronchodilator. Which treatment is most appropriate?
- A.Scheduled daily oral antihistamine therapy
- B.Add a daily leukotriene receptor antagonist
- C.Add a low-dose inhaled glucocorticoid alone
- D.Add a low-dose inhaled glucocorticoid plus long-acting beta-2 agonistCorrect
Explanation
Daily symptoms with activity limitation and twice-weekly nocturnal waking define moderate persistent asthma, which is treated with a combination of a low-dose inhaled glucocorticoid and a long-acting beta-2 agonist. The diagnosis is confirmed by the reduced FEV1 with 18% bronchodilator reversibility, since an increase of 12% and 200 mL or more demonstrates variable expiratory airflow limitation. Inhaled glucocorticoids are the cornerstone of therapy because they suppress the underlying eosinophilic airway inflammation, reduce exacerbations and prevent airway remodelling, and no other controller matches them for these outcomes. Adding a long-acting beta-2 agonist to the inhaled steroid gives better symptom control and fewer exacerbations than doubling the steroid dose, and GINA now recommends combination inhaled corticosteroid and formoterol as both maintenance and reliever therapy at this step. A long-acting beta-2 agonist must never be prescribed as monotherapy in asthma because of the risk of severe exacerbations and asthma-related death. An inhaled glucocorticoid alone is the correct step for mild persistent disease but is insufficient when symptoms occur daily with nocturnal waking. Leukotriene receptor antagonists are weaker anti-inflammatory agents, useful as add-ons particularly with concomitant allergic rhinitis, but not as the primary controller here. Antihistamines treat rhinoconjunctivitis and have no meaningful effect on bronchial inflammation, so escalating them leaves the asthma untreated.
Why each option
- A.
- Antihistamines relieve allergic rhinoconjunctivitis but do not control bronchial inflammation, so they cannot serve as asthma controller therapy.
- B.
- A leukotriene receptor antagonist is a useful add-on, especially with allergic rhinitis, but is substantially less effective than an inhaled glucocorticoid as first-line control.
- C.
- Low-dose inhaled glucocorticoid alone suits mild persistent asthma; daily symptoms with weekly activity limitation and nocturnal waking warrant combination therapy.
- D.
- Correct. Moderate persistent asthma is treated with a low-dose inhaled glucocorticoid combined with a long-acting beta-2 agonist, which controls symptoms and reduces exacerbations better than steroid dose escalation.
Reference: GINA Global Strategy for Asthma Management and Prevention, 2025
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