Pharmacotherapeutic management of asthma in the elderly patient

ABSTRACT

Introduction

Asthma is a heterogeneous syndrome with variable phenotypes. Reversible airway obstruction and airway hyper-responsiveness often with an atopic or eosinophilic component is common in the elderly asthmatic. Asthma chronic obstructive pulmonary disease overlap syndrome (ACOS), a combination of atopy-mediated airway hyper-responsiveness and a history of smoking or other environmental noxious exposures, can lead to some fixed airway obstruction and is also common in elderly patients. Little specific data exist for the treating the elderly asthmatic, thus requiring the clinician to extrapolate from general adult data and asthma treatment guidelines.

Areas covered

A stepwise approach to pharmacotherapy of the elderly patient with asthma and ACOS is offered and the literature supporting the use of each class of drugs reviewed.

Expert opinion

Inhaled, long-acting bronchodilators in combination with inhaled corticosteroids represent the backbone of treatment for the elderly patient with asthma or ACOS . Beyond these medications used as direct bronchodilators and topical anti-inflammatory agents, a stepwise approach to escalation of therapy includes multiple options such as oral leukotriene receptor antagonist or 5-lipoxygense inhibitor therapy, oral phosphodiesterase inhibitors, systemic corticosteroids, oral macrolide antibiotics and if evidence of eosinophilic/atopic component disease exists then modifying monoclonal antibody therapies.

KEYWORDS:

• Asthma
• elderly
• geriatrics
• long-acting muscarinic antagonist (LAMA)
• long-acting beta 2 agonist (LABA)
• asthma treatment
• bronchodilators
• immunotherapy
• therapeutic monoclonal antibodies

Article highlights

• Asthma in the elderly patient is a heterogenous syndrome defined by variable reversible airflow obstruction with the presence of airway hyper-responsiveness and chronic airway inflammation

• Various phenotypes of asthma exist in the elderly patient including the smoking-associated asthma chronic obstructive pulmonary disease overlap syndrome (ACOS)

• The prevalence of asthma in the elderly in the US is estimated at 6.9% and is similar to the 8.6% reported for children

• Environmental control of allergen and tobacco smoke exposure is a key to good asthma management in the elderly

• A pharmacological stepwise approach to the management of asthma I the elderly can follow published guidelines like those of GINA

• Because of the presence of previous tobacco smoking history and the presence of some fixed airway obstruction and ACOS in this population, adjunctive therapies used in treating the patient with COPD/ACOS should be considered beyond inhaler therapies

• Atopic/eosinophilic elderly patients with asthma should be considered for injectable systemic biological immune modulator agents

This box summarizes key points contained in the article.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This manuscript has not been funded.