AMBULATORY CARE SELF-ASSESSMENT PROGRAM

2025
SERIES EDITORS

Brian K. Irons, Pharm.D., FCCP, BCACP

Ashley H. Meredith, Pharm.D., MPH, FCCP, BCACP, BCPS, CDCES

ACCP collaborates with ASHP on

Ambulatory Care Pharmacy activities.
AMBULATORY CARE SELF-ASSESSMENT PROGRAM

ACSAP Series Editors

Brian K. Irons, Pharm.D., FCCP, BCACP, Professor, Jerry H. Hodge School of Pharmacy,
Texas Tech University Health Sciences Center, Lubbock, Texas

Ashley H. Meredith, Pharm.D., MPH, FCCP, BCACP, BCPS, CDCES, Clinical Professor of
Pharmacy Practice, Purdue University, West Lafayette, Indiana

The ACSAP Series Editors design each year’s release by drawing from the domains, tasks, and knowledge statements in the BPS
Pharmacotherapy Specialist Certification Content Outline/Classification System. Working with a Faculty Panel Chair (guest editor),
the Series Editors refine the list of chapters and features so that only the most relevant topics are updated in each release.
Members of the faculty panel collaborate on the content outline for each chapter and feature, ensuring a complete review
of published evidence on that clinical topic. Generalist BCACP reviewers join the editorial process to enhance the material’s
appropriateness for the recertifying audience. The result is an evidence-based update that can be used to self-assess clinical skills
and improve patient outcomes.

New for 2025!

• Second-Chance Posttest Option Visit the ACCP Store at
• Complete single chapters/features for credit www.accp.com/store
• 12-month recertification posttest window

ACSAP Recertification ACPE Minimum

Content Planned Release Date
Release Deadline Deadline Hours

Pulmonary, Neurologic,
ACSAP 2025 Psychiatric, and Mar. 17, 2025 Mar. 17, 2026 Mar. 17, 2028 15.0
Infectious Diseases

Cardiologic and
Gastrointestinal
ACSAP 2026 Diseases and Issues Mar. 16, 2026 Mar. 16, 2027 Mar. 16, 2029 15.0
Specific to Geriatric
and Pediatric Patients

Endocrinologic,
Rheumatologic, and
Nephrologic Diseases,
ACSAP 2027 Issues Specific to Men’s Mar. 15, 2027 Mar. 15, 2028 Mar. 15, 2030 15.0
and Women’s Health,
and Ambulatory Practice
Management

ACCP’s Self-Assessment Programs are home study series that provide clinical
pharmacists with pertinent therapeutic updates to enhance their practice skills
and improve patient outcomes.
The American College of Clinical Pharmacy and American Society of Health-System
Pharmacists are approved by BPS as a provider for the recertification of BCACP. ®
IMPORTANT INFORMATION ON THE RELEASE OF ACSAP 2025
BOOK FORMATS AND CONTENT

Online book: All purchasers of this ACSAP release have access to the online book (interactive PDFs). To access, go to
www.accp.com and sign into your My Account page using your e-mail address and password (technical assistance is avail-
able). Scroll down to find your book and the required posttests under My Products. The online book can be saved to the desktop
or printed. The latest version of Adobe Acrobat Reader (available free) offers functionality such as highlighting or adding “sticky
notes” to the text.

E-Media Format: All purchasers also have access to the e-media version. Follow these instructions to load the text and self-as-
sessment questions in this book onto your e-reader, tablet, or Android phone.

Hyperlinks: To facilitate further learning and research, this publication incorporates hyperlinks to websites administered by other
organizations. Internal and external hypertext links are visible as underlined text and are active in both the Online and e-Media ver-
sions of the book. NOTE: ACCP assumes no liability for material downloaded from or accessed on these websites.

Abbreviations, Laboratory Values: At the start of each chapter/feature are hyperlinks to tables with selected medical abbrevi-
ations and reference ranges for common laboratory tests. These tables can be used as a resource in reading the material and
completing the self-assessment questions.

NOTE: The editors and publishers of ACSAP recognize that the development of this volume of material offers many opportunities
for error. Despite our best efforts, some errors may persist into publication. Drug dosage schedules are, we believe, accurate and
in accordance with current standards. Readers are advised, however, to check package inserts for the recommended dosages and
contraindications. This is especially important for new, infrequently used, and highly toxic drugs.
Director, Professional Development and Marketing: Joanna Gillette, B.A.
Director, ACCP Career Development Programs: Keri A. Sims, Pharm.D., BCPS
Senior Managing Editor: Edward Alderman, B.S., B.A.
Managing Editor: Peter Burns, B.A.
Medical Editor: Kimma Sheldon-Old, Ph.D.
Director, Information Technology: Brent Paloutzian, A.A.S.

ACSAP 2025
ISBN: 978-1-964074-16-0.

For ordering information or questions, e-mail: [email protected]

To cite ACSAP properly:

Chapter authors. Chapter name. In: Irons BK, Meredith AH, eds. Ambulatory Care Self-Assessment Program, 2025. ACSAP 2025.
Lenexa, KS: American College of Clinical Pharmacy, 2025:page range.

ACSAP™ is a registered trademark of the American College of Clinical Pharmacy.

Ambulatory Care
Self-Assessment
Program

Copyright ©2025 by the American College of Clinical Pharmacy and the American Society of Health-System Pharmacists. All
rights reserved. This book is protected by copyright. No part of this publication may be reproduced, stored in a retrieval system,
or transmitted, in any form or by any means, electronic or mechanical, including photocopy, without prior written permission of
the American College of Clinical Pharmacy and the American Society of Health-System Pharmacists. NOTE: Purchasers of this
product may have one copy of the PDF printed for their personal educational use.
Continuing Pharmacy Education
and Recertification Instructions

TESTING
Book Release Date: March 17, 2025
BCACP test deadline: 11:59 p.m. (Central) on March 17, 2026
ACPE test deadline: 11:59 p.m. (Central) on March 17, 2028

Before submitting a posttest: Check the online errata for any changes or updates to this Ambulatory Care Self-Assessment
Program release. You may complete one or all available elements for credit. Submitting a required posttest for BCACP recertifica-
tion attests that you have completed the activity as an individual effort and not in collaboration with any other individual or group.
Failure to complete this test as an individual effort may jeopardize your ability to use ACSAP for BCACP recertification.

ACSAP target Audience: The target audience for ACSAP 2025 is board-certified and advanced-level ambulatory care clinical phar-
macists who provide care for patients with a wide range of disorders related to respiratory, infectious, neurologic, and psychiatric
diseases.

Available CPE credits: Purchasers who successfully complete all posttests for ACSAP 2025 can earn 18.5 contact hours of CPE
credit. The universal activity numbers are as follows:

Learning Activity ACPE Activity Number CPE Hrs

Recorded Webcast: Chronic Obstructive Pulmonary Disease 0217-9999-25-041-H01-P 1.5

Chapter: Updates in Asthma Management 0217-9999-25-048-H01-P 1.5

Case Series: Upper Respiratory Tract Infections in Adults 0217-9999-25-049-H01-P 2.0

Chapter: HIV Preexposure Prophylaxis 0217-9999-25-044-H01-P 2.0

Case Series: Long COVID 0217-9999-25-045-H01-P 2.0

Chapter: Opioid Use Disorder 0217-9999-25-047-H01-P 2.0

Chapter: Epilepsy 0217-9999-25-043-H01-P 2.5

Chapter: Migraine 0217-9999-25-046-H01-P 2.5

Case Series: Depression and Anxiety 0217-9999-25-042-H01-P 1.0

Case Series: Bipolar Disorder 0217-9999-25-040-H01-P 1.5

TO EARN CPE CREDITS FROM THIS ACSAP BOOK

Posttest access: Go to www.accp.com and sign in with your e-mail address and password. Technical support is available from 8 a.m.
to 5 p.m. (Central) weekdays by calling (913) 492-3311. ACSAP products are listed under My Products on your My Account page.

BCACP Recertification Credit: To receive BCACP recertification CPE credit, an ACSAP posttest must be submitted
within the 1-year period after the book’s release (see above). Only completed tests are eligible for credit; no partial
or incomplete tests will be processed. You may complete one or all available learning activities for credit.

The passing point to earn BCACP recertification credit is based on an expert analysis of the assessment items in each posttest.
Any posttest submitted before the BCACP test deadline that meets this passing point will earn BCACP recertification credits.
These credits will be assigned as of the date of test submission and reported within 48 hours to BPS. For statements of recertifi-
cation credit, visit www.bpsweb.org.

Remediation: In accordance with BPS guidelines concerning remediation for products launched in 2024 and after, posttests that
do not reach the passing point for recertification credit will generate a second-chance test option. This test will automatically
appear in the learner’s My Account page and will have assessment items presented in a different order. To qualify for recertifica-
tion credit, the second-chance test must be submitted before the recertification posttest deadline stated above.

Recertification: The ACCP Recertification Dashboard is a free online tool that can track recertification credits as they are earned
through ACCP and schedule new opportunities for credits from upcoming ACCP professional development programs. Questions
regarding the number of hours required for BCACP recertification should be directed to BPS at www.bpsweb.org.

ACPE CPE Credit: To receive ACPE CPE credit for an ACSAP chapter or feature, a posttest must be submitted within 3 years after
the book’s release (see above). Only completed tests are eligible for credit; no partial or incomplete tests will be processed. You
may complete one or all available learning activities for credit. Any posttest submitted before the ACPE deadline that scores 50%
or greater will be awarded the appropriate CPE. These credits will be assigned as of the date of test submission and reported
within 48 hours. For statements of CPE credit, visit www.mycpemonitor.net.

Posttest answers: The explained answers for each learning activity – with rationale and supporting references – will be posted 2
weeks after the recertification posttest deadline and will be available on the My Account page to anyone who has either (1)
submitted a posttest or (2) waived the right to receive credit from a posttest. Go to www.accp.com and sign in with your e-mail
address and password. By completing the waiver form, you waive the opportunity to receive CPE credit for that learning activity.

Continuing Pharmacy Education Credit: The American College of Clinical Pharmacy is accredited by the Accreditation
Council for Pharmacy Education as a provider of continuing pharmacy education.

The American Society of Health-System Pharmacists is accredited by the Accreditation Council for Pharmacy Education
as a provider of continuing pharmacy education with Commendation.

The American College of Clinical Pharmacy and the American Society of Health-System Pharmacists
are approved by BPS as a provider for the recertification of BCACP.

BPS is an autonomous division of the American Pharmacists Association. To maintain its strict, inde-
pendent standards for certification, BPS does NOT endorse or provide review information, preparatory
courses, or study guides for board certification examinations. BPS, through its specialty councils, is
responsible for specialty examination content, administration, scoring, and all other aspects of its certi-
fication programs. BPS is totally separate and distinct from ACCP and ASHP. For information about BPS
specialty recertification or the BPS recertification process, go to: http://www.bpsweb.org/
ACSAP 2025 Panel

Series Editors: Faculty Panel Chair:

Brian K. Irons, Pharm.D., FCCP, BCACP Melissa Lipari, Pharm.D., BCACP
Professor Clinical Associate Professor and Pharmacy Specialist
Jerry H. Hodge School of Pharmacy Wayne State University
Texas Tech University Health Sciences Center Detroit, Michigan
Lubbock, Texas
Disclosures: ACCP Staff/Series Leaders
Ashley H. Meredith, Pharm.D., MPH,
Nothing to disclose: Ed Alderman; Peter Burns; Joanna
FCCP, BCACP, BCPS, CDCES
Gillette; Brian K. Irons; Melissa Lipari; Ashley H. Meredith;
Clinical Professor of Pharmacy Practice
Brent Paloutzian; Kimma Sheldon-Old; Keri Sims
Purdue University
West Lafayette, Indiana

Note: All relevant financial relationships listed for these individuals have been mitigated.

Note: Any views, thoughts, or opinions expressed by authors and reviewers in this publication do not necessarily reflect the fac-
ulty member’s employer, organization, committee, or other group or individual.

