The management of chronic asthma is a dynamic process centered on achieving long-term control of symptoms and reducing the risk of future exacerbations, lung function decline, and medication side effects. It involves a partnership between the patient and healthcare provider, utilizing a stepwise approach to pharmacological therapy guided by evidence-based guidelines like those from the Global Initiative for Asthma (GINA). For PharmD students, mastering the principles of chronic asthma management—from assessing control and educating patients on inhaler technique to tailoring therapy and developing personalized asthma action plans—is fundamental to providing effective pharmaceutical care and improving patients’ quality of life. This MCQ quiz will test your knowledge on the comprehensive management of chronic asthma.
1. The two primary goals in the long-term management of chronic asthma are:
- A. Curing the disease and eliminating all medication use.
- B. Achieving good symptom control and minimizing future risk (e.g., exacerbations, side effects).
- C. Only preventing exercise-induced bronchoconstriction.
- D. Only treating acute exacerbations as they occur.
Answer: B. Achieving good symptom control and minimizing future risk (e.g., exacerbations, side effects).
2. According to GINA (Global Initiative for Asthma) guidelines, assessment of asthma control should evaluate which domains over the past 4 weeks?
- A. Only daytime symptoms and reliever use
- B. Symptom control (daytime/nighttime symptoms, reliever use, activity limitation) and risk factors for future poor outcomes
- C. Only lung function (FEV1)
- D. Only the number of hospitalizations in the past year
Answer: B. Symptom control (daytime/nighttime symptoms, reliever use, activity limitation) and risk factors for future poor outcomes
3. An Asthma Action Plan is a written, individualized plan that provides patients with instructions on:
- A. How to definitively diagnose their asthma type.
- B. How to manage their asthma daily and what to do when their symptoms worsen (Green, Yellow, and Red zones).
- C. A fixed medication regimen that should never be changed.
- D. Only non-pharmacological management strategies.
Answer: B. How to manage their asthma daily and what to do when their symptoms worsen (Green, Yellow, and Red zones).
4. The cornerstone of controller therapy for all levels of persistent asthma is which class of medication?
- A. Short-acting beta2-agonists (SABAs)
- B. Long-acting beta2-agonists (LABAs)
- C. Inhaled corticosteroids (ICS)
- D. Leukotriene receptor antagonists (LTRAs)
Answer: C. Inhaled corticosteroids (ICS)
5. The “stepwise” approach to chronic asthma management involves:
- A. Starting all patients on the highest dose of medication and never adjusting.
- B. Adjusting the intensity of controller therapy up or down based on the level of asthma control.
- C. Using only reliever medication for all stages of asthma.
- D. Adding a new medication class every month regardless of symptoms.
Answer: B. Adjusting the intensity of controller therapy up or down based on the level of asthma control.
6. For safety reasons, GINA guidelines have shifted away from recommending as-needed SABA-only treatment for mild asthma. The preferred reliever therapy for most adults and adolescents is:
- A. As-needed oral corticosteroids
- B. As-needed long-acting muscarinic antagonist (LAMA)
- C. As-needed low-dose inhaled corticosteroid (ICS)-formoterol
- D. Daily scheduled SABA use
Answer: C. As-needed low-dose inhaled corticosteroid (ICS)-formoterol
7. When adding a long-acting beta2-agonist (LABA) to an asthma treatment regimen, it must:
- A. Be used as monotherapy to avoid side effects.
- B. Always be used in combination with an inhaled corticosteroid (ICS).
- C. Replace the need for a quick-relief SABA.
- D. Be administered orally for best effect.
Answer: B. Always be used in combination with an inhaled corticosteroid (ICS).
8. A patient using an inhaled corticosteroid should be counseled to rinse their mouth with water and spit after each use to reduce the risk of:
- A. Tachycardia
- B. Oral candidiasis (thrush) and dysphonia
- C. Bronchospasm
- D. Systemic adrenal suppression
Answer: B. Oral candidiasis (thrush) and dysphonia
9. Which of the following is a critical component of patient education for effective asthma management?
- A. Discouraging the use of an asthma action plan.
- B. Ensuring correct inhaler technique and understanding the purpose of each medication (reliever vs. controller).
- C. Advising the patient to stop all controller medications once they feel better.
- D. Recommending frequent exposure to known asthma triggers.
Answer: B. Ensuring correct inhaler technique and understanding the purpose of each medication (reliever vs. controller).
10. Leukotriene receptor antagonists (LTRAs) like montelukast can be considered as an alternative or add-on therapy in asthma, particularly for patients with:
- A. Frequent severe exacerbations requiring hospitalization.
