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Asthma — ABIM Board MCQ

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EasyAsthma ManagementAsthmaABIM Board

A 28-year-old with asthma has symptoms requiring albuterol on 3 days each week but has no nighttime awakenings, activity limitation, or exacerbations requiring systemic glucocorticoids. Inhaler technique is appropriate. According to NHLBI/NAEPP guidance, which is a preferred Step 2 controller and reliever regimen?

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Correct answer: B — Daily low-dose inhaled corticosteroid with albuterol as needed

This patient has mild persistent asthma (symptoms more than twice weekly but not daily, no nocturnal or activity impairment), which corresponds to Step 2. The 2020 NHLBI/NAEPP focused updates recommend either daily low-dose inhaled corticosteroid with as-needed SABA, or as-needed concomitant ICS and SABA, so daily low-dose ICS with as-needed albuterol is correct. Daily plus as-needed ICS-formoterol (SMART) is the NAEPP-preferred regimen at Steps 3 and 4 for moderate to severe persistent asthma; choosing it here would over-escalate therapy and does not match US Step 2 guidance (GINA differs, but the question asks about NHLBI/NAEPP). Montelukast is only an alternative Step 2 agent and carries an FDA boxed warning for neuropsychiatric events. Theophylline is less effective, requires level monitoring, and is not preferred. SABA alone fails to treat airway inflammation and is inappropriate for persistent asthma.

Reference: NHLBI/NAEPP. 2020 Focused Updates to the Asthma Management Guidelines: At-a-Glance Guide for Clinicians — Stepwise Approach, Step 2 (Ages 12+). 2020. https://www.nhlbi.nih.gov/sites/default/files/publications/Asthma%20Clinicians%20At-a-Glance%20508_02-03-21.pdf