Learning Activity Authors Reviewers Disclosures

Recorded Webcast: Suzanne G. Bollmeier, Pharm.D., Dennis Williams, Pharm.D., FCCP, BCPS, Suzanne G. Bollmeier:
Chronic Obstructive FCCP, BCPS, AE-C AE-C Nothing to disclose
Pulmonary Disease Professor Associate Professor Dennis Williams: Nothing to
Department of Pharmacy Practice Division of Pharmacotherapy and disclose
St. Louis College of Pharmacy Experimental Therapeutics Lisa Chastain: Nothing to
at UHSP UNC Eshelman School of Pharmacy disclose
St. Louis, Missouri Chapel Hill, North Carolina Mason Bowman: Nothing to
disclose
Lisa Chastain, Pharm.D., BCACP
Associate Professor and Division Head
Department of Pharmacy Practice,
Ambulatory Care Division
Texas Tech University Health Sciences
Center Jerry H. Hodge School of Pharmacy
Dallas, Texas
PACT Clinical Pharmacist Practitioner
Department of Pharmacy
Fort Worth Outpatient Clinic, VA North Texas
Health Care System
Fort Worth, Texas

Mason Bowman, Pharm.D., BCACP

Ambulatory Pharmacist Specialist
Department of Ambulatory Care
Intermountain Health – Peaks Region
Billings, Montana
Learning Activity Authors Reviewers Disclosures

Chapter: Updates Amanda Eades, Pharm.D., BCACP Shannon M. Rotolo, Pharm.D., BCPS Amanda Eades: Nothing to
in Asthma Clinical Assistant Pharmacist Pharmacy Education Coordinator disclose
Management Department of Pharmacy Practice Department of Pharmacy Lori Ann Wilken:
University of Illinois Chicago Retzky University of Rochester Medical Center Consultancies (Astra
College of Pharmacy Rochester, New York Zeneca)
Chicago, Illinois Shannon M. Rotolo: Nothing
Shivani Bhakta, Pharm.D., BCACP
to disclose
Lori Ann Wilken, Pharm.D., FCCP, Ambulatory Care Pharmacist
Shivani Bhakta: Stocks
BCACP Department of Pharmacy
(NovoNordisk; Lily)
Clinical Associate Pharmacist Parkview Healthcare
Angela Baalmann: Nothing
Department of Pharmacy Practice Fort Wayne, Indiana
to disclose
University of Illinois Chicago Retzky
Angela Baalmann, Pharm.D., BCACP
College of Pharmacy
Assistant Professor
Chicago, Illinois
Department of Clinical Services
Fred Wilson School of Pharmacy
High Point, North Carolina

Case Series: Upper Paul M. Boylan, Pharm.D., BCPS Ryan P. Mynatt, Pharm.D., BCPS Paul M. Boylan: Stocks
Respiratory Tract Associate Professor Clinical Pharmacist, Infectious Diseases and (Lily); Grants (Pfizer);
Infections in Adults Department of Pharmacy: Clinical Outpatient Parenteral Antimicrobial Therapy Honoraria (Pharmacy
and Administrative Sciences (OPAT) Times Continuing
The University of Oklahoma Health Department of Pharmacy Services Education)
Sciences Center University of Kentucky HealthCare Ryan P. Mynatt: Nothing to
Oklahoma City, Oklahoma Lexington, Kentucky disclose
Kelly Mullican: Nothing to
Kelly Mullican, Pharm.D., BCACP
disclose
Clinical Pharmacy Coordinator
Melissa R. Palguta: Nothing
Department of Pharmacy
to disclose
Kaiser Permanente – Mid-Atlantic States
Sterling, Virginia

Melissa R. Palguta, Pharm.D., BCACP

Primary Care Clinical Pharmacy Specialist
Clinical Pharmacy Department
Kaiser Permanente Colorado
Colorado Springs, Colorado

Chapter: HIV Sarah E. Pérez, Pharm.D., BCACP, Nathan Everson, Pharm.D., BCIDP Sarah E. Pérez: Nothing to
Preexposure AAHIVP Clinical Pharmacy Specialist: Infectious disclose
Prophylaxis Clinical Pharmacist Diseases Nathan Everson: Nothing to
Department of Pharmacy Department of Pharmacy disclose
Ruth M. Rothstein CORE Center Henry Ford Health Shelly Rutledge: Nothing to
Chicago, Illinois Detroit, Michigan disclose
Rafael Sánchez: Nothing to
Shelly Rutledge, Pharm.D., BCACP
disclose
Manager, Clinical Pharmacy Outcomes and
Quality Programs
Department of Pharmacy
Providence Health and Services – Oregon
Beaverton, Oregon

Rafael Sánchez, Pharm.D., BCACP, AAHIVP,

CDCES
Clinical Assistant Professor
Department of Pharmacy Practice and
Clinical Sciences
University of Texas at El Paso, School of
Pharmacy
El Paso, Texas
Learning Activity Authors Reviewers Disclosures

Case Series: Long Katherine Yang, Pharm.D., MPH Adamo Brancaccio, Pharm.D. Katherine Yang: Nothing to
COVID Health Sciences Clinical Professor Clinical Pharmacist disclose
Department of Clinical Pharmacy Clinical Team Lead Adult Medicine Adamo Brancaccio: Nothing
UCSF School of Pharmacy Michigan Medicine to disclose
San Francisco, California Adjunct Clinical Instructor Karen L. Kier: Nothing to
University of Michigan College of Pharmacy disclose
University of Michigan
Ann Arbor, Michigan

Karen L. Kier, Ph.D., FCCP, BCPS, BCACP

Professor of Pharmacy Practice
Director of Drug and Health Information
Department of Pharmacy Practice
Raabe College of Pharmacy, Ohio Northern
University
Ada, Ohio

Chapter: Opioid Use Krystal KC Riccio, Pharm.D., FCCP, Keri D. Hager, Pharm.D., BCACP Krystal KC Riccio: Nothing
Disorder BCACP, CDCES Professor to disclose
Professor of Pharmacy Practice Department of Pharmacy Practice and Keri D. Hager: Nothing to
College of Pharmacy Pharmaceutical Sciences disclose
Roseman University of Health University of Minnesota, College of Brice Labruzzo Mohundro:
Sciences Pharmacy Nothing to disclose
Henderson, Nevada Duluth, Minnesota

Brice Labruzzo Mohundro, Pharm.D., BCACP

Manager, Pharmacy Population Health
Department of Pharmacy Services
Blue Cross and Blue Shield of Louisiana
Baton Rouge, Louisiana

Chapter: Epilepsy McKenzie Grinalds, Pharm.D., BCPS Viet-Huong V. Nguyen, Pharm.D., BCCCP McKenzie Grinalds: Nothing
Clinical Pharmacist Associate Professor to disclose
Cedarville, Ohio Department of Pharmacy Practice Viet-Huong V. Nguyen:
Chapman University School of Pharmacy Grants (Ionis
Irvine, California Pharmaceuticals)
Clinical Pharmacist Specialist Lisa Edgerton: Nothing to
Department of Pharmacy Services disclose
Harbor UCLA Medical Center Mikiko Takeda: Grants (UCB
Torrance, California Pharma)

Lisa Edgerton, Pharm.D., BCACP, BCPS

Clinical Pharmacist
Department of Pharmacy
Novant Health New Hanover Regional
Medical Center
Wilmington, North Carolina

Mikiko Takeda, Pharm.D., FAES, BCACP

Associate Professor
Department of Pharmacy Practice and
Administrative Sciences
University of New Mexico College of
Pharmacy
Albuquerque, New Mexico
Learning Activity Authors Reviewers Disclosures

Chapter: Migraine Alison W. Martin, Pharm.D., BCPS, Nicole Hahn, Pharm.D., BCACP Alison W. Martin: Nothing to
BCACP Clinical Pharmacy Specialist in Neurology disclose
Clinical Pharmacy Practitioner Kaiser Permanente Nicole Hahn: Nothing to
Department of Neurology Denver, Colorado disclose
Ralph H. Johnson VA Medical Harleen Singh: Nothing to
Harleen Singh, Pharm.D., BCACP
Center disclose
Clinical Professor
Charleston, South Carolina
Department of Pharmacy Practice and
Clinical Sciences
School of Pharmacy
The University of Texas at El Paso
El Paso, Texas

Case Series: Megan O’Connell, Pharm.D., BCPP Richard J. Silvia, Pharm.D., MA, FCCP, FAAPP, Megan O’Connell: Nothing
Depression and Clinical Pharmacy Specialist, BCPP to disclose
Anxiety Psychiatry and Neurology Professor of Pharmacy Practice Richard J. Silvia: Honoraria
Department of Pharmacy Department of Pharmacy Practice (PsychU – supported by
Michigan Medicine Massachusetts College of Pharmacy and Otsuka Pharmaceuticals)
Ann Arbor, Michigan Health Sciences Maurice N. Tran: Nothing to
Boston, Massachusetts disclose
Jason Chau: Nothing to
Maurice N. Tran, Pharm.D., BCACP
disclose
Ambulatory Care Pharmacist
Pharmacist Provider Services Department
EvergreenHealth
Kirkland, Washington

Jason Chau, Pharm.D., BCPS, BCACP

Senior Clinical Pharmacist
Department of Pharmacy Affordability
Optum
Everett, Washington

Case Series: Bipolar David Dadiomov, Pharm.D., BCPP Shari N. Allen, Pharm.D., BCPP David Dadiomov: Nothing to
Disorder Assistant Professor of Clinical Associate Professor of Pharmacy Practice disclose
Pharmacy Department of Pharmacy Shari N. Allen: Nothing to
Titus Family Department of Clinical PCOM School of Pharmacy disclose
Pharmacy Suwanee, Georgia Beth Powell: Nothing to
University of Southern California disclose
Beth Powell, Pharm.D., BCACP
Mann School of Pharmacy and Melissa A. Pendoley:
Director of Pharmacy
Pharmaceutical Sciences Nothing to disclose
Residency Program Director
Los Angeles, California
The Centers
Cleveland, Ohio

Melissa A. Pendoley, Pharm.D., BCACP,

BCGP
Geriatric Clinical Pharmacy Specialist
Department of Pharmacy
Kaiser Permanente Georgia
Atlanta, Georgia
TABLE OF CONTENTS
Recorded Webcast: Chronic Obstructive Conclusion������������������������������������������������������������������������������������������ 73
Pulmonary Disease References ����������������������������������������������������������������������������������������� 75
By Suzanne G. Bollmeier, Pharm.D., FCCP, BCPS, AE-C Self-Assessment Questions������������������������������������������������������������� 78

References ������������������������������������������������������������������������������������������� 1
Self-Assessment Questions��������������������������������������������������������������� 4
Case Series: Long COVID
By Katherine Yang, Pharm.D., MPH

Chapter: Updates in Asthma Management Introduction����������������������������������������������������������������������������������������� 84

By Amanda Eades, Pharm.D., BCACP; and Lori Ann Wilken, Pharm.D., Risk Factors���������������������������������������������������������������������������������������� 88
FCCP, BCACP Prevention and Treatment����������������������������������������������������������������� 93
Introduction������������������������������������������������������������������������������������������� 9 Conclusion������������������������������������������������������������������������������������������ 97
Asthma Phenotyping������������������������������������������������������������������������� 10 References ����������������������������������������������������������������������������������������� 97
Disease Assessment������������������������������������������������������������������������� 12 Self-Assessment Questions����������������������������������������������������������� 104
Pharmacologic Management of Asthma ��������������������������������������� 13
Pipeline Agents����������������������������������������������������������������������������������� 16 Chapter: Opioid Use Disorder

Nonpharmacologic Management of Asthma��������������������������������� 19 By Krystal KC Riccio, Pharm.D., FCCP, BCACP, CDCES

Conclusion������������������������������������������������������������������������������������������ 20 Introduction��������������������������������������������������������������������������������������� 107

References ����������������������������������������������������������������������������������������� 20 Understanding OUD������������������������������������������������������������������������� 108

Self-Assessment Questions������������������������������������������������������������� 24 Clinical Guidelines, Tools, and Resources ������������������������������������111

Screening and Diagnosis������������������������������������������������������������������112
Case Series: Upper Respiratory Tract Nonpharmacologic Interventions ������������������������������������������������� 114
Infections in Adults Pharmacological Management ����������������������������������������������������� 116
By Paul M. Boylan, Pharm.D., BCPS
Special Populations������������������������������������������������������������������������� 122
Introduction����������������������������������������������������������������������������������������� 30 Harm Reduction Strategies������������������������������������������������������������� 125
The Common Cold����������������������������������������������������������������������������� 33 Role of the Pharmacist ������������������������������������������������������������������� 126
Mild to Moderate COVID-19��������������������������������������������������������������� 37 References ��������������������������������������������������������������������������������������� 127
Rhinosinusitis������������������������������������������������������������������������������������� 40 Self-Assessment Questions ���������������������������������������������������������� 131
Influenza ��������������������������������������������������������������������������������������������� 43
Pharyngitis ����������������������������������������������������������������������������������������� 46 Chapter: Epilepsy
Laryngitis��������������������������������������������������������������������������������������������� 49 By McKenzie Grinalds, Pharm.D., BCPS

Conclusion������������������������������������������������������������������������������������������ 51 Introduction��������������������������������������������������������������������������������������� 135

References ����������������������������������������������������������������������������������������� 51 Definition and Classification of Epilepsy��������������������������������������� 136
Self-Assessment Questions������������������������������������������������������������� 56 Review of ASMs ������������������������������������������������������������������������������� 139
General Approach to Management of Epilepsy��������������������������� 151
Chapter: HIV Preexposure Prophylaxis Patient Education����������������������������������������������������������������������������� 156
By Sarah E. Pérez, Pharm.D., BCACP, AAHIVP
Conclusion���������������������������������������������������������������������������������������� 157
Introduction����������������������������������������������������������������������������������������� 59 References ��������������������������������������������������������������������������������������� 157
PrEP Eligibility������������������������������������������������������������������������������������� 61 Self-Assessment Questions����������������������������������������������������������� 163
Current Pharmacotherapy Options ������������������������������������������������� 63
Oral PrEP��������������������������������������������������������������������������������������������� 64 Chapter: Migraine
Cabotegravir Long-Acting Injectable PrEP������������������������������������� 67 By Alison W. Martin, Pharm.D., BCPS, BCACP

