PEBC MCQ study guide: Respiratory Disorders

Providing Care – Clinical Care

Asthma, COPD, and allergic rhinitis pharmacotherapy.

Asthma

GINA's 2026 strategy report continues to move away from short-acting beta-agonist (SABA)-only "reliever" therapy across all steps. Track 1 — ICS-formoterol used as both the maintenance AND the reliever (MART/SMART approach) — is now the GINA-preferred strategy from Step 1 through Step 4, reflecting evidence that SABA-only reliance (without anti-inflammatory therapy) increases exacerbation and mortality risk, even in patients with seemingly mild, infrequent symptoms.

Track 2 (ICS-SABA as an alternative reliever paired with regular ICS-containing maintenance) exists for settings/patients where ICS-formoterol isn't practical, but Track 1 is preferred where available.

Step 5 (severe asthma) adds a LAMA to ICS-formoterol (triple therapy) and/or a biologic (omalizumab, mepolizumab, benralizumab, dupilumab) selected by phenotype (allergic vs. eosinophilic vs. type-2-high disease).

Never give a LABA as monotherapy in asthma without an ICS — this is a boxed-warning-level safety point (increased risk of asthma-related death), and remains a heavily tested exam concept even though modern combination inhalers make pure LABA monotherapy uncommon in practice.

COPD

GOLD 2026 redefined the "Group E" high-exacerbation-risk category as ≥1 hospitalization for exacerbation OR ≥2 moderate exacerbations in the past year — initial therapy for Group E is LABA+LAMA dual bronchodilator therapy, with ICS added on top only if blood eosinophils are ≥300 cells/µL (reflecting a likely asthma-COPD overlap or steroid-responsive phenotype). GOLD 2026 also lowered the bar for escalating therapy — even a single moderate exacerbation on current therapy is now grounds to step up treatment, not just severe/hospitalized exacerbations.

Unlike asthma, ICS is not first-line/routine in COPD — unnecessary ICS use in COPD increases pneumonia risk without proportional benefit in low-eosinophil patients, so eosinophil-guided ICS use is a key modern stewardship point.

Smoking cessation and pulmonary rehabilitation remain the two interventions with the strongest mortality benefit in COPD — more impactful than any single pharmacologic choice, and a common "best next step" exam answer.

Allergic Rhinitis

Second-generation (non-sedating) oral antihistamines (cetirizine, loratadine, fexofenadine, desloratadine) are preferred over first-generation agents (diphenhydramine, chlorpheniramine) due to significantly less sedation and anticholinergic burden — first-generation antihistamines are flagged on the Beers Criteria for older adults.

Intranasal corticosteroids (fluticasone, mometasone) are the most effective single therapy for moderate-to-severe allergic rhinitis, superior to oral antihistamines for nasal congestion specifically, and can be combined with an antihistamine for inadequate response.

High-yield points

GINA 2026: ICS-formoterol as both maintenance AND reliever (Track 1/MART) is preferred from Step 1–4; never give LABA monotherapy without ICS.
GOLD 2026 Group E (≥1 hospitalization OR ≥2 moderate exacerbations/year): start LABA+LAMA; add ICS only if eosinophils ≥300 cells/µL.
Even one moderate COPD exacerbation now justifies escalating therapy per GOLD 2026.
Smoking cessation + pulmonary rehab have the strongest mortality benefit in COPD.
First-generation antihistamines (diphenhydramine) are Beers-listed — avoid in older adults.

Guideline references

Global Initiative for Asthma (GINA) 2026 Strategy Report
Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2026 Report
Canadian Thoracic Society