Budesonide (glucocorticoid)/formoterol (LABA)

Well-done! This is the most appropriate choice for Amy, as it aligns with the updated GINA guidelines for the management of mild asthma. Budesonide/formoterol is a combination of an inhaled corticosteroid (ICS) and a long-acting beta-agonist (LABA) with fast onset of action (formoterol acts as both a controller and a reliever).

In patients with mild asthma, using budesonide/formoterol provides both anti-inflammatory control (via ICS) and rapid symptom relief (via formoterol-mediated bronchodilation). This approach reduces exacerbation risk more effectively than using a beta-2-agonist alone. Using the LABA further allows dosage reduction of ICS.

You explain to Amy how to use her inhaler.

Progress

Two weeks after starting treatment with budesonide/formoterol, Amy returns to the clinic for a follow-up appointment. She reports a significant improvement in her symptoms. She no longer experiences night-time coughing or shortness of breath. Her wheezing during exercise has resolved. However, she mentions that she has started experiencing mild tremor in her hands, especially shortly after using her inhaler. She describes the tremor as transient and not severe enough to interfere with her daily activities, but she finds it unpleasant and is concerned about its cause. She denies any new or worsening asthma symptoms and has no other significant complaints, other than headaches, for which she has been taking paracetamol.

Dr. Christou asks you to evaluate the possible causes of her tremor.

What is the most likely explanation for Amy’s tremor?