Future PrEP����������������������������������������������������������������������������������������� 68 Introduction��������������������������������������������������������������������������������������� 167

Doxycycline Postexposure Prophylaxis ����������������������������������������� 69 Clinical Presentation and Classification��������������������������������������� 168
Role of the Pharmacist in HIV Prevention��������������������������������������� 69 General Approach to Treatment����������������������������������������������������� 169

ACSAP 2025 ix Table of Contents

Acute Treatment������������������������������������������������������������������������������� 170 References ��������������������������������������������������������������������������������������� 219
Preventive Treatment����������������������������������������������������������������������� 177 Self-Assessment Questions����������������������������������������������������������� 221
Nonpharmacologic Management ������������������������������������������������� 185
Place in Therapy������������������������������������������������������������������������������� 186
Case Series: Bipolar Disorder
Conclusions ������������������������������������������������������������������������������������� 190
By David Dadiomov, Pharm.D., BCPP
References ��������������������������������������������������������������������������������������� 190
Introduction��������������������������������������������������������������������������������������� 226
Self-Assessment Questions����������������������������������������������������������� 198
Signs and Symptoms�����������������������������������������������������������������������228
Case Series: Depression and Anxiety General Approach to Treatment�����������������������������������������������������229
By Megan O’Connell, Pharm.D., BCPP Pharmacotherapy for the Treatment of Bipolar Disorder�����������230
Clinical Assessment of Depression and Anxiety �����������������������204 Treatment of Bipolar Disorder in Special Populations ��������������� 236
Treatment of Depression and Anxiety������������������������������������������� 207 Conclusion���������������������������������������������������������������������������������������� 238
Monitoring Response and Adjusting Treatment�������������������������� 214 References ��������������������������������������������������������������������������������������� 238
Recently Approved Treatments for Depression��������������������������� 216 Self-Assessment Questions�����������������������������������������������������������240

ACSAP 2025 x Table of Contents

Chapter: Updates in Asthma Management
By Amanda Eades, Pharm.D., BCACP; and Lori Ann Wilken, Pharm.D., FCCP, BCACP

Reviewed by Shannon M. Rotolo, Pharm.D., BCPS; Shivani Bhakta, Pharm.D., BCACP; and Angela Baalmann, Pharm.D., BCACP

LEARNING OBJECTIVES

1. Distinguish the most likely asthma phenotype based on symptoms, patient characteristics, and laboratory values.
2. Classify asthma severity based on current symptoms and future risk of asthma exacerbations.
3. Evaluate individual patient characteristics when choosing an appropriate inhaled drug delivery device.
4. Develop an appropriate pharmacotherapy treatment plan for a patient with newly diagnosed asthma, symptoms of worsen-
ing asthma, and difficult-to-treat asthma.

INTRODUCTION
ABBREVIATIONS IN THIS CHAPTER
Asthma is a chronic disease that affects both children and adults.
DPI Dry powder inhaler
In the United States, about 4.5 million children under 18 and 22 mil-
FeNO Fraction of exhaled nitric oxide
lion adults are affected by asthma. Although the rate of asthma
FEV1 Forced expiratory volume in 1
second attacks has declined in recent years, 63.1% of children younger
GINA Global Initiative for Asthma than 5 years, 38.7% of children 18 years and younger, and 39.6% of
ICS Inhaled corticosteroid adults continue to experience asthma exacerbations (CDC 2023; CDC
2024a; CDC 2024b). In 2020, a national survey showed that deaths
Ig Immunoglobulin
caused by asthma rose for the first time in 20 years, and around
IL Interleukin
10 people in the United States die from asthma each day (CDC 2022).
LABA Long-acting β2-agonist
Pharmacists can play a pivotal role in reducing asthma morbidity and
LAMA Long-acting muscarinic antagonist
mortality through the optimization of pharmacotherapy regimens and
MART Maintenance and reliever therapy
providing patients with the knowledge and resources for self-care
MDI Metered-dose inhaler
during exacerbations.
OCS Oral corticosteroid
Individuals with asthma encounter airway hyperresponsiveness
PFT Pulmonary function test
to triggers, which can lead to bronchoconstriction and ultimately
SABA Short-acting β2-agonist
cause symptoms such as breathlessness, coughing, chest tightness,
T2 Type 2 (asthma endotype)
and limitations in physical activity. These symptoms vary daily, even
Th2 T-helper type 2 within a single day, often worsening at night or on waking. The gold
standard for diagnosing asthma continues to be pulmonary function
Table of other common abbreviations
testing (PFT) via spirometry. A confirmed asthma diagnosis requires
evidence of variable expiratory airflow that is responsive to broncho-
dilator therapy.
Bronchodilator responsiveness has historically been defined as
an increase in forced expiratory volume in 1 second (FEV1) from
baseline by at least 12% and 200 mL following bronchodilator admin-
istration (Global Initiative for Asthma [GINA] 2024). However, the
American Thoracic Society and European Respiratory Society 2021
technical standards for interpreting lung function tests defines a pos-
itive response as at least a 10% change in the predicted value of the
FEV1 or forced vital capacity (Stanojevic 2022). In some cases, PFT
results within normal range may be observed, but asthma is still highly

ACSAP 2025 9 Chapter: Updates in Asthma Management

suspected based on the patient’s medical and family history. blood count with differential is performed. However, clini-
In such instances, a bronchial provocation test may be used cal trials often examine sputum cell counts. In cases where
to assess the lung responsiveness to a bronchoconstrictor, patients do not respond to conventional asthma therapies and
such as methacholine. In other cases, PFTs are not feasible lack type 2-mediated biomarkers, neutrophilic asthma is often
because of the patient’s age or cognitive disabilities. In these suspected. Asthma can broadly be categorized into two main
instances, an asthma diagnosis is based on symptoms, family endotypes: type 2 (T2)-mediated and non-type 2 (non-T2)-­
history, exclusion of other causes, and symptom improvement mediated. Biomarkers associated with T2-high inflammation
with bronchodilators (Levy 2006). include elevated blood and/or sputum eosinophils, immuno-
globulin E (IgE), and fraction of exhaled nitric oxide (FeNO).
ASTHMA PHENOTYPING The level of FeNO increases secondary to inflammation in the
The diverse presentation of asthma has led to the discovery of lungs and is associated with lower lung function and increased
various endotypes that represent the pathophysiologic mech- risk for future asthma exacerbations (Murugesan 2023; Carr
anisms and biomarkers triggering a response. When coupled 2018). Although biomarker profiling of T2-high asthma has led
with patient presentation, endotypes can be used to determine to the development of targeted medication therapies, targeted
a patient’s asthma phenotype, which are observable char- therapies for treatment of T2-low asthma are currently lacking
acteristics that result from a combination of hereditary and (Kuruvilla 2019).
environmental influences. For patients who do not respond
to conventional asthma therapies, additional diagnostic tests T2-Mediated Asthma
and biomarker analyses are warrented to help identify the Asthma phenotypes that fall under the category of T2 inflam-
most likely asthma endotype and guide treatment decisions mation include early-onset allergic asthma, late-onset
(Table 1). In clinical practice, sputum eosinophil and neutro- eosinophilic asthma, and aspirin-exacerbated respiratory dis-
phil counts are not typically collected; instead, only a complete ease (Kuruvilla 2019). This inflammation is primarily regulated
by T-helper type 2 (Th2) cytokines, including interleukin (IL)-4,
IL-5, and IL-13, as well as group 2 innate lymphoid cells. When
exposed to triggers such as infection or inflammation, alarm-
BASELINE KNOWLEDGE STATEMENTS ins signal for the release of IL-5 and IL-13 from group 2 innate
lymphoid cells, leading to T2 inflammation.
Readers of this chapter are presumed to be familiar
with the following:
Allergic Asthma
• General asthma pathophysiology
As the most common phenotype of asthma, often presenting in
• Interpretation of common pulmonary function tests
childhood, allergic asthma is often encountered as part of the
such as forced expiratory volume in 1 second
(FEV1) and FEV1/forced vital capacity ratio “atopic triad” that is asthma, atopic dermatitis, and allergic rhi-
nitis (Hamilton 2020). In allergic asthma, an allergen stimulates
• Baseline knowledge of oral and inhaled pharmaco-
a Th2 cell-mediated immune response, causing the release of
therapy agents used to treat asthma including drug
class, mechanism of action, pharmacokinetic and type 2 cytokines, including IL-4, IL-5, and IL-13. This action ulti-
pharmacodynamic properties, dosage form, and mately leads to release of eosinophils in the airways, excess
proper administration mucus production, and generation of IgE antibodies (Kuruvilla
2019). Early-onset allergic asthma usually responds well to
Table of common laboratory reference values
treatment with inhaled corticosteroids (ICS) (GINA 2024).
Patients with allergic asthma often have hypersensitivity to
ADDITIONAL READINGS
common allergens, which may be confirmed by allergy testing
The following free resources have additional back- such as skin prick testing, provocation testing, or blood test-
ground information on this topic: ing. Blood tests such as enzyme-linked immunosorbent assay
• Global Initiative for Asthma (GINA). Global Strategy (ELISA) and radioallergosorbent test measure specific IgE in
for Asthma Management and Prevention, 2024. the blood. Both tests provide total IgE and serum-specific IgE.
• National Heart, Lung, and Blood Institute (NHLBI). The presence of a positive allergy test does not necessarily
Guidelines for diagnosis and management of mean the allergen is causing symptoms; the diagnosis must
asthma (EPR-3) [Expert Panel Report], 2007. also be confirmed through the patient’s history of symptoms
• Expert Panel Working Group of the National Heart, when exposed to the allergen (Siles 2011).
Lung, and Blood Institute (NHLBI). Focused updates
to the asthma management guidelines. Eosinophilic Asthma
• American Lung Association. Comparative doses Eosinophilic asthma is the T2-mediated endotype that
chart. accounts for most severe asthma cases, and patients with
this phenotype are considered to be at elevated risk of

ACSAP 2025 10 Chapter: Updates in Asthma Management

Table 1. Characteristics of Asthma Phenotypes

Phenotype Patient Characteristics Biomarkersa

Type 2 Mediation

Allergic asthma • Childhood onset • Elevated serum IgE

• Allergen triggers • Elevated FeNO
• Allergic rhinitis
• Atopic dermatitis

Eosinophilic asthma • Adult onset • Elevated blood and/or sputum

• Severe exacerbations eosinophil counts
• Less atopic • Elevated FeNO
• Sinusitis
• Nasal polyps

Aspirin-exacerbated respiratory disease • Adult-onset • Elevated blood and/or sputum

• Nasal polyposis eosinophil counts
• Reactivity to NSAIDS • Leukotrienes

Non-Type 2 Mediation

Neutrophilic asthma • Adult onset Elevated sputum neutrophil counts

• Variable severity
• Insufficient response to ICS
• Reduced lung function
• Less bronchodilator reversibility
• History of smoking
• Common comorbidities are GERD and
obesity

Paucigranulocytic asthma • Fixed airflow obstruction • Normal blood and/or sputum

• Bronchial hyperreactivity eosinophil counts
• Insufficient response to ICS • Normal sputum neutrophil counts

Information from Carr 2018.

Abbreviations: FeNO, fractional exhaled nitric oxide; GERD, gastroesophageal reflux disease; ICS, inhaled corticosteroid; IgE,
immunoglobulin E.
a
Patients may exhibit only one elevated biomarker characteristic of an asthma phenotype or exhibit multiple elevated biomarkers.

exacerbations. This type of asthma is defined by elevated asthma, and an intolerance to aspirin or NSAIDS. This disease
blood and/or sputum eosinophils (≥ 150 cells/µL, or ≥ 3%, often overlaps with severe eosinophilic asthma, and patients
respectively) and typically presents later in life (Walford 2014). commonly have a lower baseline FEV1. Several studies found
Patients with eosinophilic asthma commonly present with that patients with AERD have an overexpression of IL-33 and
sinusitis with or without nasal polyps as a comorbidity. They thymic stromal lymphopoietin, which can drive Th2 pathway
often lack a sufficient response to corticosteroids and require inflammation (Hamilton 2020).
more specialized treatment with biologic agents. Late-onset
eosinophilic asthma is often driven by alarmins for group 2 Non-T2-Mediated Asthma
innate lymphoid cells, such as thymic stromal lymphopoie- Asthma phenotypes that are non-T2-mediated include
tin, IL-25, and IL-33 (Kuruvilla 2019). Alarmins trigger stronger paucigranulocytic asthma and neutrophilic asthma, which
immune responses in asthma and contribute to the resis- are sometimes collectively referred to as non-eosinophilic
tance linked to group 2 innate lymphoid cell-induced airway asthma (Kuruvilla 2019). Patients with non-T2-mediated
inflammation. phenotypes tend to be older and often present with late-on-
set, severe, or steroid-resistant asthma (Kang 2022).
Aspirin-Exacerbated Respiratory Disease Biomarkers associated with this endotype are currently
Patients with aspirin-exacerbated respiratory disease (AERD) under investigation, and biomarker-targeted therapies are
are characterized by chronic rhinosinusitis with nasal polyps, lacking.

