A 14-year-old boy has severe and worsening asthma that has been responsible for three hospitalizations in the last 18 months. He has been using an albuterol inhaler, two puffs four times daily. He is referred for consultation on modification of his therapy. Which of the following regimens is most likely to reduce the incidence and severity of his attacks?
(A) aminophylline twice daily and albuterol four times daily
(B) beclomethasone twice daily and albuterol for acute attacks
© cromolyn once daily and salmeterol for acute attacks
(D) prednisone once daily and montelukast for acute attacks
(E) terbutaline six times daily
Explanation:
(B) All of the drugs listed have been used in asthma, but only the combination of beclomethasone and albuterol is rational as described. Beclomethasone is a very effective corticosteroid for preventing attacks, although it is not a bronchodilator. When used by the inhalation route, it has very low corticosteroid toxicity and can be used on a regular schedule. Albuterol is a very effective, short-acting, beta-2—selective bronchodilator that should be used for acute symptoms, not on a regular four-times-daily schedule. Aminophylline (choice A) is a long-acting bronchodilator that is rarely used except for control of nocturnal asthma. Albuterol should be used for acute attacks, not on a regular schedule. Cromolyn (choice C) is a mast cell stabilizer that is sometimes effective for prophylaxis, but salmeterol is also a prophylactic agent; there is no drug for managing acute attacks in this regimen. Prednisone (choice D) is reserved for patients who cannot be managed with inhaled steroids because it must be given systemically and has a high incidence of chronic toxicities. Montelukast is a leukotriene receptor blocker that is used prophylactically. Terbutaline (choice E) is a short acting beta-2 agonist that should only be used for acute symptoms. This regimen lacks any drug for prophylaxis.