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Child asthma controller — USMLE Step 3 MCQ

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HardPediatrics (Well-child / Chronic Management)Child asthma controllerUSMLE Step 3

A 16-year-old remains symptomatic despite confirmed adherence and technique with medium-dose inhaled corticosteroid-formoterol maintenance-and-reliever therapy. Triggers and comorbidities have been addressed. Higher inhaled corticosteroid exposure caused troublesome dysphonia, there is no glaucoma or urinary retention, and specialist phenotyping is pending. Which interim add-on best follows the NHLBI focused updates?

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Correct answer: A — Add a long-acting muscarinic antagonist to the existing inhaled corticosteroid-LABA regimen

The best answer is “Add a long-acting muscarinic antagonist to the existing inhaled corticosteroid-LABA regimen”. For patients at least 12 years old whose asthma remains uncontrolled on ICS-LABA, NHLBI conditionally recommends adding a LAMA. The expected benefit is modest, but it is a rational interim inhaled add-on when adherence and modifiable factors are addressed and further corticosteroid escalation is poorly tolerated. Biologic selection requires phenotype and eligibility assessment, while chronic macrolide or leukotriene-receptor-antagonist substitution is not the focused-update add-on supported here.

Reference: NHLBI 2020 Focused Updates to the Asthma Management Guidelines: https://www.nhlbi.nih.gov/sites/default/files/publications/AsthmaManagementGuidelinesReport-2-4-21.pdf