ACSAP 2025 11 Chapter: Updates in Asthma Management

Neutrophilic Asthma and Asthma Control Questionnaire (ACQ) are useful tools for
Neutrophilic asthma is defined by elevated neutrophil counts assessing symptom management but do not take into account
in the airways, typically greater than 40% (Kuruvilla 2019). the future risk of exacerbations. Risk factors for asthma exac-
Some patients have both elevated sputum neutrophils and erbations include overuse of reliever medications, inadequate
eosinophils, which is known as mixed granulocytic asthma. ICS use, FEV1 less than 60% predicted, major psychological
Neutrophilic asthma typically emerges during adulthood and disease or socioeconomic limitations, exposure to known
accounts for 20%–30% of all asthma cases in adults (Kang triggers for asthma, recent history of severe asthma exacerba-
2022). Neutrophilic asthma is believed to be orchestrated by tions, and poorly controlled comorbidities (Table 2).
Th-17 and group 3 innate lymphoid cells which produce IL-17 Asthma severity is assessed retrospectively based on
and IL-17a, ultimately inducing neutrophil activation (Kang the treatment required to achieve disease control. Severe
2022; Yamasaki 2022). Bronchial biopsy and sputum collec- asthma is characterized by ongoing symptoms despite the
tion in patients with moderate to severe asthma are often use of optimized, high-dose inhaled corticosteroid/long-act-
positive for IL-17. Comorbidities associated with neutrophilic ing β2-agonist (ICS/LABA) therapy or cases that require such
asthma include gastroesophageal reflux disease, obesity, and
tobacco dependence. Neutrophilic inflammation is associated
with airway remodeling and more severe airflow obstruction,
ultimately resulting in lower lung function. Table 2. Risk Factors for Asthma Exacerbations

Paucigranulocytic Asthma Risk Factor Comments

Paucigranulocytic asthma is an asthma phenotype with no Medications • Overuse of short-acting β2-agonist:

evidence of increased neutrophil and eosinophil counts in use of ≥ 3 refills of reliever inhaler (ie,
sputum or blood. Individuals with paucigranulocytic asthma albuterol) per year
exhibit changes in airway smooth muscle contractile proper- • Inadequate use of inhaled
ties, which plays a significant role in the development of airway corticosteroid: not prescribed,
hyperresponsiveness. Inflammatory cytokines, pollutants, and inappropriately prescribed, poor
adherence, poor technique)
mechanical strain can prime the airway smooth muscle to
become hyperresponsive. Individuals with paucigranulocytic Comorbidities • Obesity
asthma are generally resistant to conventional asthma thera- • Chronic rhinosinusitis
pies, including anti-inflammatory agents (Tliba 2019). • Gastroesophageal reflux disease
• Obstructive sleep apnea
• Food allergy/allergies
DISEASE ASSESSMENT
• Pregnancy
When assessing asthma control, it is important to con-
Exposures • Tobacco or vaping
sider both symptom management and risk factors for future
• Allergen exposure (once sensitized)
severe asthma exacerbations. Important indicators of symp-
• Air pollution
tom management include limitations to physical activity and
the frequency of asthma symptoms, reliever medication use, Psychosocial • Major psychological disease, such as
and nighttime awakenings because of asthma symptoms factors anxiety or depression
(Box 1). Questionnaires such as the Asthma Control Test (ACT) • Socioeconomic limitations, such as
lack of access to high-quality health
care, poor health literacy, poor housing
conditions
Box 1. Assessment of Asthma Control
Lung function • Low FEV1 (especially < 60% predicted)
Symptoms
• High bronchodilator responsiveness
• Daytime asthma symptoms > 2 times/wk (or > 1 time/wk for
age < 6 yr) T2 markers • Elevated blood eosinophil counts
• Short-acting β2-agonist use for symptom relief > 2 times/wk • Elevated fractional exhaled nitric oxide
(or > 1 time/wk for age < 6 yr)
• Any nighttime awakenings because of asthma symptoms Exacerbation • History of intubation or ICU admission
• Any activity limitation because of asthma symptoms history for asthma exacerbation
• ≥ 1 serious asthma exacerbations in
Degree of Control
past year
• Well-controlled asthma: No symptoms present
• Partly controlled asthma: 1 or 2 symptoms present
• Uncontrolled asthma: 3 or 4 symptoms present Information from Global Initiative for Asthma (GINA) 2024.
Abbreviations: FEV1, forced expiratory volume in 1 second;
Information from Global Initiative for Asthma (GINA) 2024.
T2, type 2-mediated asthma.

ACSAP 2025 12 Chapter: Updates in Asthma Management

therapy to manage symptoms. Moderate asthma is controlled and management of contributory, modifiable factors. About
with a low to medium dose of ICS-LABA, and mild asthma is 5%–10% of individuals with asthma have severe asthma (GINA
managed with as-needed relievers with or without a low-dose 2024). In those with severe asthma, T2-mediated inflamma-
ICS. Although patients with mild asthma typically maintain tory biomarkers such as blood and sputum eosinophil counts
good symptom control without disrupting daily activities, they and FeNO correlate to severe airway inflammation, persistent
still face a risk of asthma exacerbations. Thus, it is crucial to symptoms, frequent exacerbations, and low responsiveness
consider both current control and future risks when selecting to ICS therapy (Lee 2021). Collection of these biomarkers is
the optimal treatment. Including an anti-inflammatory medi- an important part of a thorough assessment of a patient with
cation in all patients’ regimens can help minimize future risks severe asthma.
(GINA 2024).
It is important to note a difference between the terminology PHARMACOLOGIC MANAGEMENT
difficult-to-treat-asthma and severe asthma. The GINA guide- OF ASTHMA
lines define difficult-to-treat asthma as uncontrolled despite Pharmacologic management of asthma involves the selection
prescribing of a medium- or high-dose ICS with a second of an initial treatment regimen based on symptom frequency
controller or asthma that requires this treatment to maintain (Table 3) and then using a stepwise approach to adjust the
good control. Modifiable risk factors for this type of asthma regimen based on symptom control (Table 4). Two different
include incorrect inhaler technique, poor adherence, smok- treatment tracks may be followed for asthma management,
ing, and other poorly controlled comorbidities. Severe asthma which are driven by the choice of reliever therapy. Reliever
is considered a subset of difficult-to-treat asthma and is therapy options include albuterol, ICS-formoterol, and albuter-
defined as asthma that remains uncontrolled despite adher- ol-budesonide; however, albuterol-budesonide is currently
ence to maximal optimized high-dose ICS-LABA treatment only approved for individuals age 18 and older.

Table 3. Initial Asthma Treatment (GINA Guidelines)

Presentation Adults/Adolescents (≥ 12 yr) Children (6–11 yr)

Symptoms ≤ 1 or • Preferred: As-needed low-dose ICS–formoterol • Preferred: Low-dose ICS whenever SABA is used
2 days/wk • Alternative: Low-dose ICS whenever SABA is • Alternative: None
used

Symptoms 2-5 days/ • Preferred: As-needed low-dose ICS-formoterol • Preferred: Low-dose ICS plus as-needed SABA
wk • Alternative: Low-dose ICS plus as-needed SABA • Alternative: None

Symptoms most days • Preferred: Low-dose ICS-formoterol as MART • Options

of the week, waking up • Alternative | Low-dose ICS plus as-needed SABA

because of asthma at | Low-dose ICS-LABA plus as-needed SABA —OR—

least once per week, —OR— | Medium-dose ICS plus as-needed SABA

or low lung function | Low-dose ICS-LABA plus as-needed ICS-SABA —OR—

—OR— | Very low-dose ICS-formoterol MART

| Medium-dose ICS plus as-needed SABA

—OR—
| Medium-dose ICS plus as-needed ICS-SABA

Daily symptoms, • Preferred: Medium-dose ICS-formoterol MART • Options

waking at night with • Alternative | Medium-dose ICS-LABA plus as-needed SABA

asthma once per week | Medium- or high-dose ICS-LABA +/− oral steroid burst
or more, with low lung plus as-needed SABA +/- oral steroid burst —OR—
function, or with an —OR— | Low-dose ICS-formoterol MART +/– oral

exacerbation | Medium- or high-dose ICS-LABA plus steroid burst

as-needed ICS-SABA +/– oral steroid burst • Alternative: None
—OR—
| High-dose ICS plus as-needed SABA +/– OCS

Information from Global Initiative for Asthma (GINA) 2024.

Abbreviations: GINA, Global Initiative for Asthma; ICS, inhaled corticosteroid; LABA, long-acting β2-agonist; LTRA, leukotriene receptor
antagonist; MART, maintenance and reliever therapy; OCS, oral corticosteroid; SABA, short-acting β2-agonist.

ACSAP 2025 13 Chapter: Updates in Asthma Management

Table 4. GINA Stepwise Asthma Management Approach

Step Preferred Controller Other Controllers Preferred Reliever

Age ≥ 12 yr

1 As-needed low-dose ICS–formoterol — As-needed low-dose

ICS–formoterol
2 As-needed low-dose ICS–formoterol

3 Low-dose maintenance ICS-formoterol

4 Medium dose maintenance ICS-formoterol

5 Add-on LAMA; consider high dose ICS-formoterol

+/–biologic

Age 6–11 yr

1 Low-dose ICS taken when SABA taken — SABA

2 Daily low-dose ICS LTRA; or low-dose ICS whenever SABA

SABA is used

3 Daily low-dose ICS-LABAa; or medium-dose ICS; or very Low-dose ICS + LTRA SABA; or as-needed low-dose
low-dose ICS-formoterol MART ICS-formoterol if taking
maintenance ICS-formoterol
4 Medium-dose ICS-LABAa; or low-dose ICS-formoterol MART Add tiotropium; or add LTRA

5 Higher-dose ICS-LABAa; or add-on biologic Add low-dose OCS as last option SABA

Age ≤ 5 yr

1 No controller Intermittent ICS at symptom onset SABA

2 Daily low-dose ICS LTRA; or intermittent ICS at SABA

symptom onset

3 Double “low-dose” ICSb Low-dose ICS + LTRA SABA

4 Continue controller; refer for expert advice Add LTRA; or increase ICS SABA
frequency; or add intermittent ICS

Information from Global Initiative for Asthma (GINA) 2024.

Abbreviations: GINA, Global Initiative for Asthma; ICS, inhaled corticosteroid; LAMA, long-acting muscarinic antagonist; LABA,
long-acting β2-agonist; LTRA, leukotriene receptor antagonist; MART, maintenance and reliever therapy; OCS, oral corticosteroid;
SABA, short-acting β2-agonist.
a
If patient is on a LABA other than formoterol, then a SABA should be used as reliever.
b
Double the dose of the low-dose inhaled corticosteroid.

