1. Use the following CASE to answer questions 1 through 10:
KD is a 31-year-old female who has had asthma for 15 years. She has been poorly controlled for the past 2 years, experiencing 2 exacerbations, 1 of which required a hospitalization. She is currently treated with a budesonide-formoterol combination inhaler that she uses twice daily and as needed for acute symptoms, which happen 4 to 5 times weekly. She reports that she “always takes her prescribed medication doses,” but she does express a concern about the long-term effects of the corticosteroid.

In the past, spirometry has revealed a forced expiratory volume in 1 second (FEV1) of 1.98 L (66% predicted) with a forced vital capacity (FVC) of 2.68 L and a FEV1/FVC ratio of 69%. After albuterol, her FEV1 improved to 2.3 L (76% predicted). She had a serum immunoglobulin (Ig) E level measured 3 months ago, which was reported as 59 IU/mL; however, allergen skin testing was negative. She reports that “everything seems to bother her asthma,” although she cannot identify any specific aeroallergen to which she is allergic. Her last fraction of exhaled nitric oxide (FeNO) measurement was 40 ppb.


Which the following features represents the cut-off point for the presence of severe asthma in KD, despite aggressive guideline-directed therapy with inhaled corticosteroids and other controllers?

2. KD's asthma pattern (history of exacerbations, frequent symptoms, and reversible airflow obstruction) is best described as her asthma ______:

3. According to the Global Initiative for Asthma (GINA) guidelines, for a patient like KD, which of the following medications might warrant a therapeutic trial prior to considering biologic therapy?

4. If KD's history reveals a positive allergy skin test, which of the following biomarkers would be most consistently elevated by association?

5. The clinician decided to pursue an additional workup for KD's asthma. Which of the following tests would be most practical and useful?

6. Case Update:
KD undergoes a comprehensive assessment, which includes the following:
Repeat spirometry: post-bronchodilator FEV1 of 2.2 L (73% predicted)
Methacholine challenge: positive for bronchial hyperresponsiveness
Serum IgE: 56 IU/mL
Serum eosinophils: 285 cells/µL
WBC: 9000 cells/mm3
FeNO: 42 ppb
Sputum for eosinophils: too numerous epithelial cells; unacceptable for testing


Which of the following agents is an interleukin (IL)-5 inhibitor therapy that has the most evidence of benefit for a patient like KD?

7. If KD is started on a treatment for eosinophilic asthma, what reduction in asthma exacerbations can be anticipated?

8. Which of the following therapies would be appropriate to consider if KD indicated that she was unable to commit to regular visits to the clinic to receive her treatments?

9. What additional factor may favor a trial of dupilumab (over other biologics) in a patient like KD?

10. When KD starts a trial of a biologic for her asthma, she should be monitored for which of the following infections?

Evaluation Questions

11. How confident are you in your decision about treatment for KD in the questions above?

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