- B. Concomitant allergic rhinitis and exercise-induced bronchoconstriction.
- C. Neutrophilic asthma.
- D. A need for immediate bronchodilation.
Answer: B. Concomitant allergic rhinitis and exercise-induced bronchoconstriction.
11. The use of a spacer device with a metered-dose inhaler (MDI) is recommended to:
- A. Increase the speed of medication delivery.
- B. Eliminate the need to shake the MDI.
- C. Improve lung deposition of the medication and reduce oropharyngeal deposition and the need for perfect hand-breath coordination.
- D. Make the medication more potent.
Answer: C. Improve lung deposition of the medication and reduce oropharyngeal deposition and the need for perfect hand-breath coordination.
12. According to the stepwise approach, if a patient’s asthma is not well-controlled on a low-dose ICS, a common next step is to:
- A. Discontinue the ICS and use a SABA only.
- B. Increase the ICS dose to medium, OR add a LABA (preferred for many patients).
- C. Add an oral corticosteroid daily.
- D. Initiate biologic therapy immediately.
Answer: B. Increase the ICS dose to medium, OR add a LABA (preferred for many patients).
13. A patient reports using their albuterol (SABA) inhaler 4-5 times per week for symptom relief. This level of use indicates:
- A. Well-controlled asthma
- B. Not well-controlled asthma and the need to assess and likely step-up controller therapy
- C. An allergic reaction to albuterol
- D. The patient should switch to an oral SABA
Answer: B. Not well-controlled asthma and the need to assess and likely step-up controller therapy
14. Omalizumab is a biologic therapy indicated for selected patients with severe persistent allergic asthma. Its use is guided by:
- A. High blood eosinophil counts.
- B. A positive skin test or in vitro reactivity to a perennial aeroallergen and elevated serum IgE levels.
- C. Low FEV1 only.
- D. Frequent viral infections.
Answer: B. A positive skin test or in vitro reactivity to a perennial aeroallergen and elevated serum IgE levels.
15. Mepolizumab, reslizumab, and benralizumab are biologic agents for severe asthma that target:
- A. The IgE pathway
- B. The IL-5 pathway, making them effective for severe eosinophilic asthma
- C. The TNF-alpha pathway
- D. Muscarinic receptors
Answer: B. The IL-5 pathway, making them effective for severe eosinophilic asthma
16. Which of the following is an essential non-pharmacological management strategy for a patient whose asthma is triggered by dust mites?
- A. Increasing home humidity levels.
- B. Weekly exposure to high concentrations of dust mites to build immunity.
- C. Implementing allergen avoidance measures (e.g., mattress/pillow covers, high-efficiency air filters, regular cleaning).
- D. Adopting a pet cat or dog.
Answer: C. Implementing allergen avoidance measures (e.g., mattress/pillow covers, high-efficiency air filters, regular cleaning).
17. “Stepping down” therapy in a patient whose asthma has been well-controlled for at least 3 months involves:
- A. Abruptly stopping all medications.
- B. A cautious, systematic reduction in controller medication to find the lowest effective dose that maintains control.
- C. Increasing the use of SABA reliever medication.
- D. Switching from an ICS/LABA to a LABA monotherapy.
Answer: B. A cautious, systematic reduction in controller medication to find the lowest effective dose that maintains control.
18. Management of Exercise-Induced Bronchoconstriction (EIB) typically involves:
- A. Avoiding all physical activity.
- B. Pre-treatment with an inhaled SABA 5-20 minutes before exercise, or ensuring adequate daily controller therapy is in place for patients with underlying persistent asthma.
- C. A short course of oral steroids before every workout.
- D. Using a LAMA immediately after exercise.
Answer: B. Pre-treatment with an inhaled SABA 5-20 minutes before exercise, or ensuring adequate daily controller therapy is in place for patients with underlying persistent asthma.
19. What is the role of Long-Acting Muscarinic Antagonists (LAMAs), like tiotropium, in the management of chronic asthma?
- A. They are a preferred first-line controller therapy.
- B. They are used for quick relief of acute symptoms.
- C. They are considered as an add-on therapy for patients (typically age 6+ or 12+) with moderate-to-severe asthma who are not well-controlled on ICS/LABA therapy.
- D. They are contraindicated in all asthma patients.
Answer: C. They are considered as an add-on therapy for patients (typically age 6+ or 12+) with moderate-to-severe asthma who are not well-controlled on ICS/LABA therapy.