Asthma Treatment Track 1 Current guidelines, including GINA and National Asthma
The Track 1 approach to treatment uses ICS-formoterol for Education and Prevention Program, emphasize the impor-
both maintenance and reliever therapy (MART) instead of the tance of prescribing anti-inflammatory therapy for all patients
conventional use of a short-acting β2-agonist (SABA) for reliev- age 6 years and older with asthma, despite disease severity,
ing symptoms. Following Track 1 treatment recommendations,
and underscore the dangers of relying solely on a SABA for
clinicians will initiate patients with intermittent asthma symp-
asthma treatment (GINA 2024; Expert Panel 2020). Evidence
toms on an as-needed regimen of ICS-formoterol to manage
supports the use of low-dose ICS-formoterol on an as-needed
their symptoms (GINA 2024). Patients experiencing symp-
basis to reduce the risk of severe exacerbations, ED vis-
toms more often or with more significant lung obstruction on
PFTs will start on low-dose ICS-formoterol MART. Medium or its, and hospitalizations compared with using SABA alone
high doses of ICS-formoterol MART are reserved for patients (O’Byrne 2021, 2009; Bousquet 2007; Buhl 2012). In addition,
presenting with acute exacerbations or daily asthma symp- initiating low-dose ICS treatment early in the course of the
toms, commonly initiated together with a short course of oral disease results in greater improvements in lung function com-
corticosteroids to achieve rapid improvement of symptoms. pared with delaying treatment. Early intervention may also

ACSAP 2025 14 Chapter: Updates in Asthma Management

reduce the likelihood of patients needing higher doses of ICS (if the patient is on oral corticosteroids), or the anti-thymic
to maintain asthma control in the future. Any patient with at stromal lymphopoietin therapy tezepelumab. Maintenance
least one risk factor for severe exacerbations should be on an therapy with an oral corticosteroid (OCS) should only be
ICS-containing treatment regimen and, preferably, an anti-in- used as a last option because of the risk of adverse effects
flammatory reliever (GINA 2024). with chronic use. Mepolizumab, benralizumab, and dup-
ilumab have all demonstrated oral steroid-sparing effects
Asthma Treatment Track 2 in patients with moderate-to-severe asthma requiring sys-
The Track 2 approach is an alternative that uses either a temic corticosteroids (Klaus, 2018). While the anti-IL-5
SABA or ICS-SABA as the reliever therapy rather than ICS- agents mepolizumab and benralizumab require elevated
formoterol. For those with symptoms occurring at least 3 blood eosinophil levels for initiation, dupilumab does not
days per week, a low-dose ICS is recommended in addition have this requirement for patients on maintenance treat-
to reliever therapy. If symptoms occur more than three days ment with oral corticosteroids.
per week, a LABA is also recommended in combination with Use of long-acting muscarinic antagonists (LAMAs) may
the low-dose ICS. Patients with daily asthma symptoms are be considered as an add-on therapy for patients on a mod-
initiated on medium- to high-dose ICS-LABA plus as-needed erate- to high-dose ICS-LABA who are at least age 6 years
SABA, with high-dose ICS plus as-needed SABA as an alter- and have uncontrolled asthma (GINA 2024). For those at
native but less preferred option (GINA 2024). A key factor in least age 18 years, an inhaler containing triple therapy with
the consideration for initiating Track 2 therapy is the patient’s an ICS-LAMA-LABA may be considered, such as fluticasone
adherence to maintenance therapy, and those with suspected furoate-umeclidinium-vilanterol or mometasone-glycopyrroni-
nonadherence to ICS are not good candidates for this treat- um-indacaterol. For patients prescribed an ICS-LAMA-LABA
ment track. with a non-formoterol LABA, the appropriate reliever is SABA
or ICS-SABA. Individuals with a non-eosinophilic asthma phe-
Difficult-To-Treat Asthma notype may particularly benefit from addition of a LAMA. In
Difficult-to-treat asthma necessitates a personalized strat- two studies assessing tiotropium as add-on therapy to ICS-
egy for treatment. The initial evaluation requires confirming LABA in patients with symptomatic asthma, tiotropium
the asthma diagnosis and examining potential factors that improved lung function and asthma control and reduced the
could exacerbate poor asthma control, including unman- risk of exacerbation independent of T2 inflammation (Casale
aged comorbidities, incorrect medication administration, 2019; Szefler 2019).
frequent exposures to asthma triggers, or barriers to adher- Azithromycin administered three times per week can be
ence. If these variables are ruled out as contributors to poorly considered as an add-on therapy for patients with uncon-
controlled asthma, further investigation is warranted to cate- trolled asthma, despite the use of high-dose ICS-LABA (GINA
gorize the asthma phenotype and inform the choice of add-on 2024). However, the potential benefits must be weighed
therapies. against the risk of developing antibiotic resistance. Clinical tri-
Patients with severe asthma who are not adequately als support that azithromycin can reduce exacerbation rates in
controlled on moderate to high-dose ICS-LABA should be individuals with both eosinophilic and non-eosinophilic asthma
assessed for biomarkers of type 2 (T2) airway inflamma- profiles (Taylor 2019; Gibson 2017; Brusselle 2013). Notably,
tion. Key biomarkers to evaluate include elevated eosinophil the therapeutic benefits typically become evident after at least
levels (≥ 150 cells/μL), elevated FeNO (≥ 20 ppb), and ele- 3 months of treatment, so a minimum of 6 months of therapy
vated IgE (30–1300 IU/mL). If any of these biomarkers are is recommended with this approach.
elevated, consideration should be given to initiating a bio-
logic therapy targeting T2 inflammatory pathways, such as Selecting an Inhaled Delivery Device
omalizumab, benralizumab, mepolizumab, reslizumab, dup- Efficacy of inhaled asthma therapy depends on how much
ilumab, or tezepelumab, as outlined in Table 5 (McGregor medication reaches the airways for deposition. For this
2019). When selecting a biologic, it is crucial to take into reason, it is imperative to educate all patients on proper
account factors such as payer eligibility criteria, patient use of the inhaled drug delivery device and ensure that the
comorbidities, and predictors of response. The biologic most appropriate device is selected based on patient-spe-
should be continued for at least 4 months before determin- cific characteristics. Available delivery devices include
ing treatment response. If the patient had a poor response nebulizers, pressurized metered-dose inhalers (MDIs),
to therapy, then consider switching to a different type 2-tar- dry powder inhaler (DPIs), and soft mist inhalers
geted therapy (GINA 2024). (Table 6).
For management of severe asthma that does not appear Many factors are important to consider when choosing the
to be allergy-driven and lacks markers of T2 inflammation, best delivery device for a patient. Key patient considerations
add-on therapies to consider include tiotropium, low-dose for device selection include the patient’s dexterity, visual acu-
azithromycin, or biologic therapy with either an anti-IL4R ity, inhalation velocity, ability to coordinate inhalation with

ACSAP 2025 15 Chapter: Updates in Asthma Management

Table 5. Biologics For Asthma Management

Dosing Range
(Pediatric and
Biologic Class Drug Adult) Eligibility Criteria Clinical and Practical Considerations

Anti-IgE Omalizumab • 75–375 mg SC • Allergic asthma shown by • Other indications with FDA-approval:
(Xolair) every 2-4 wk sensitization on skin prick chronic spontaneous urticaria, CRSwNP,
• Dose based on testing or specific IgE IgE-mediated food allergies
total serum IgE • IgE 30–1300 IU/mL • Elevated blood eosinophil counts and
level and body • Exacerbation in past year FeNO are predictors of treatment
weight • Age ≥ 1 yr response

Anti-IL-5/ Benralizumab 10–30 mg SC every • Exacerbation in past year • Other indications with FDA-approval
Anti-IL-5Rα (Fasenra) 4 wk for first 3 • Blood eosinophil counts (mepolizumab only):
doses, then every > 150 cells/μL in the past • CRSwNP, eosinophilic granulomatosis
8 wk 6 months or > 300 cells/μL with polyangiitis, hypereosinophilic
in the past year syndrome
Mepolizumab 40–100 mg SC every
• Age ≥ 6 yr for benralizumab • In obesity, mepolizumab is less
(Nucala) 4 wk
and mepolizumab effective
Reslizumab 3 mg/kg IV infusion • Age ≥ 18 yr for reslizumab • Reslizumab is administered
(Cinqair) every 4 wk intravenously, thus requiring in-office
administration
• Mepolizumab and benralizumab have
efficacy data for oral corticosteroid-
sparing effects
• Predictors of treatment response
include nasal polyposis, adult-onset of
asthma, higher blood eosinophil counts,
and frequent exacerbations.

Anti-IL-4Rα Dupilumab 400–600 mg SC • Exacerbation in past year • Other indications with FDA-approval:
(Dupixent) loading dose, then • Blood eosinophil counts > COPD, atopic dermatitis, CRSwNP,
200–300 mg SC 150 cells/μL to <1500 cells/ eosinophilic esophagitis, prurigo
every 2 wk μL; or FeNO > 25 ppba; or nodularis
taking OCS • Dupilumab has efficacy data for oral
• Age ≥ 6 yr corticosteroid-sparing effects
• Predictors of treatment response
include higher blood eosinophil counts
and higher FeNO

Anti-thymic Tezepelumab 210 mg SC every • Exacerbation in past year • Clinical efficacy irrespective of
stromal (Tezspire) 4 wk • Age ≥ 12 yr presence of T2 inflammatory
lymphopoietin biomarkers
• Predictors of treatment response
include higher blood eosinophil counts
and higher FeNO

Information from McGregor 2019.

Abbreviations: COPD, chronic obstructive pulmonary disease; CRSwNP, chronic rhinosinusitis with nasal polyposis; FeNO, fractional
concentration of exhaled nitric oxide; IgE, immunoglobulin E; IL, interleukin; IV, intravenous; OCS, oral corticosteroid; Rα, receptor
alpha; SC, subcutaneously.
a
No type 2 inflammation biomarkers are required for treatment eligibility.

actuation of device, and ability to hold breath for an extended PIPELINE AGENTS
period after inhalation. Key device considerations include cost, The study of asthma biomarkers has opened up a new ave-
portability, bulkiness, and simplicity (Lavorini 2019; Dolovich nue of investigational treatments targeting specific asthma
2005; Rubin 2011; Iwanaga 2019). phenotypes. Currently more than 90 potential therapies are

ACSAP 2025 16 Chapter: Updates in Asthma Management

Table 6. Inhaled Drug Devices for Management of Asthma

Inhaler
Class Advantages Disadvantages Key Considerations

Metered-dose • Compact, portable • Aerosol particles rapidly exit • Populations especially prone to difficulty using
inhalers • Can use with spacer mouthpiece, making correct MDIs include pediatric and geriatric patients
(MDIs) use difficult • Using MDI with a 1-way valve spacer device
• Drug delivery relies on completely diminishes need for patient
good coordination between coordination with device actuation and inhalation
inhalation and device • If a mask is used with the spacer,a the patient
activation should take 6 tidal breaths vs. 1 single deep breath
• A mask is not preferred if the patient can hold
breath after inhalation because mask use results
in more drug loss
• Breath-actuated MDIs (e.g., RediHaler) can
address coordination issues, but are often not on
formulary, resulting in high costs

Dry powder • Compact, portable • Must not have severe airflow • Most useful in patients with impaired fine-motor
inhalers • Less need for fine-motor limitations; relies solely on skills
(DPIs) coordination user’s strong inhalation • Most DPIs contain either an ICS, ICS/LABA, or
ICS-LABA-LAMA
• Albuterol sulfate is available with the Respiclick®
DPI for patients with compelling reasons to use
DPI vs. MDI

Soft mist • Compact, portable • Assembly of device can be • Only available as tiotropium for treatment of
inhalers • Operates without difficult asthma
(SMIs) propellent, released at
slower velocity vs. MDI
• Reduces requirements for
patient coordination and
inspiratory effort
• High drug deposition
to lung and peripheral
airways

Nebulized • Less risk of error vs. MDI • Long administration time • Useful in pediatric and geriatric patients
medications • No coordination needed • Bulky machinery • Patients should also be prescribed a more
• May use normal tidal • Requires a power source portable drug delivery device
breathing during • Requires routine/thorough • Mouthpiece is preferred to face mask for aerosol
administration cleaning to prevent mold/ delivery (improves delivery to lungs)
bacteria accumulation • Nebulizers are often used with face masks in
within machine and tubing critically ill patients
• Lung deposition from
nebulizers often primarily in
proximal airways because of
larger particle size

a
Suggested for patients age < 4 yr or who cannot hold breath after inhalation.
Abbreviations: ICS, inhaled corticosteroid; LABA, long-acting β2-agonist; LAMA, long-acting muscarinic antagonist.

in different stages of the drug approval process. Details of Depemokimab

agents in phase III trials are discussed below. Depemokimab is a subcutaneous long-acting monoclo-
nal antibody targeting IL-5. The phase III trials SWIFT-1 and
SWIFT-2 (currently ongoing at the time of this publication) are

