A 28-year-old woman with moderate persistent asthma has been using inhaled salbutamol 3–4 times weekly for the past 6 months. She reports frequent nocturnal symptoms and morning wheeze. On examination, peak expiratory flow is 65% of predicted. She is started on inhaled fluticasone propionate 250 μg twice daily. After 2 weeks, she complains of a hoarse voice and white patches in her mouth. What is the most appropriate next step in management?

Explanation

## Clinical Presentation & Diagnosis **Key Point:** The patient has developed oral candidiasis (thrush) and dysphonia — both common local adverse effects of inhaled corticosteroids (ICS). ### Mechanism of Local ICS Adverse Effects Inhaled corticosteroids deposit in the oropharynx and can cause: 1. **Oral candidiasis** — local immunosuppression allows *Candida albicans* overgrowth 2. **Dysphonia/hoarseness** — direct irritation and myopathy of laryngeal muscles 3. **Cough** — airway irritation These effects are dose-dependent and **preventable** with proper inhaler technique. ### Prevention & Management Strategy | Preventive Measure | Mechanism | Effectiveness | |---|---|---| | Spacer device | Reduces oropharyngeal deposition; directs drug to lower airways | Reduces candidiasis by ~50% | | Mouth rinsing after use | Removes residual drug from oral cavity | Highly effective | | Gargling with water | Clears throat and pharynx | Adjunctive | | Proper technique education | Minimizes poor deposition | Essential | **High-Yield:** A spacer device is the single most important intervention — it reduces particle size and oropharyngeal impaction, directing more drug to the lungs and less to the mouth. ### Why NOT Discontinue or Reduce ICS? **Clinical Pearl:** Stopping or reducing ICS in a patient with moderate persistent asthma who has poor control on SABA alone will worsen asthma outcomes. The solution is **technique optimization**, not cessation. ### Why NOT Add Antifungal Without Addressing Technique? While oral antifungal (e.g., miconazole gel) may be needed acutely, the **root cause** — poor inhaler technique leading to oropharyngeal deposition — must be addressed first. Treating the symptom without preventing recurrence is suboptimal. ## Correct Management Sequence 1. **Educate on proper technique:** slow, deep inhalation; hold breath 10 seconds 2. **Prescribe a spacer device** (metered-dose inhaler + spacer reduces oropharyngeal deposition by 50–75%) 3. **Rinse mouth with water** after each dose 4. **Continue ICS at current dose** — asthma control requires it 5. **Monitor for candidiasis resolution** within 1–2 weeks 6. **Consider topical antifungal** (miconazole gel) if candidiasis persists despite technique improvement **Mnemonic: RINSE** — **R**inse mouth, **I**nhaler technique, **N**eed spacer, **S**tay on ICS, **E**valuate after 2 weeks.