20. A patient’s “Green Zone” on their asthma action plan signifies:
- A. A medical emergency requiring immediate attention.
- B. Caution, as asthma is worsening.
- C. Good asthma control; the patient should continue their routine controller medications.
- D. The need to double all medication doses.
Answer: C. Good asthma control; the patient should continue their routine controller medications.
21. A patient’s PEF reading is in the “Yellow Zone” (typically 50-80% of personal best). Their asthma action plan will likely instruct them to:
- A. Continue their current regimen with no changes.
- B. Use their quick-relief inhaler, potentially increase their controller medication as specified, and monitor symptoms closely.
- C. Go to the emergency department immediately.
- D. Discontinue their controller medication.
Answer: B. Use their quick-relief inhaler, potentially increase their controller medication as specified, and monitor symptoms closely.
22. Which of the following is a key risk factor for asthma-related death?
- A. Use of inhaled corticosteroids as prescribed.
- B. A history of a near-fatal asthma exacerbation (e.g., requiring intubation/mechanical ventilation).
- C. Excellent adherence to controller medication.
- D. Having a written asthma action plan.
Answer: B. A history of a near-fatal asthma exacerbation (e.g., requiring intubation/mechanical ventilation).
23. For a patient with persistent asthma, the primary difference between their “reliever” and “controller” medication is that:
- A. Relievers are anti-inflammatory, while controllers are bronchodilators.
- B. Controllers are taken daily to manage underlying inflammation and maintain control, while relievers are used as-needed for acute symptoms.
- C. Both are taken on a fixed daily schedule.
- D. Relievers have a long duration of action, while controllers are short-acting.
Answer: B. Controllers are taken daily to manage underlying inflammation and maintain control, while relievers are used as-needed for acute symptoms.
24. Which of the following is a potential systemic side effect of long-term, high-dose inhaled corticosteroid therapy?
- A. Improved bone mineral density
- B. Reduced risk of cataracts and glaucoma
- C. Increased growth velocity in children
- D. Adrenal suppression and decreased bone mineral density
Answer: D. Adrenal suppression and decreased bone mineral density
25. Dupilumab, a biologic for severe asthma, works by targeting:
- A. The IgE molecule
- B. The alpha subunit of the IL-4 receptor, thereby blocking both IL-4 and IL-13 signaling
- C. The IL-5 receptor
- D. Tumor Necrosis Factor-alpha
Answer: B. The alpha subunit of the IL-4 receptor, thereby blocking both IL-4 and IL-13 signaling
26. In the management of Aspirin-Exacerbated Respiratory Disease (AERD), what is a crucial non-pharmacological strategy?
- A. Regular, high-dose aspirin intake
- B. Strict avoidance of aspirin and other COX-1 inhibiting NSAIDs
- C. Exposure to high levels of allergens
- D. Discontinuation of all inhaled corticosteroids
Answer: B. Strict avoidance of aspirin and other other COX-1 inhibiting NSAIDs (unless undergoing desensitization).
27. What is the correct way to use a typical metered-dose inhaler (MDI) with a spacer?
- A. Inhale rapidly from the spacer as soon as the canister is pressed.
- B. Press the canister multiple times into the spacer before inhaling once.
- C. Press the canister once into the spacer, then begin a slow, deep inhalation from the spacer, followed by a breath-hold.
- D. Use the spacer only for cleaning the inhaler.
Answer: C. Press the canister once into the spacer, then begin a slow, deep inhalation from the spacer, followed by a breath-hold.
28. A patient is prescribed a dry powder inhaler (DPI). The pharmacist should counsel them to:
- A. Shake the device vigorously before each use.
- B. Exhale fully into the device before inhaling.
- C. Inhale deeply and forcefully to aerosolize the powder.
- D. Use a spacer with the DPI.
Answer: C. Inhale deeply and forcefully to aerosolize the powder.
29. The concept of Maintenance And Reliever Therapy (MART) using a single ICS/formoterol inhaler is beneficial because:
- A. It ensures patients receive an anti-inflammatory dose (ICS) every time they use their reliever inhaler.
- B. It increases the total number of inhalers a patient must carry.
- C. Formoterol has a very slow onset of action.
- D. It is primarily used for COPD, not asthma.
Answer: A. It ensures patients receive an anti-inflammatory dose (ICS) every time they use their reliever inhaler.
30. Which of the following is an appropriate long-term management goal for a patient with chronic asthma?
- A. Using their SABA inhaler 3-4 times per day for symptom control.