ACSAP 2025 17 Chapter: Updates in Asthma Management

Patient Care Scenario
J.M. is a 42-year-old woman presenting to the clinic for 10 years ago, gastroesophageal reflux disease 5 years
a follow-up on asthma control. She was recently treated ago, and asthma 1 year ago, and she has obesity. Her cur-
in the ED for an asthma exacerbation and was discharged rent medications are ICS-LABA (fluticasone-salmeterol
home on a prednisone burst. Today, she reports wors- 500/50 μg, 1 puff orally twice daily); a reliever inhaler
ening asthma symptoms over the past 3 months. She (albuterol 90 μg, 1 puff orally every 4–6 hours as needed);
experiences frequent episodes of wheezing, shortness which she is currently using 2 to 3 times daily; and ser-
of breath, and chest tightness. Symptoms worsen with traline (100 mg 1 tablet orally daily).
exertion and at nighttime, but she is unsure about other On physical examination, blood pressure is 130/85 mm
triggers. Her pharmacy says it is too soon to refill her Hg, heart rate is 88 beats/minute, and respiratory rate is
albuterol inhaler, but she only has a few doses remain- 20 breaths/min; her oxygen saturation is 96%. She does
ing. You review her pharmacy fill history and note she not appear in respiratory distress, and her lungs are clear
last filled her fluticasone-salmeterol 45 days ago and her bilaterally to wheezing.
albuterol inhaler 20 days ago. Develop a treatment plan for the patient that addresses
Her family history is significant for diabetes (mother) the following: additional diagnostic assessment, mod-
and for hypertension and congestive heart failure (father). ifiable risk factors, pharmacologic therapies, and
She does not use tobacco, and she drinks 1 or 2 glasses nonpharmacologic therapies.
of wine per week. Depression and anxiety were diagnosed
ANSWER
Multi-Faceted Approach to a Treatment Plan (2) Collect and Assess Information Pertaining to Triggers
A multi-faceted approach involving patient education, and Relevant Comorbidities
mitigation of allergens and other asthma triggers, • Perform a detailed evaluation of environmental and occupa-
control of pertinent comorbidities, and optimization of tional triggers. Advise patient to avoid/minimize exposure to
medication therapies is vital to achieving asthma control any known asthma triggers and allergens to which they have
in those with difficult-to-treat asthma. The key elements known sensitivity. Common triggers include:
of this approach are encompassed in the following four ○ Indoor allergens: Dust mites, mold, pet dander, or cock-
roach allergens.
steps.
○ Outdoor allergens: Pollen, grass, or air pollution.
(1) Discuss Adherence to Maintenance Therapies and Con- ○ Irritants: Smoke, strong odors, or chemical fumes such
firm Proper Technique as in in the workplace, including like factories, hair sa-
A review and demonstration of proper inhaler technique lons, farms, and other settings.
is essential. Proper inhaler technique is critical for effec- Next, consider the patient’s comorbid conditions, as
tive delivery of the medication to the lungs, and many pa- follows:
tients use their inhaled medications incorrectly, resulting
in minimal lung deposition. Common issues with inhaler ○ Comorbidities such as gastroesophageal reflux disease
use include incorrect timing of breath, failure to shake (GERD), obstructive sleep apnea, rhinosinusitis, and
the inhaler prior to use, and not holding the breath long obesity can worsen asthma symptoms.
enough after use. These issues can reduce the effec- ○ A comprehensive evaluation should be performed to
tiveness of therapy. For the patient in this scenario, ask identify and treat these conditions. In particular, GERD
about barriers to adherence to fluticasone-salmeterol, can cause reflux of stomach acid, irritating the airways
and worsening asthma. In this case, managing GERD
given it is not being filled monthly. Potential modifiable
with dietary changes, proton pump inhibitors, or hista-
barriers may include the following:
mine-2 receptor blockers may improve asthma control.
• Cost: Discuss the possibility of switching to a more afford- ○ Referral to the relevant specialist for appropriate man-
able alternative or look into patient assistance programs and/ agement of these comorbid conditions may be needed
or coupons. for asthma control.
• Adverse effects: Use of ICS can cause oral thrush, sore
throat, or hoarseness, which may deter use. Reinforce the (3) Perform a Biomarker Analysis
importance of rinsing the mouth after use to prevent adverse Assess the following biomarkers:
effects.
• Blood eosinophil counts are often elevated in patients with
• Perceived necessity: Some patients may skip their mainte- eosinophilic asthma. Management typically involves ICS as
nance inhaler when they feel better. They also may choose the cornerstone of therapy. However, in more severe cases,
only to use their quick-relief medication rather than their biologics targeting IL-5, IL-4/13, or IgE may be necessary. If
maintenance medications because the improvement in this patient’s symptoms persist despite improved adherence
symptoms occurs more rapidly. Emphasize the importance to maintenance ICS therapy, she should be considered for a
of regular use of a maintenance inhaler to prevent exacerba- biologic agent.
tions and maintain control of asthma. Patients should also be
• Total IgE levels can provide insight into the presence of atopy
educated that albuterol overuse can result in loss of efficacy. or allergic asthma. Elevated IgE levels may suggest that
• Complexity of regimen: If the dosing schedule is too complex, treatments such as omalizumab (an anti-IgE biologic) might
simplifying the regimen may improve adherence. be beneficial.

(Continued)

ACSAP 2025 18 Chapter: Updates in Asthma Management

Patient Care Scenario (Continued)
• FeNO levels are often elevated in those with poorly controlled present to minimize inflammation in the airways and improve
asthma and indicate active inflammation. The FeNO level is a asthma control.
value used to determine eligibility for biologic therapies. • Reliever inhaler: Educate the patient on when to use the re-
liever inhaler for treatment of asthma symptoms. Emphasize
(4) Consider Pharmacologic Treatment Adjustments that frequent need for reliever doses is a sign of uncontrolled
Consider changing the patient from fluticasone-salmet- asthma.
erol to ICS-formoterol MART. This patient demonstrates
• Trigger avoidance: Provide tailored advice on how to avoid
poor adherence to her fluticasone-salmeterol therapy and or minimize exposure to known asthma triggers, whether
overuse of her albuterol, which is diminishing the effects environmental or occupational.
of the SABA and putting her at an increased risk of severe
exacerbations. Providing the patient with a single inhaler Next, it is important to create an asthma action plan. Help
that can both reduce airway inflammation and quickly the patient create an asthma action plan that outlines
reverse bronchoconstriction will reduce risk of future how to adjust treatment based on symptoms and peak
severe asthma exacerbations and simplify her treatment flow readings and when to seek medical attention. Finally,
regimen. address patient concerns and questions:

(5) Provide Patient Education and an Action Plan and Ad- • Create a comfortable environment for the patient to ask
dress Concerns and Questions questions and voice concerns about medications, adverse
effects, and overall management.
The first step in patient education is to reinforce the fol-
• Empower patients to take an active role in managing their
lowing key points regarding asthma management:
condition through education and support.
• Maintenance/controller inhaler: Emphasize the importance
of taking maintenance inhalers even when symptoms are not

Information from Bosnic-Anticevich 2018; Mosen 2008; Grandes 2022; Wan 2016; Beasley 2022

evaluating depemokimab as an adjunctive therapy in patients asthma that is not sufficiently managed with standard treat-
12 years and older who have severe uncontrolled asthma ments. A phase III trial (currently ongoing at the time of this
with an eosinophilic phenotype (Pavord 2024). The primary publication) is comparing budesonide-glycopyrronium-for-
endpoint is the annual rate of clinically significant exacerba- moterol with budesonide-formoterol and placebo to assess
tions over 52 weeks; completion is expected in May 2025. If its impact on asthma exacerbation rates and changes in FEV1
approved, depemokimab will require administration every (AstraZeneca 2024).
6 months, compared with other similar approved agents
(mepolizumab, reslizumab, benralizumab) that require admin- NONPHARMACOLOGIC
istration every 4–8 weeks (GlaxoSmithKline 2021). MANAGEMENT OF ASTHMA
The risk of asthma exacerbations can be reduced through non-
Masitinib
pharmacologic interventions (Table 7), as well as by addressing
Masitinib is an orally administered tyrosine kinase inhibitor modifiable risk factors. Patients should be assessed for any
that selectively targets mast cell activity and platelet-derived
socioeconomic barriers that may be preventing them from
growth factor receptor signaling, both of which are implicated
accessing their medications, including lack of transportation,
in various mechanisms of asthma pathogenesis. In a phase
lack of support, low health literacy, and high drug costs.
III trial of patients with severe asthma uncontrolled by high-
Those who have exposure to tobacco or e-cigarette
dose ICS and blood eosinophil counts 150 cells/μL or greater,
emissions should be strongly advised to minimize further
masitinib showed a statistically significant 29% reduction in
exposure. Environmental tobacco smoke increases the risk
severe exacerbations relative to placebo. In another phase III
of hospitalization and poor asthma control, and active smok-
study for the treatment of severe uncontrolled asthma either
with OCS or high-dose inhaled ICS-LABA, masitinib reduced ing has been proven to increase the rate of decline of lung
severe asthma exacerbations by 35% compared with placebo function and increase the risk of developing COPD (Rayens
(AB Science 2020). 2008; Chaudhuri 2007; Osborne 2007). Furthermore, smoking
reduces the effectiveness of inhaled and oral corticosteroids,
Budesonide-Glycopyrronium-Formoterol requiring higher doses to achieve a response (Lazarus 2007).
Budesonide-glycopyrronium-formoterol, which is a combi- Patients who consume inhaled tobacco products should be
nation ICS-LAMA-LABA MDI approved for COPD, is under counseled on the negative health impact that smoking has
investigation for use in adults and adolescents with severe on their asthma. Referral to smoking cessation programs and

ACSAP 2025 19 Chapter: Updates in Asthma Management

Table 7. Nonpharmacologic Asthma Management

Modifiable Risk Factor Recommendation

Smoking, environmental • Strongly encourage cessation of smoking/vaping and avoidance of environmental smoke
tobacco exposure exposure

Obesity • Address strategies for weight loss (nutrition, physical activity, behavioral therapy, pharmacologic,
and/or surgical)

Major psychological disease • Refer to mental health services for assessment

Confirmed food allergy • Emphasize appropriate food avoidance; ensure access to epinephrine and discuss anaphylaxis
plan

Physical activity • Educate on using a preventative inhaler before activity, as well as “warm-up” before vigorous
exercise

Indoor allergens • Assess exposure to mold and provide remediation strategies when appropriate
• Educate patients on avoidance/remediation strategies for other allergens, including dust mites
and pets (often complicated and expensive, with unclear evidence of benefit)

Indoor pollution • Encourage use of non-polluting heating and cooking sources, if possible

Outdoor allergens • Educate sensitized patients to keep windows and doors closed when pollen and mold counts
are highest

Occupational asthma • Educate patient on occupational sensitizers

Medications that may worsen • Counsel patients with history of aspirin-exacerbated respiratory disease on avoidance of aspirin
asthma and NSAIDs
• Identify nonselective β-blocker usage and collaborate with prescriber to switch to cardioselective
agent if asthma is uncontrolled

Information from Global Initiative for Asthma (GINA) 2024.

recommendations for smoking cessation therapies are highly function. While the cornerstone of asthma management con-
recommended. tinues to be bronchodilators and ICS treatment, adjunctive
Because many exacerbations are triggered by infec- biologic therapies targeting specific inflammatory pathways
tions, vaccines are another important preventative factor for offer personalized treatment options that can be tailored to
decreasing risk of severe asthma exacerbations. All patients the individual pathophysiological processes present for a spe-
with asthma should receive an annual influenza and corona- cific patient.
virus disease 2019 vaccine (GINA 2024). In addition, the CDC
In addition, the emergence of novel therapies holds prom-
recommends the pneumococcal vaccine (PCV15 or PCV20)
ise for further refining asthma management in the future.
for patients age 19–64 years with a history of chronic lung
However, the importance of proper device selection, patient
disease, including asthma. If PCV20 is used, no additional
education, adherence to treatment regimens, and nonphar-
vaccines are needed to complete the series; however, if
PCV15 is used, this vaccination should be followed by a dose macologic strategies in achieving optimal outcomes cannot
of pneumococcal polysaccharide vaccine (PPSV23) at least be overstated. By embracing a comprehensive approach that
1 year later unless the patient has already received PPSV23 combines pharmacotherapy with patient empowerment
(CDC 2024). An interval of 8 weeks may be considered in and personalized care, pharmacists and other health care
adults with certain immunocompromising conditions, such providers can effectively manage asthma and decrease asth-
as chronic renal failure, HIV infection, sickle cell disease, or ma-related morbidity and mortality.
asplenia.
REFERENCES
CONCLUSION
AB Science. Positive top-line phase 3 results for oral
Treatment of asthma requires a multifaceted approach to masitinib in severe asthma. October 20, 2020. Accessed
achieve optimal symptom control, reduce exacerbations, March 5, 2024. www.ab-science.com/positive-top-line-
improve quality of life, and prevent deterioration in pulmonary phase-3-results-for-oral-masitinib-in-severe-asthma

