Asthma and allergic conditions are chronic ailments that profoundly impact a patient’s quality of life and demand a cohesive, evidence-based strategy for effective long-term management, establishing the internist as the primary orchestrator of care in the vast majority of adult cases.
The Internist as the Primary Care Coordinator
In the complex world of chronic respiratory and allergic diseases, the internist acts as the patient’s first line of defense and main coordinator of care. We are uniquely positioned to manage these conditions because we see the whole patient, not just a single organ system. This holistic view is crucial since asthma and allergies often coexist with other comorbidities, such as gastroesophageal reflux disease (GERD) or rhinosinusitis, which can significantly complicate symptom control. A large portion of adult asthma and allergic rhinitis cases can and should be managed in the internal medicine setting, following globally recognized protocols like the Global Initiative for Asthma (GINA) guidelines. Our job involves continuous monitoring, patient education, and knowing exactly when to bring in specialist expertise.
Foundational Diagnostic Approach for Asthma and Allergies
Accurate diagnosis forms the cornerstone of successful asthma and allergy management. We begin with a thorough medical history, focusing on the variability of respiratory symptoms like wheezing, shortness of breath, chest tightness, and coughing, particularly those that worsen at night or with specific triggers like exercise or cold air. A physical exam is also essential, allowing us to check for signs of allergic conditions such as eczema or hives, and to listen for the characteristic wheezing sound in the lungs.
To confirm an asthma diagnosis in adults, we rely heavily on lung function tests, with spirometry being the mainstay of evaluation. Spirometry measures the amount of air a patient breathes in and out, and how quickly the patient exhales, providing objective data on airflow obstruction. A significant improvement in lung function after administering a bronchodilator strongly suggests asthma is at play. For cases where the diagnosis remains uncertain, more specialized tests, such as a methacholine challenge, can be considered to provoke a reaction and confirm airway hyper-responsiveness.
Identifying and Mitigating Environmental Triggers
A key component of non-pharmacological management is helping the patient identify and effectively avoid their specific triggers. Many patients with asthma have an underlying allergic component, meaning their symptoms are set off by common allergens like pollen, dust mites, pet dander, or mold. While we perform an initial clinical assessment, we can also use basic allergy tests, such as blood tests, to pinpoint these environmental culprits.
Once triggers are identified, we provide actionable steps for environmental control. For instance, advising patients on mite-proof mattress covers, washing bedding at high temperatures—typically above 55∘C—and reducing “dust traps” like heavy rugs and upholstered furniture in the home, especially in the bedroom, becomes a crucial intervention. In a regional context like the UAE, we often highlight the importance of indoor air quality, given the high levels of dust and humidity, which can exacerbate both asthma and allergic rhinitis symptoms significantly.
Pharmacological Management and Stepwise Therapy
The pharmacological management of stable asthma in the internal medicine setting adheres to a stepwise approach, as outlined by major guidelines, ensuring therapy is personalized to the patient’s severity and level of control. The general strategy involves using maintenance inhalers, primarily inhaled corticosteroids (ICS), to reduce airway inflammation, which is the underlying problem in asthma. These are often combined with long-acting bronchodilators in a single device for improved adherence and efficacy.
We also prescribe a rescue inhaler, a short-acting bronchodilator (SABA), for quick relief during an acute attack or before exercise. It is our role to ensure the patient fully understands the difference between these two types of inhalers and, most importantly, masters the correct inhaler technique. Inhaler technique errors are a common pitfall that leads to poorly controlled asthma, making patient education on this topic a top priority. Furthermore, for patients with allergic asthma, we can manage associated symptoms with appropriate antihistamines or leukotriene modifiers.
Developing a Written Asthma Action Plan
One of the most impactful tools in the internist’s arsenal is the Written Asthma Action Plan (WAAP). This plan empowers the patient to actively manage their chronic condition by clearly defining what actions to take based on their symptoms or peak flow measurements. The WAAP uses a simple traffic light system—green for controlled, yellow for caution, and red for medical alert—to guide self-management.
A robust action plan details how and when to adjust maintenance medications, when to increase the use of the rescue inhaler, and, critically, clear criteria for when to seek urgent medical care or when to contact us for a reassessment. By providing this structured roadmap, we move from a reactive treatment model to a proactive self-management model, which is proven to reduce hospitalizations and emergency department visits. This is a prime example of the close patient-physician partnership we strive for in internal medicine.
Management of Comorbidities Affecting Control
As internists, we are keenly aware that asthma rarely travels alone; it is often complicated by comorbid conditions that hinder its optimal control. Conditions like chronic rhinosinusitis, obesity, and GERD can directly exacerbate asthma symptoms, making them refractory to standard treatment. Therefore, our comprehensive approach includes actively screening for and aggressively treating these associated conditions.
For a patient with uncontrolled asthma, we must pause and evaluate if GERD is causing nocturnal symptoms or if chronic sinusitis is contributing to a persistent cough. Addressing these underlying factors with targeted treatment, such as nasal corticosteroids for rhinitis or acid suppression therapy for GERD, can dramatically improve asthma control without necessarily escalating the primary respiratory medication. This ability to manage the entire clinical picture is what truly defines the internist’s crucial role in this field.
When to Consult a Specialist: Referral Criteria
While we manage the vast majority of stable and mild-to-moderate asthma, we must know when it is time to bring in the experts—the pulmonologist or the allergist. Referral is not a sign of failure but a testament to our commitment to providing the highest level of care. Standard guidelines suggest considering a referral if the patient has moderate-to-severe persistent asthma that remains uncontrolled despite three to six months of optimal treatment at the appropriate stepwise care level.
Other key referral triggers include an atypical presentation that makes the diagnosis uncertain, the presence of a complicating condition that requires advanced management like aspergillosis, or if the patient has had a life-threatening asthma exacerbation in the past. We also refer if the patient needs specialized procedures like bronchoprovocation testing, allergy immunotherapy (allergy shots), or if we are considering biologic therapies for severe asthma. This collaborative approach ensures the patient receives the most advanced care possible.
Advancements in Asthma Care and Future Directions
The field of asthma and allergy management is constantly evolving, and it is our professional duty to stay abreast of the latest guidelines, such as the Saudi Initiative for Asthma (SINA) 2024 update, which often focuses on personalized medicine and the integration of new biologic agents. While the use of biologics is usually initiated and managed by a specialist, the internist plays a supportive role in identifying patients who may benefit most from these cutting-edge therapies due to their refractory symptoms.
Our future role will continue to focus on integrating technology, potentially using electronic medical records to deliver digital action plans and monitor inhaler usage data in real-time. This blend of clinical expertise and technological application helps us ensure our patients in cities like Dubai receive consistent, high-quality care. We aim to empower our patients to not just live with asthma and allergies, but to thrive despite them.