Poorly controlled asthma in a teacher with low adherence and eosinophilia
A 38-year-old secondary-school teacher was diagnosed with asthma at age 12. She has never smoked, but her partner smokes indoors. She takes fluticasone/formoterol 500/24 via metered-dose inhaler, two puffs twice daily, plus montelukast 10 mg. Despite this she wakes three nights a week, uses salbutamol four to five times a week, and has had two prednisolone courses and one emergency department visit in the past 12 months. Spirometry shows FEV1 68% predicted, FEV1/FVC 0.64, and bronchodilator reversibility of 15% and 220 mL. Blood eosinophils are 480 cells/µL, FeNO is 62 ppb, and total IgE is 210 IU/mL. Inhaler review shows poor coordination with the metered-dose inhaler; pharmacy refill records suggest she collects about half her prescribed preventer. Examination reveals widespread expiratory wheeze but no crackles. She asks whether she needs a stronger inhaler or a new injection.
1. What is the most appropriate next step, and why would escalating to a biologic now be premature?
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The next step is to confirm the diagnosis and correct reversible causes of poor control before changing drug class. Her refill record and poor metered-dose inhaler coordination are strong evidence of incomplete adherence and ineffective delivery, either of which can mimic severe asthma. Provide structured adherence support, simplify to a once-daily regimen if possible, correct technique with a spacer or switch to a dry-powder device, and give a written action plan. Review rhinitis, reflux, obesity and anxiety, and address smoke exposure. Escalating now would be premature because uncontrolled symptoms with low adherence do not establish treatment-resistant asthma; biologics are expensive, require monitoring and should not compensate for poor inhaler use. Reassess after about three months of optimised therapy using symptom control, exacerbations, spirometry and eosinophils. Only if control remains poor despite confirmed adherence and technique should she be phenotyped for biologic therapy.
2. Six months later, after adherence support and a large-volume spacer, she remains symptomatic with two exacerbations, blood eosinophils 520 cells/µL and FeNO 58 ppb. How would you phenotype her and choose a biologic?
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First confirm severe asthma: persistent symptoms and exacerbations despite high-dose inhaled corticosteroid plus long-acting beta-agonist, with adherence and technique now verified, and alternative diagnoses excluded. Her eosinophilic phenotype is supported by blood eosinophils above 300 cells/µL and raised FeNO. Check total and specific IgE, allergic sensitisation, oral corticosteroid burden, nasal polyps, eczema and parasitic infection risk. Reasonable options are an anti-interleukin-5 or anti-interleukin-5 receptor agent, or dupilumab, which targets the interleukin-4 receptor alpha and is attractive with high FeNO. Omalizumab is an option if she is sensitised to a perennial allergen and total IgE lies within the approved range. Selection should weigh exacerbation frequency, oral corticosteroid dependence, comorbidities, dosing burden and patient preference. Arrange review at six to twelve months to assess exacerbations, symptom control, lung function and corticosteroid reduction.
3. How would you manage the household smoke exposure and her self-management plan?
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Use a brief, non-judgemental intervention: explain that second-hand smoke increases exacerbations and reduces controller response, and that a smoke-free home is the goal. Offer nicotine replacement and referral to a cessation service for her partner, and suggest smoking outside and changing clothes after smoking if complete cessation is not immediate. Avoid simply telling her to move out. Provide a written, personalised asthma action plan covering daily preventer use, reliever use, recognition of deterioration, and when to seek urgent care. Check and document inhaler technique at every visit, arrange vaccination, and schedule early follow-up after any exacerbation. Addressing exposure and self-management is not peripheral: it reduces the risk that a biologic is started for what is partly an environmental and behavioural problem.