- B. Requiring minimal to no SABA use for symptom relief (e.g., <2 times per week).
- C. Avoiding all physical activity.
- D. Maintaining a PEF in the “Red Zone”.
Answer: B. Requiring minimal to no SABA use for symptom relief (e.g., <2 times per week).
31. When managing chronic asthma, it is important to assess and manage comorbidities that can worsen asthma control, such as:
- A. Osteoporosis
- B. Gastroesophageal reflux disease (GERD), obesity, and chronic sinusitis
- C. Peripheral artery disease
- D. Primary hyperaldosteronism
Answer: B. Gastroesophageal reflux disease (GERD), obesity, and chronic sinusitis
32. What is the role of Fractional Exhaled Nitric Oxide (FeNO) in chronic asthma management?
- A. It is the gold standard for diagnosing asthma.
- B. It can serve as a non-invasive biomarker of eosinophilic (Type 2) airway inflammation to help predict ICS response and monitor adherence.
- C. It measures the degree of bronchoconstriction.
- D. It is used to guide beta-blocker therapy.
Answer: B. It can serve as a non-invasive biomarker of eosinophilic (Type 2) airway inflammation to help predict ICS response and monitor adherence.
33. For a patient with well-controlled asthma on medium-dose ICS, a “step-down” in therapy could involve:
- A. Adding a LABA.
- B. Discontinuing all therapy immediately.
- C. Reducing the ICS dose to low-dose and reassessing control in 1-3 months.
- D. Starting daily oral steroids.
Answer: C. Reducing the ICS dose to low-dose and reassessing control in 1-3 months.
34. A patient is prescribed an ICS/LABA combination product and a SABA for their asthma. The pharmacist should counsel the patient to use the SABA for:
- A. Daily scheduled maintenance therapy.
- B. Quick relief of acute breakthrough symptoms if they occur.
- C. Prophylaxis against oral thrush.
- D. Only when they have a cold.
Answer: B. Quick relief of acute breakthrough symptoms if they occur. (Unless on a MART regimen with ICS/formoterol).
35. Management of asthma during pregnancy aims to:
- A. Discontinue all medications to protect the fetus.
- B. Maintain optimal asthma control for the mother to ensure fetal oxygenation, as uncontrolled asthma poses a greater risk.
- C. Use only oral medications.
- D. Avoid all inhaled corticosteroids.
Answer: B. Maintain optimal asthma control for the mother to ensure fetal oxygenation, as uncontrolled asthma poses a greater risk.
36. A key component of assessing risk factors for poor asthma outcomes includes:
- A. A history of frequent oral corticosteroid use or hospitalizations for asthma.
- B. A low serum IgE level.
- C. A high FEV1/FVC ratio.
- D. A preference for dry powder inhalers.
Answer: A. A history of frequent oral corticosteroid use or hospitalizations for asthma.
37. The primary reason LABA monotherapy is contraindicated in asthma is that it:
- A. Does not effectively manage the underlying airway inflammation and may mask worsening inflammation, leading to severe exacerbations.
- B. Causes severe bronchoconstriction.
- C. Is not an effective bronchodilator.
- D. Leads to rapid development of tolerance.
Answer: A. Does not effectively manage the underlying airway inflammation and may mask worsening inflammation, leading to severe exacerbations.
38. Which biomarker would be most useful in determining eligibility for omalizumab therapy?
- A. Blood neutrophil count
- B. Serum IgE level and evidence of perennial allergen sensitization
- C. Fractional Exhaled Nitric Oxide (FeNO) alone
- D. Peak Expiratory Flow (PEF)
Answer: B. Serum IgE level and evidence of perennial allergen sensitization
39. For a patient with severe eosinophilic asthma not controlled on high-dose ICS/LABA, an appropriate next step could be to consider adding:
- A. As-needed SABA only
- B. An anti-IL-5/IL-5Rα or anti-IL4Rα biologic agent
- C. Oral theophylline
- D. Cromolyn sodium
Answer: B. An anti-IL-5/IL-5Rα or anti-IL4Rα biologic agent
40. What is a “SMART” or “MART” regimen in asthma management?
- A. A complex, multi-inhaler regimen for severe asthma only.
- B. A Single Maintenance And Reliever Therapy regimen, using a single ICS/formoterol inhaler for both daily control and as-needed relief.
- C. A strategy focused solely on non-pharmacological management.
- D. A plan that uses only short-acting medications.
Answer: B. A Single Maintenance And Reliever Therapy regimen, using a single ICS/formoterol inhaler for both daily control and as-needed relief.