ACSAP 2025 20 Chapter: Updates in Asthma Management

Ther. 2018;4(1):1-12. https://doi.org/10.1007/
Practice Points s41030-018-0051-0
• Conduct a thorough history and physical examination to
identify asthma triggers, symptoms, and comorbid condi- Bousquet J, Boulet LP, Peters MJ, Magnussen H, Quiralte
tions. J, Martinez-Aguilar, NE, et al. Budesonide/formoterol
○ Assess biologic markers such as IgE, blood eosino- for maintenance and relief in uncontrolled asthma
phil counts, and FeNO for those with severe asthma vs. high-dose salmeterol/fluticasone. Respir Med.
uncontrolled on conventional asthma therapies. 2007;101(12):2437-2446. https://doi.org/10.1016/j.
rmed.2007.07.014
• Use MART with ICS-formoterol over SABA alone for reliev-
er therapy. Brusselle GG, Vanderstichele C, Jordens P, Deman R,
○ Has been shown to improve asthma control and re- Slabbynck H, Ringoet V, et al. Azithromycin for preven-
duce exacerbations. tion of exacerbations in severe asthma (AZISAST): a
• Initiate ICS at the time of asthma diagnosis. multicentre randomized double-blind placebo-controlled
○ Even if only used as needed together with a broncho- trial. Thorax. 2013;68:322-329. https://doi.org/10.1136/
dilator (e.g., ICS-formoterol, ICS-albuterol). thoraxjnl-2012-202698
○ ICS continues to be the staple of asthma mainte-
nance therapy, with the addition of LABAs for moder- Buhl R, Kuna P, Peters MJ. The effect of budesonide/formo-
ate to severe cases. terol maintenance and reliever therapy on the risk of severe
• Reserve oral corticosteroids for acute exacerbations and asthma exacerbations following episodes of high reliever
severe uncontrolled asthma. use; an exploratory analysis of two randomized, controlled
• Consider biologic agents for patients with severe asthma studies with comparisons to standard therapy. Respir Res.
not controlled with optimized ICS-LABA. 2012;13(1):59. https://doi.org/10.1186/1465-9921-13-59
○ They have the most evidence for treatment of eosin-
Carr TF, Kraft M. Use of biomarkers to identify phenotypes
ophilic asthma.
and endotypes of severe asthma. Ann Allergy Asthma
○ Anti-thymic stromal lymphopoietin agents may be Immunol. 2018;121(4):414-420. https://doi.org/10.1016/j.
considered for those with severe asthma, even if no
anai.2018.07.029
eosinophilic biomarkers are present.
• Consider azithromycin three times per week for six months Casale TB, Aalbers R, Bleecker ER, Meltzer EO, Zaremba-
for patients with uncontrolled asthma despite high-dose Pechmann L, de la Hoz A, et al. Tiotropium Respimat®
ICS-LABA add-on therapy to inhaled corticosteroids in patients
○ May reduce exacerbation rates after at least three with symptomatic asthma improves clinical out-
months. comes regardless of baseline characteristics. Respir
○ May be used for T2 or Non-T2 endotypes. Med. 2019;158:97–109. https://doi.org/10.1016/j.
• Consider LAMAs (e.g., tiotropium) as an add-on therapy for rmed.2019.09.014
patients who remain uncontrolled on ICS-LABA.
Centers for Disease Control and Prevention (CDC). About
○ Can improve lung function and reduce exacerbations.
underlying cause of death, 2018–2022, single race [CDC
○ May be beneficial in those with non-eosinophilic
WONDER online database]. 2022. Accessed November 22,
phenotypes.
2024. https://wonder.cdc.gov/ucd-icd10-expanded.html
• Educate patients on identifying and avoiding asthma trig-
gers, such as allergens, smoke, and pollution. Centers for Disease Control and Prevention (CDC). 2021
• Recommend influenza, pneumococcal, and coronavirus National Health Interview Survey (NHIS) data. Updated
disease 2019 vaccinations to prevent respiratory infections March 29, 2023. Accessed November 22, 2024. https://
that can exacerbate asthma. www.cdc.gov/asthma/nhis/2021/table6-1.htm

Centers for Disease Control and Prevention (CDC). NHIS Adult

Summary Health Statistics. Data accessed February 13,
AstraZeneca. Study to Assess PT010 in adult and adolescent 2025. Available from https://data.cdc.gov/d/25m4-6qqq.
participants with inadequately controlled asthma (KALOS).
ClinicalTrials.gov identifier: NCT04609878. Updated Centers for Disease Control and Prevention (CDC). NHIS Child
September 19, 2024. Accessed February 12, 2025. https:// Summary Health Statistics. Data accessed February 13,
clinicaltrials.gov/study/NCT04609878?cond=asthma%20 2025. Available from https://data.cdc.gov/d/wxz7-ekz9.
&intr=BGF%20MDI&checkSpell=&rank=2
Centers for Disease Control and Prevention (CDC).
Beasley R, Harrison T, Peterson S, et al. Evaluation of Pneumococcal vaccine recommendations. Updated
budesonide-formoterol for maintenance and reliever October 26, 2024. Accessed November 22, 2024. https://
therapy among patients with poorly controlled asthma: www.cdc.gov/vaccines/vpd/pneumo/hcp/recommenda-
a systematic review and meta-analysis. JAMA Netw tions.html
Open. 2022;5(3):e220615. https://doi.org/10.1001/
jamanetworkopen.2022.0615 Chaudhuri R, Livingston E, McMahon AD, Lafferty J, Fraser I,
Spears M, et al. Effects of smoking cessation on lung func-
Bosnic-Anticevich SZ, Cvetkovski B, Azzi EA, Srour P, Tan R, tion and airway inflammation in smokers with asthma. Am
Kritikos V. Identifying critical errors: addressing inhaler J Respir Crit Care Med. 2006;174(2):127-133. https://doi.
technique in the context of asthma management. Pulm org/10.1164/rccm.200510-1589OC

ACSAP 2025 21 Chapter: Updates in Asthma Management

Expert Panel Working Group of the National Heart, Lung, evaluating the current inhaler landscape. Ther Adv
and Blood Institute (NHLBI) administered and coordi- Respir Dis. 2019;13:1753466619884532. https://doi.
nated National Asthma Education and Prevention Program org/10.1177/1753466619884532
Coordinating Committee (NAEPPCC); Cloutier MM, Baptist
AP, Blake KV, Brooks EG, Bryant-Stephens T, et al. 2020 Lazarus SC, Chinchilli VM, Rollings NJ, Rollings NJ, Boushey
Focused updates to the asthma management guidelines: a HA, Cherniack R, et al. Smoking affects response to inhaled
report from the National Asthma Education and Prevention corticosteroids or leukotriene receptor antagonists in
Program Coordinating Committee Expert Panel Working asthma. Am J Respir Crit Care Med. 2007;175(8):783-790.
Group. J Allergy Clin Immunol. 2020;146(6):1217-1270. https://doi.org/10.1164/rccm.200511-1746oc
https://doi.org/10.1016/j.jaci.2020.10.003 Lee Y, Quoc QL, Park HS. Biomarkers for severe asthma: les-
Dolovich MB, Ahrens RC, Hess DR, Anderson P, Dhand R, sons from longitudinal cohort studies. Allergy Asthma
Rau JL, et al. Device selection and outcomes of aerosol Immunol Res. 2021;13(3):375-389. https://doi.org/10.4168/
therapy: evidence-based guidelines: American College of aair.2021.13.3.375
Chest Physicians/American College of Asthma, Allergy, Levy ML, Fletcher M, Price DB, Hausend T, Halbert RJ, Yawn
and Immunology. Chest. 2005;127(1):335-371. https://doi. BP. International Primary Care Respiratory Group (IPCRG)
org/10.1378/chest.127.1.335 guidelines: diagnosis of respiratory diseases in primary
Gibson PG, Yang IA, Upham JW. Effect of azithromycin care. Prim Care Respir J. 2006;15(1):20-34. https://doi.
on asthma exacerbations and quality of life in adults org/10.1016/j.pcrj.2005.10.004
with persistent uncontrolled asthma (AMAZES): a ran- McGregor MC, Krings JG, Nair P, Castro M. Role of biologics
domized, double-blind, placebo-controlled trial. Lancet. in asthma. Am J Respir Crit Care Med. 2019;199(4):433-
2017;390(10095):659-668. https://doi.org/10.1016/ 445. https://doi.org/10.1164/rccm.201810-1944ci
S0140-6736(17)31281-3
Mosen DM, Schatz M, Magid DJ, Camargo CA Jr. The rela-
Global Initiative for Asthma (GINA). Global Strategy for tionship between obesity and asthma severity and control
Asthma Management and Prevention, 2024. Updated May in adults. J Allergy Clin Immunol. 2008;122(3):507-511.e6.
2024. Accessed November 22, 2024. https://ginasthma. https://doi.org/10.1016/j.jaci.2008.06.024
org/reports/
Murugesan N, Saxena D, Dileep A, Adrish M, Hanania
GlaxoSmithKline (GSK). GSK starts the first phase 3 study NA. Update on the role of FeNO in asthma manage-
with a long-acting anti-IL-5 treatment for patients with ment. Diagnostics (Basel). 2023;13(8):1428. https://doi.
severe asthma. GSK, March 18, 2021. Accessed March 5, org/10.3390/diagnostics13081428
2024. https://www.gsk.com/en-gb/media/press-releases/
gsk-starts-the-first-phase-3-study-with-a-long-acting-anti- O’Byrne PM, FitzGerald JM, Bateman ED, Barnes PJ, Zheng
il-5-treatment-for-patients-with-severe-asthma/ JP, Gustafson P, et al. Effect of a single day of increased
as-needed budesonide-formoterol use on short-term risk
Grandes XA, Talanki Manjunatha R, Habib S, Sangaraju SL, of severe exacerbations in patients with mild asthma:
Yepez D. Gastroesophageal reflux disease and asthma: a a post-hoc analysis of the SYGMA 1 study. Lancet
narrative review. Cureus. 2022;14(5):e24917. https://doi. Respir Med. 2021;9:149-158. https://doi.org/10.1016/
org/10.7759/cureus.24917 S2213-2600(20)30416-1
Hamilton D, Lehman H. Asthma phenotypes as a guide for O’Byrne PM, Pederson S, Lamm CJ, Tan WC, Busse WW;
current and future biologic therapies. Clin Rev Allergy START Investigators Group. Severe exacerbations and
Immunol. 2020;59(2):160-174. https://doi.org/10.1007/ decline in lung function in asthma. Am J Respir Crit
s12016-019-08760-x Care Med. 2009;179:19-24. https://doi.org/10.1164/
Iwanaga T, Tohda Y, Nakamura S, Suga Y. The Respimat® rccm.200807-1126OC
soft mist inhaler: implications of drug delivery characteris- Osborne ML, Pedula KL, O’Hollaren M, Ettinger KM, Stibolt
tics for patients. Clin Drug Investig. 2019;39(11):1021-1030. T, Buist AS, et al. Assessing future need for acute care in
https://doi.org/10.1007/s40261-019-00835-z adult asthmatics. Chest. 2007;132(4):1151-1161. https://doi.
Kang N, Song WJ. Discovering biomarkers of neutro- org/10.1378/chest.05-3084
philic asthma: a clinician’s perspective. Allergy Asthma Pavord ID, Jackson D, Wechsler M, Jackson D, Jarreta D,
Immunol Res. 2022;14(1):1-4. https://doi.org/10.4168/ Schalkwijk S, et al. SWIFT-1 and SWIFT-2 study design:
aair.2022.14.1.1 replicate phase 3a randomized, double-blind, placebo-
Kuruvilla ME, Lee FEH, Lee GB. Understanding asthma phe- controlled, multicenter studies of the efficacy and safety
notypes, endotypes, and mechanisms of disease. Clin of depemokimab in patients with asthma with an eosin-
Rev Allergy Immunol. 2019;56(2):219-233. https://doi. ophilic phenotype [abstract]. Am J Respir Crit Care Med.
org/10.1007/s12016-018-8712-1 2024;209:A5384. https://doi.org/10.1164/ajrccm-confer-
ence.2024.209.1_MeetingAbstracts.A5384
Lavorini F, Janson C, Braido F, Stratelis G, Løkke
A. What to consider before prescribing inhaled Rayens MK, Burkhart PV, Zhang M, Lee S, Moser DK, Mannino
medications: a pragmatic approach for D, et al. Reduction in asthma-related emergency depart-
ment visits after implementation of a smoke-free law. J

ACSAP 2025 22 Chapter: Updates in Asthma Management

Allergy Clin Immunol. 2008;122(3):537-541.e3. https://doi. Taylor SL, Leong L, Mobegi FM, Choo JM, Wesselingh S, Yang
org/10.1016/j.jaci.2008.06.029 IA, et al. Long-term azithromycin reduces Haemophilus
influenzae and increases antibiotic resistant in severe
Rubin BK. Pediatric aerosol therapy: new devices and new asthma. Am J Respir Crit Care Med. 2019;200:309-317.
drugs. Respir Care. 2011;56(9):1411-1421; discussion https://doi.org/10.1164/rccm.201809-1739OC
1421-1423. https://doi.org/10.4187/respcare.01246
Tliba O, Panettieri RA Jr. Paucigranulocytic asthma: uncou-
Stanojevic S, Kaminsky DA, Miller MR, Thompson B, pling of airway obstruction from inflammation. J Allergy
Aliverti A, Barjaktarevic I, et al. ERS/ATS technical stan- Clin Immunol. 2019;143(4):1287-1294. https://doi.
dard on interpretive strategies for routine lung function org/10.1016/j.jaci.2018.06.008
tests. Eur Respir J. 2022;60(1):2101499. https://doi.
org/10.1183/13993003.01499-2021 Walford H, Doherty T. Diagnosis and management of eosin-
ophilic asthma: a US perspective. J Asthma Allergy.
Siles RI, Hsieh FH. Allergy blood testing: a practical guide for 2014;2014(7):53-65. https://doi.org/10.2147/JAA.S39119
clinicians. Cleve Clin J Med. 2011;78(9):585-592. https://
doi.org/10.3949/ccjm.78a.11023 Wan XC, Woodruff PG. Biomarkers in severe asthma. Immunol
Allergy Clin North Am. 2016;36(3):547-557. https://doi.
Szefler SJ, Vogelberg C, Bernstein JA, Goldstein S, Mansfield org/10.1016/j.iac.2016.03.004
L, Zaremba-Pechmann L, et al. Tiotropium is efficacious in
6- to 17-year-olds with asthma, independent of T2 pheno- Yamasaki A, Okazaki R, Harada T. Neutrophils and
type. J Allergy Clin Immunol Pract. 2019;7(7):2286-2295.e4. asthma. Diagnostics (Basel). 2022;12(5):1175. https://doi.
https://doi.org/10.1016/j.jaip.2019.03.019 org/10.3390/diagnostics12051175

