Practical Considerations for the Diagnosis and Management of Asthma in Older Adults

  • Yawn MD, MSc, MSPH B
  • Han MD, MS M
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Abstract

[...]asthma, although traditionally considered a disease of the young, should be considered as a potential diagnosis in older adults with respiratory symptoms, even without a history of asthma or allergies. Theoretically, older patients may have a reduced response to bronchodilators as a result of age-related changes such as stiffening of the chest wall, reduced respiratory muscle function, and an increase in residual volume from loss of elastic recoil in the lung.14 However, data have revealed that albuterol is effective in both younger and older patients,18 and the addition of the LABA salmeterol to the ICS fluticasone has been reported to decrease the risk of asthma-related serious exacerbations compared with fluticasone alone.19 Although LABAs have traditionally been the main addon to ICSs in asthma, a long-acting muscarinic antagonist has also demonstrated efficacy as an ICS add-on, independent of patient age.20 Taken together, these data suggest that inhaled long-acting bronchodilators are effective in older patients with asthma. Other Therapy Options Other controller options for the management of asthma are leukotriene receptor antagonists and theophylline.4 Theophylline has a low therapeutic index and a high risk of adverse effects or toxicity, especially in older individuals, making close monitoring of blood theophylline levels essential when using therapeutic doses.7 Leukotriene receptor antagonists such as montelukast, although in general less effective anti-inflammatories than ICSs, may be effective in some older patients, especially those with apparent corticosteroid resistance.4,7 In addition, their oral route of administration could have advantages over inhaled administration for some patients.23 A number of monoclonal antibodies are available for the management of more severe asthma, including omalizumab (for allergic asthma) and mepolizumab or reslizumab (for eosinophilic asthma).4 Although none of these treatments have upper age limits for their use, little efficacy and safety data are available for older patients, and the high cost of such therapies may limit their acceptability for this as well as all other populations. Potential Competing Interests: Dr Yawn has served as a consultant to Thermo Fischer Scientific related to allergy evaluation in asthma, a consultant to ndd Medical Technologies, Inc, related to spirometry use in asthma and chronic obstructive pulmonary disease in primary care, and as an advisory board member for Boehringer Ingelheim Pharmaceuticals, Inc, Novartis AG, and GlaxoSmithKline plc for asthma and chronic obstructive pulmonary disease; she has received free inhaled corticosteroid drugs from Teva Pharmaceutical Industries Ltd for patients enrolled in a Patient-Centered Outcomes Research Institute-fundedtrial for which she is a coinvestigator.

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Yawn  MD, MSc, MSPH, B. P., & Han  MD, MS, M. K. (2017). Practical Considerations for the Diagnosis and Management of Asthma in Older Adults. Mayo Clinic Proceedings, 92(11), 1697–1705. https://doi.org/http://dx.doi.org/10.1016/j.mayocp.2017.08.005

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