1
|
Albertson TE, Pugashetti JV, Chau-Etchepare F, Chenoweth JA, Murin S. Pharmacotherapeutic management of asthma in the elderly patient. Expert Opin Pharmacother 2020; 21:1991-2010. [PMID: 32686969 DOI: 10.1080/14656566.2020.1795131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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.
Collapse
Affiliation(s)
- Timothy E Albertson
- Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, School of Medicine, U. C. Davis , Sacramento, CA, USA.,Department of Emergency Medicine, School of Medicine, U. C. Davis , Sacramento, CA, USA.,Department of Medicine, Veterans Administration Northern California Health Care System , Mather, CA, USA
| | - Janelle V Pugashetti
- Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, School of Medicine, U. C. Davis , Sacramento, CA, USA.,Department of Medicine, Veterans Administration Northern California Health Care System , Mather, CA, USA
| | - Florence Chau-Etchepare
- Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, School of Medicine, U. C. Davis , Sacramento, CA, USA.,Department of Medicine, Veterans Administration Northern California Health Care System , Mather, CA, USA
| | - James A Chenoweth
- Department of Emergency Medicine, School of Medicine, U. C. Davis , Sacramento, CA, USA.,Department of Medicine, Veterans Administration Northern California Health Care System , Mather, CA, USA
| | - Susan Murin
- Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, School of Medicine, U. C. Davis , Sacramento, CA, USA.,Department of Medicine, Veterans Administration Northern California Health Care System , Mather, CA, USA
| |
Collapse
|
2
|
Arnetz BB, Arnetz J, Harkema JR, Morishita M, Slonager K, Sudan S, Jamil H. Neighborhood air pollution and household environmental health as it relates to respiratory health and healthcare utilization among elderly persons with asthma. J Asthma 2019; 57:28-39. [PMID: 30810414 DOI: 10.1080/02770903.2018.1545856] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Objective: The study investigated the associations between fine particulate matter (PM2.5; <2.5 μm in diameter), indoor environment, pulmonary function, and healthcare utilization in a vulnerable group of elderly persons with asthma. We hypothesized that environmental conditions were associated with adverse pulmonary health outcomes. Methods: The study involved elderly (n = 76; mean age 64.6 years; 48 women) vulnerable persons in Detroit, Michigan, USA, with physician-diagnosed asthma. Exposure variables included measured outdoor PM2.5, self-rated outdoor and household environmental pollutants. Outcome variables were self-rated and measured pulmonary function, and asthma-related healthcare utilization. Results: Mean ambient PM2.5 concentrations during the study was 14.14 ± (S.D. 6.36) µg/m3 during the summer and 14.20 (6.33) during the winter (p = 0.95). In multiple regression analyses, adjusting for age and gender, mean 6-month concentration of PM2.5 was related to shortness of breath (SHOB; standardized β = 0.26, p = 0.02) and inversely with self-rated respiratory health (SRRH; β = 0.28, p = 0.02). However, PM2.5 did not predict lung function (FEV1% predicted and FEV1/FVC). However, PM2.5 was related to use of asthma controller drugs (β = 0.38, p = 0.001). Participants' air pollution ratings predicted total healthcare utilization (β = 0.33, p = 0.01). Conclusions: In elderly persons with asthma, living near heavy industry and busy highways, objective and perceived environmental pollution relate to participants' respiratory health and healthcare utilization. Importantly, air pollution might increase use of asthma controller drugs containing corticosteroids with implication for elderly persons' risk to develop osteoporosis and cardiovascular disease.
