A 54-year-old female with a history of moderate persistent asthma presented to the hospital with worsening shortness of breath, wheezing, and nighttime cough. Over the previous week, she had been using her rescue inhaler six to eight times daily before ultimately requiring emergency department evaluation and hospitalization for an asthma exacerbation. Prior to admission, her maintenance regimen included Advair Diskus 250/50 mcg one inhalation twice daily along with as-needed albuterol. During medication reconciliation, the patient reported that she was “pretty good” about taking her morning dose but frequently forgot the evening dose because of a busy work schedule and caring for grandchildren in the evenings. She estimated missing the nighttime dose three to four times per week.
This scenario highlights an important real-world issue in asthma management: adherence often matters more than simply escalating therapy. Before increasing doses or adding therapies, evaluating how the patient actually uses the regimen is essential. In this case, inconsistent use of her inhaled corticosteroid/long-acting beta agonist combination likely contributed significantly to poor asthma control and eventual hospitalization.
During hospitalization, the clinical pharmacist discussed simplifying the regimen to improve adherence while also considering SMART (single maintenance and reliever therapy). The patient was transitioned from twice-daily Advair Diskus to Breo Ellipta once daily for maintenance along with as-needed Symbicort SMART-style reliever use instead of albuterol alone (excellent board exam nugget). Education focused on recognizing worsening symptoms early and using the ICS/formoterol inhaler PRN to deliver both rapid bronchodilation and additional anti-inflammatory therapy during symptom escalation.
The patient appreciated the simplified morning maintenance routine and the idea of using an inhaler containing an inhaled corticosteroid during exacerbation symptoms rather than relying exclusively on albuterol. Inhaler technique and adherence counseling were reviewed extensively prior to discharge.
At six-week follow-up, she reported excellent adherence with the once-daily maintenance inhaler, fewer asthma symptoms, no nighttime awakenings, and significantly reduced rescue inhaler use. This case demonstrates how regimen simplification and incorporating SMART-style therapy principles may improve asthma control and reduce future exacerbation risk.
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