41. Smoking cessation is a critical management strategy for asthmatic patients who smoke because smoking:
- A. Improves the efficacy of inhaled corticosteroids.
- B. Reduces airway inflammation and hyperresponsiveness.
- C. Can worsen asthma severity, accelerate lung function decline, and blunt the response to corticosteroids.
- D. Decreases the risk of asthma exacerbations.
Answer: C. Can worsen asthma severity, accelerate lung function decline, and blunt the response to corticosteroids.
42. Which of the following would be an appropriate instruction for the “Red Zone” of an asthma action plan?
- A. “Continue current medications and monitor.”
- B. “Use your reliever inhaler; you are having an exacerbation.”
- C. “This is a medical alert! Use your reliever medication as prescribed and seek immediate medical attention (e.g., call 911 or go to the emergency department).”
- D. “Decrease your controller medication dose.”
Answer: C. “This is a medical alert! Use your reliever medication as prescribed and seek immediate medical attention (e.g., call 911 or go to the emergency department).”
43. A common error patients make when using a dry powder inhaler (DPI) is:
- A. Inhaling too forcefully.
- B. Not holding their breath after inhalation.
- C. Exhaling into the device after loading the dose, which can disperse the powder.
- D. Shaking the device when not required.
Answer: C. Exhaling into the device after loading the dose, which can disperse the powder.
44. The primary goal of using controller medications in persistent asthma is to:
- A. Provide immediate relief of acute symptoms.
- B. Address the underlying chronic airway inflammation to prevent symptoms and exacerbations.
- C. Replace the function of the patient’s own adrenal glands.
- D. Only be used during seasonal allergy periods.
Answer: B. Address the underlying chronic airway inflammation to prevent symptoms and exacerbations.
45. Which of the following is NOT a goal of chronic asthma care according to GINA?
- A. Maintain normal activity levels.
- B. Minimize side effects from medication.
- C. Prevent asthma exacerbations and mortality.
- D. Eliminate the need for any reliever medication in all patients.
Answer: D. Eliminate the need for any reliever medication in all patients. (Even well-controlled patients need a reliever for occasional symptoms or emergencies).
46. Personalized medicine in asthma management involves:
- A. Prescribing the same ICS/LABA combination for every patient.
- B. Tailoring treatment based on patient phenotype, biomarkers (e.g., eosinophils, IgE, FeNO), genotype, and preferences.
- C. Using only genetic testing to guide all therapy choices.
- D. Focusing only on patient-reported symptoms without objective measures.
Answer: B. Tailoring treatment based on patient phenotype, biomarkers (e.g., eosinophils, IgE, FeNO), genotype, and preferences.
47. A patient with persistent asthma is prescribed an ICS/LABA DPI. The pharmacist’s role in initiating this therapy should include:
- A. Only dispensing the medication.
- B. Demonstrating correct inhaler technique and confirming patient understanding, and counseling on its role as a controller.
- C. Advising the patient to use it only when they feel short of breath.
- D. Performing spirometry to confirm the diagnosis.
Answer: B. Demonstrating correct inhaler technique and confirming patient understanding, and counseling on its role as a controller.
48. In the stepwise approach, if a patient is well-controlled on low-dose ICS/LABA, a potential step-down option could be:
- A. Stopping all treatment.
- B. Increasing the LABA dose while stopping the ICS.
- C. Reducing the regimen to a low-dose ICS monotherapy and reassessing control.
- D. Adding a LAMA.
Answer: C. Reducing the regimen to a low-dose ICS monotherapy and reassessing control.
49. For a patient with severe asthma and evidence of Th2-driven inflammation (high eosinophils, high FeNO), which class of add-on therapy would be most specifically targeted to their pathophysiology?
- A. Theophylline
- B. A biologic agent like dupilumab (anti-IL4Rα) or mepolizumab (anti-IL5)
- C. A short-acting muscarinic antagonist
- D. A systemic antibiotic
Answer: B. A biologic agent like dupilumab (anti-IL4Rα) or mepolizumab (anti-IL5)
50. The foundation of successful chronic asthma management relies on:
- A. The most potent medications available.
- B. A strong partnership between the patient and healthcare team, focusing on education, self-management skills, and regular follow-up to assess and adjust therapy.
- C. Eliminating all potential environmental triggers, which is often impractical.
- D. Frequent use of oral corticosteroids to suppress inflammation.
Answer: B. A strong partnership between the patient and healthcare team, focusing on education, self-management skills, and regular follow-up to assess and adjust therapy.