Collapse
Affiliation(s)
- Bengt B Arnetz
- Department of Family Medicine, College of Human Medicine, Michigan State University, Grand Rapids, Michigan, USA.,Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Judy Arnetz
- Department of Family Medicine, College of Human Medicine, Michigan State University, Grand Rapids, Michigan, USA.,Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Jack R Harkema
- Department of Pathobiology and Diagnostic Investigation, College of Veterinary Medicine, Michigan State University, East Lansing, Michigan, USA
| | - Masako Morishita
- Department of Family Medicine, College of Human Medicine, Michigan State University, Grand Rapids, Michigan, USA
| | - Kathleen Slonager
- Asthma and Allergy Foundation of America, Michigan Chapter, Franklin, MI, USA
| | - Sukhesh Sudan
- Department of Family Medicine, College of Human Medicine, Michigan State University, Grand Rapids, Michigan, USA
| | - Hikmet Jamil
- Department of Family Medicine, College of Human Medicine, Michigan State University, Grand Rapids, Michigan, USA
| |
Collapse
|
3
|
Altawalbeh SM, Thorpe CT, Zgibor JC, Kane-Gill S, Kang Y, Thorpe JM. Economic Burden Associated with Receiving Inhaled Corticosteroids with Leukotriene Receptor Antagonists or Long-Acting Beta Agonists as Combination Therapy in Older Adults. J Manag Care Spec Pharm 2018; 24:478-486. [PMID: 29694289 PMCID: PMC7977940 DOI: 10.18553/jmcp.2018.24.5.478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND There is a paucity of literature on the health care expenditures associated with different pharmacologic treatments in older adults with asthma that is not well controlled on inhaled corticosteroids (ICS). OBJECTIVE To compare asthma-related and all-cause health care expenditures associated with leukotriene receptor antagonists (LTRA) versus long-acting beta agonists (LABA) when added to ICS in older adults with asthma. METHODS A retrospective cohort was constructed using 2009-2010 Medicare fee-for-service medical and pharmacy claims from a 10% random sample of beneficiaries continuously enrolled in Parts A, B, and D in 2009. The sample comprised patients who were aged 65 years and older, diagnosed with asthma, and treated exclusively with ICS + LABA or ICS + LTRA. Outcomes assessed were asthma-related expenditures (medical, pharmacy, and total) and all-cause health care expenditures (medical, pharmacy, and total). Outcomes were measured from the date of the first prescription for the add-on treatment (LABA or LTRA in combination with ICS) after having at least a 4-month "wash-in" period in which patients were receiving no controller, ICS alone, or ICS plus the add-on treatment of the follow-up period. Patients were followed until death, switching to or adding the other add-on treatment, or the end of the study (December 31, 2010). Multivariable regression models with nonparametric bootstrapped standard errors were used to compare all-cause and asthma-related expenditures per patient per month (PPPM) between ICS + LABA and ICS + LTRA users. All models were adjusted for demographics, comorbidities, and county-level health care access variables. RESULTS The primary analysis included 14,702 patients, of whom 12,940 were treated with ICS + LABA and 1,762 were treated with ICS + LTRA. The mean (SD) follow-up periods were 12.3 (± 5.7) months for the ICS + LABA group and 15.3 (± 5.1) months for the ICS + LTRA group. Adjusted asthma-related expenditures PPPM were $400 for the ICS + LTRA group compared with $286 for the ICS + LABA group (P < 0.001). However, adjusted total all-cause expenditure PPPM was significantly lower for patients treated with ICS + LTRA ($6,087 for ICS + LTRA compared with $6,975 for ICS + LABA, P = 0.029). CONCLUSIONS Older adults with asthma often experience economic burden from asthma and other chronic illnesses. Compared with ICS + LTRA, ICS + LABA was associated with lower asthma-related expenditures but with higher all-cause expenditures in older adults. DISCLOSURES Support for this study was provided by the University of Pittsburgh School of Pharmacy and the Pittsburgh Claude D. Pepper Older Americans Independence Center (NIA P30 AGAG024827). C. Thorpe reports grants from the National Institute of Aging during the conduct of this study. The other authors have nothing to disclose.
