Clinical Pearls & Morning Reports

Posted by Carla Rothaus, MD

Published September 13, 2023


What is the preferred treatment for mild asthma in adults?

Among U.S. adults, asthma disproportionately affects women, persons who are Black or Puerto Rican, and persons with low household income. Read the NEJM Clinical Practice Article here.

Clinical Pearls

Q: How common is new-onset asthma in adults?

A: Although asthma often presents in childhood, many children have a remission of symptoms in puberty and a recurrence in adulthood. Approximately half of adults who present with what appears to be newly diagnosed asthma instead have had a recurrence of childhood asthma.

Q: How often is new-onset adult asthma related to occupational exposures?

A: Up to 10 to 25% of new-onset adult asthma cases are attributable to work-related exposures (e.g., wood dust, grain dust, and animal dander), a correlation that emphasizes the importance of an occupational-history assessment and the identification of contact with known sensitizing agents to determine whether there is a temporal relationship between work exposures and symptoms.

Morning Report Questions

Q: What is the preferred treatment for mild asthma in adults?

A: The preferred initial treatment for mild asthma is low-dose combination inhaled glucocorticoid-formoterol as needed for symptom relief; controller treatment is no longer recommended. Alternative treatments include the use of inhaled glucocorticoid whenever a short-acting β2-agonist (SABA) is taken and daily low-dose inhaled glucocorticoid plus either as-needed SABA or as-needed inhaled glucocorticoid-SABA. The evidence clearly shows a benefit of adding inhaled glucocorticoid to a β-agonist for as-needed symptom relief, although comparative data are limited regarding which combinations are best. Patient behaviors and preferences, as well as treatment access and cost, should also be considered in the shared decision-making process of treatment selection. Some asthma experts have advocated changing the availability of inhaled glucocorticoid-formoterol from prescription to over-the-counter to increase patient access.

Q: Describe some of the information that is still needed to advance the care of adults with asthma.

A: Better strategies are needed for the objective evaluation of patient adherence and inhaler technique preceding a recommendation to step-up therapy. Clinical trials to evaluate the efficacy of digital inhalers and clinician dashboards (which provide the patient and health care professional with real-time data about medication-taking behavior and inhalation quality) regarding clinically important asthma outcomes are warranted. More studies to assess the role of biomarkers, such as blood and sputum eosinophil counts, fractional exhaled nitric oxide levels, and serum total and allergen-specific IgE levels, are needed to better guide the selection of medications.

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