In persistent asthma, what is the first-line long-term controller, and what class is added for moderate to severe disease?

• A. Leukotriene receptor antagonists are first-line; add inhaled corticosteroids for moderate to severe disease.
• B. Inhaled corticosteroids (ICS) are first-line; add a long-acting beta-agonist (LABA) for moderate to severe disease.
• C. Short-acting beta-agonists are first-line; add inhaled corticosteroids for moderate to severe.
• D. Theophylline is first-line; add LABA for moderate to severe.

Answer: (B)

In persistent asthma, addressing the underlying airway inflammation is the main approach to long-term control, and inhaled corticosteroids are the standard first-line controller for this purpose. They reduce inflammation, decrease airway hyperresponsiveness, and cut the frequency of symptoms and exacerbations. When the disease is moderate to severe, adding a long-acting beta-agonist improves symptom control and lung function beyond what ICS alone can achieve, and this combination therapy is commonly used. It’s important to note that a LABA should always be used with an inhaled corticosteroid rather than alone. Short-acting beta-agonists treat acute symptoms and do not provide long-term control; leukotriene receptor antagonists can be alternatives or add-ons in some patients but are not first-line; theophylline is older and less favored due to narrow therapeutic index and interactions.