ACSAP 2025 23 Chapter: Updates in Asthma Management

Self-Assessment Questions
1. A 25-year-old woman with asthma and allergic rhini- the following biologic therapies is best to recommend for
tis presents to the clinic for a follow-up. She reports full this patient?
adherence to fluticasone (100 μg)-salmeterol (50 μg) dry
A. Mepolizumab
powder inhaler (DPI) as 1 puff twice daily and demon-
B. Omalizumab
strates proper inhaler technique. She has been using her
C. Reslizumab
albuterol inhaler 3 to 4 times per week to relieve her cough
D. Dupilumab
and chest tightness after being outdoors for walks. She
denies nighttime awakenings due to asthma. She has no 3. Which one of the following patients would be the most
history of ED visits, hospitalizations, or oral corticoste- appropriate to consider for initiation of tiotropium
roid (OCS) use specifically related to asthma. Her mother therapy?
has asthma, hypertension, and hyperlipidemia. Her father A. A 15-year-old female adolescent with allergic asthma
has hypertension, hyperlipidemia, and heart failure. The on mometasone (100 μg)-formoterol (5 μg) 2 puffs
patient denies the use of any tobacco products currently twice daily who uses albuterol daily before soccer
or in the past. Laboratory and diagnostic findings include practice
forced expiratory volume in 1 second (FEV1) 75% pre- B. A 10-year-old boy on fluticasone (100 μg)-salmeterol
dicted, FEV1/forced vital capacity 80%, fraction of exhaled (50 μg) 1 puff twice daily who has experienced
nitric oxide (FeNO) 55 ppb, blood eosinophil count 2 severe asthma exacerbations in the past year
50 cells/µL, and serum immunoglobulin E (IgE) 900 IU/ requiring hospitalization
mL. A skin allergy test is positive for grass pollen, tree pol- C. A 24-year-old woman on budesonide (160 μg)-
len, and ragweed. Which one of the following therapeutic formoterol (4.5 μg) 2 inhalations twice daily who
interventions is best to recommend for this patient? needs to use reliever therapy 4 days per week due to
A. Continue fluticasone (100 μg)-salmeterol (50 μg) DPI shortness of breath
as 1 puff twice daily; focus on nonpharmacologic D. A 20-year-old man on fluticasone (200 μg)-
interventions to minimize exposure to allergens. umeclidinium (62.5 μg)-vilanterol (25 μg) 1 inhalation
B. Continue fluticasone (100 μg)-salmeterol (50 μg) DPI daily who is experiencing frequent nighttime
as 1 puff twice daily; add tiotropium soft mist inhaler awakenings due to asthma symptoms.
1.25 μg as 2 inhalations daily.
C. Increase fluticasone (250 μg)-salmeterol (50 μg) DPI The next two questions pertain to the following case.
as 2 puffs twice daily. M.J. is a 50-year-old woman reporting to clinic for follow-up on
D. Change fluticasone-salmeterol to budesonide (160 her asthma (diagnosed at age 45 years). Her medical history is
μg)-formoterol (4.5 μg) as 1 inhalation twice daily significant for hypertension, gastroesophageal reflux disease,
as maintenance and reliever therapy and before obesity, and tobacco use (quit smoking 1 year ago). She is cur-
exposure to allergens; discontinue albuterol. rently managed on mometasone (200 μg)-formoterol (5 μg) as
2. A 12-year-old boy presents to his pulmonologist for 2 inhalations twice daily and as needed and tiotropium soft
follow-up after being seen in the ED 3 days ago for an mist inhaler 1.25 μg as 2 inhalations daily. Today, she reports
acute exacerbation of asthma. He was treated with bron- adherence to her inhalers and demonstrates proper tech-
chodilators and sent home on a 3-day oral prednisone nique. She has had 2 asthma exacerbations in the past year,
burst. Leading up to his ED visit, he was experiencing per- which resulted in ED visits; the most recent was 2 weeks ago
sistent dyspnea, coughing, and nocturnal awakenings 1 after being at her mother’s house, who smokes. The other was
to 2 nights per week. Allergy testing reveals sensitivity to preceded by a viral respiratory infection. Her FeNO is 15 ppb,
multiple allergens, including dust mites, mold, and cock- blood eosinophil count is 20 cells/μL, IgE is 5 units/mL, and
roach allergens. His FeNO is 55 ppb, blood eosinophil sputum neutrophils are 50%.
count is 100 cells/µL, and IgE is 400 IU/mL. He is currently 4. Which one of the following is the most likely phenotype of
on maintenance therapy with budesonide (160 μg)-formo- M.J.’s asthma?
terol (4.5 μg) as 2 inhalations twice daily. Which one of
A. Allergic asthma
B. Late onset-eosinophilic asthma
C. Paucigranulocytic asthma
D. Neutrophilic asthma

ACSAP 2025 24 Chapter: Updates in Asthma Management

5. Which one of the following is best to recommend for M.J.? most days of the week. She has also experienced one
severe asthma exacerbation in the past year, which was
A. Continue current management and counsel on
treated in the ED. She has a normal eosinophil count, but
management of comorbidities
elevated neutrophil count. Which one of the following
B. Change patient’s maintenance inhaler to fluticasone/
add-on therapies is best to recommend for this patient?
umeclidium/vilanterol to simplify regimen
C. Initiate mepolizumab. A. Tiotropium soft mist inhaler 1.25 μg as 2 inhalations
D. Initiate tezepelumab. daily
B. Prednisone 10 mg daily
6. An 8-year-old boy has complaints of coughing and
C. Azithromycin 500 mg daily
wheezing around 3 days per week. He denies nighttime
D. Benralizumab 30 mg subcutaneously every 4 weeks
awakenings due to asthma. He is using albuterol HFA
for 3 doses, then every 8 weeks
90 μg/inhalation before soccer practices and when he
experiences coughing/wheezing but has no maintenance
inhaler. He displays good inhaler technique. Which one of The next two questions pertain to the following case.

the following medication regimens is best to recommend S.J. is a 42-year-old woman with history of hypertension,
for this patient? hyperlipidemia, adult-onset asthma, and chronic sinusitis with
nasal polyps who presents to pulmonary clinic for follow-up.
A. Start mometasone (100 μg)-formoterol (50 μg) as
She is experiencing asthma symptoms most days of the week
2 inhalation twice daily and as needed; discontinue
despite proper adherence to inhalers. In addition, she com-
albuterol.
plains of symptoms of uncontrolled rhinosinusitis, including
B. Change albuterol to albuterol (90 μg)-budesonide
sinus pressure and post-nasal drip. She has had two seri-
(80 μg) as 2 inhalations as needed for symptoms.
ous asthma exacerbations in the past year, one that required
C. Start fluticasone 44 μg as 2 puffs twice daily;
hospitalization. Skin allergy testing is negative for allergens.
continue albuterol MDI 90 μg/inhalation as needed.
Her blood eosinophil count is 350 cells/µL. Her medications
D. Start fluticasone (100 μg)-salmeterol (50 μg) as
include the following: amlodipine 10 mg daily, atorvastatin 40
1 inhalation twice daily; continue albuterol MDI
mg daily, budesonide (160 μg)-formoterol (4.5 μg) as 2 inhala-
90 μg/inhalation as needed.
tions twice daily, and triamcinolone nasal spray 55 μg/spray
7. Which one of the following patients is the most appropri- as 2 sprays daily.
ate candidate for mepolizumab?
9. Which one of the following is the most likely phenotype of
A. An 18-year-old male adolescent with a blood S.J.’s asthma?
eosinophil count of 150 cells/μL who uses
A. Allergic asthma
fluticasone (500 μg)-salmeterol (50 μg) as 1 puff
B. Late onset-eosinophilic asthma
twice daily, montelukast 10 mg orally daily, and
C. Paucigranulocytic asthma
albuterol 2 or 3 days per month after physical activity
D. Neutrophilic asthma
B. A 52-year-old man with a FeNO of 55 ppb, blood
eosinophil count of 100 cells/μL, and sputum 10. The decision is made to initiate S.J. on a biologic therapy.
neutrophils of 60% who is not controlled on Which one of the following is best to recommend for S.J.?
fluticasone-umeclidinium-vilanterol and as-needed A. Mepolizumab
albuterol B. Omalizumab
C. A 12-year-old girl with allergic asthma and an IgE C. Tezepelumab
of 600 units/mL who continues to have frequent D. Reslizumab
asthma symptoms despite therapy with tiotropium
11. A 16-year-old female adolescent has a history of asthma
soft mist inhaler 1.25 μg as 2 inhalations daily
and seasonal allergies. She has no known food or drug
and budesonide (160 μg)-formoterol (4.5 μg) as 1
allergies but tested positive for the following allergens on
inhalation twice daily and as needed
skin allergy testing: pet dander, dust mites, mold. Pulmo-
D. A 42-year-old woman with a blood eosinophil
nary function tests confirmed reversible airflow limitation
count of 450 cells/μL who was recently admitted
consistent with an asthma diagnosis, and her FEV1 is 85%
for an asthma exacerbation despite adherence to
predicted. She experiences asthma symptoms 2 or 3 days
mometasone (200 μg)-formoterol (5 μg) as 2 puffs
per month, and symptoms respond well to albuterol ther-
twice daily
apy. She has a history of one severe asthma exacerbation
8. A 51-year-old woman with severe persistent asthma has when she was around a cat at her grandmother’s house.
been taking fluticasone (200 μg)-vilanterol (5 μg) as 1 She was treated in the ICU and discharged on an oral
inhalation daily and continues to have asthma symptoms steroid burst. She denies nighttime awakenings due to

ACSAP 2025 25 Chapter: Updates in Asthma Management

asthma. She is on the soccer team and uses her albuterol 14. A 23-year-old man states that he is unable to get a refill of
daily before practice, which controls her symptoms. his albuterol inhaler due to a “refill too soon” rejection by
Which one of the following best classifies this patient’s his insurance. He has another albuterol inhaler at home
asthma? with only a few doses remaining. He is not currently short
of breath, wheezing or coughing, but admits to waking up
A. Well controlled; high future risk
every night coughing and using his albuterol. He admits
B. Well controlled; low future risk
to poor adherence to his fluticasone-salmeterol ther-
C. Uncontrolled; high future risk
apy because “it just doesn’t seem to help my shortness
D. Uncontrolled; low future risk
of breath like albuterol does.” He also states it is difficult
12. A 62-year-old man is on low-dose budesonide-formoterol to remember to use an inhaler twice a day. Which one of
MDI. He has low inspiratory flow and states that he does the following is best to recommend for minimizing this
not always feel that the inhaler relieves his symptoms. patient’s risk of an asthma exacerbation?
When demonstrating his inhaler technique, you observe
A. Ask his insurance for an override so that albuterol
that he does the following in a stepwise fashion: 1) takes
can be refilled.
a deep breath out; 2) places the inhaler in his mouth and
B. Request that his provider change albuterol to
seals his lips around the device; 3) takes a slow, deep
budesonide-formoterol to use as MART and
inhalation in; 4) actuates the inhaler at the end of his
discontinue fluticasone-salmeterol.
inhalation; and 5) holds his breath for 10 seconds, then
C. Request a prednisone burst from his provider to
breathes out. Which one of the following is best to recom-
achieve rapid reversal in airway inflammation.
mend for this patient?
D. Provide counseling to the patient on the importance
A. Using a spacer with his inhaler of using fluticasone-salmeterol therapy to reduce
B. Using a spacer and mask with his inhaler inflammation in the lungs.
C. Switching to a DPI formulation
15. A 42-year-old woman with severe asthma and multiple
D. Increasing to medium-dose budesonide-formoterol
severe exacerbations has been on prednisone 20 mg
13. A 10-year-old boy with asthma experiences exercise- daily for 3 months in addition to fluticasone/umeclid-
induced bronchospasms and uses an albuterol MDI before ium/vilanterol 200/62.5/25 mcg once daily. She does not
physical activity but often still needs to take rest breaks have biomarkers of type 2 (T2) inflammation. The doctor
for shortness of breath. The patient has good inspiratory wants to wean the patient off prednisone, but her symp-
flow but is not able to coordinate the actuation of his MDI toms worsen each time the dose is tapered. Which one of
with his inhalation to be used as needed before physical the following add-on therapies is best to recommend for
activity. He has a spacer at home, but often forgets it and this patient?
notes it is not convenient to bring with him when he does.
A. Tiotropium
Which one of the following is best to recommend for this
B. Dupilumab
patient?
C. Mepolizumab
A. Counsel the patient on the importance of D. Azithromycin
remembering his spacer device when he leaves
home.
B. Switch the patient to a slow mist inhaler.
C. Switch the patient to albuterol nebulizer solution and
ensure he has a nebulizer.
D. Change the patient to albuterol sulfate inhalation
powder.

ACSAP 2025 26 Chapter: Updates in Asthma Management