Collapse
Affiliation(s)
- Shoroq M. Altawalbeh
- Department of Clinical Pharmacy, Jordan University of Science and Technology School of Pharmacy, Irbid, Jordan, and Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania
| | - Carolyn T. Thorpe
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, and Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Janice C. Zgibor
- Department of Epidemiology and Biostatistics, University of South Florida College of Public Health, Tampa
| | - Sandra Kane-Gill
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania
| | - Yihuang Kang
- Department of Information Management, National Sun Yat-sen University, Kaohsiung, Taiwan
| | - Joshua M. Thorpe
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, and Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| |
Collapse
|
4
|
Yawn BP, Han MK. Practical Considerations for the Diagnosis and Management of Asthma in Older Adults. Mayo Clin Proc 2017; 92:1697-1705. [PMID: 29101938 DOI: 10.1016/j.mayocp.2017.08.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 08/08/2017] [Accepted: 08/08/2017] [Indexed: 11/29/2022]
Abstract
Although often considered a disease of childhood, the prevalence of asthma in US adults aged 65 years or older is similar to that in children, with the number of older patients needing care for asthma likely to continue to increase. As with most chronic diseases, there are challenges associated with the diagnosis and management of asthma in an older population. This review discusses these challenges, suggesting practical management strategies for primary care physicians and their teams. Asthma comprises a spectrum of phenotypes, some associated with adult onset. The symptoms and characteristics of patients with late-onset asthma can differ from those of patients with early-onset disease. Furthermore, older patients may fail to recognize respiratory symptoms as abnormal and have other comorbidities, complicating the differential diagnosis of asthma. Once diagnosed, the long-term goals of asthma management are no different in older adults than in anyone with asthma, with inhaled corticosteroids being the cornerstone of therapy. Comorbid conditions become more common with age and have a direct impact on a patient's respiratory symptoms and potential adverse effects of therapy, thereby influencing the choice of therapies and delivery systems and potentially increasing the likelihood of complex polypharmacy. In conclusion, 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. As with all patients, the primary goals of asthma management in older adults are symptom control and exacerbation reduction.
Collapse
Affiliation(s)
- Barbara P Yawn
- Department of Family Medicine and Community Health, University of Minnesota, Blaine, MN.
| | - MeiLan K Han
- Women's Respiratory Clinic, Division of Pulmonary and Critical Care Medicine, University of Michigan Health System, Ann Arbor, MI
| |
Collapse
|
5
|
Abstract
Late-onset asthma is common, associated with poor outcome, underdiagnosed and undertreated, possibly due to the modifying effect of ageing on disease expression. Although the diagnostic work-up in elderly individuals suspected of having asthma follows the same steps as in younger individuals (case history and spirometry), it is important to acknowledge that elderly individuals are likely to have diminished bronchodilator reversibility and some degree of fixed airflow obstruction. Elderly individuals, therefore, often require further objective tests, including bronchial challenge testing, to objectively confirm asthma. If necessary, a trial of oral or inhaled corticosteroid might be necessary. Asthma can be diagnosed when increased airflow variability is identified in a symptomatic patient, and if the patient does not have a history of exposure, primarily smoking, known to cause chronic obstructive pulmonary disease, the diagnosis is asthma even if the patient does not have fully reversible airflow obstruction. Pharmacological therapy in patients with late-onset asthma follows international guidelines, including treatment with the lowest effective dose of inhaled corticosteroid to minimize the risk of systemic effects. However, most recommendations are based on extrapolation from findings in younger patients. Comorbidities are very common in patients with late-onset asthma and need to be taken into account in the management of the disease. In conclusion, late-onset asthma is poorly recognized and sub-optimally treated, the latter not least because elderly patients are excluded from most randomized controlled trials. Future studies should focus on the development of evidence-based guidelines for diagnosis and the pharmacological therapy of asthma in the elderly, including late-onset asthma.
Collapse
Affiliation(s)
- Charlotte Suppli Ulrik
- Department of Respiratory Medicine, Hvidovre Hospital, 2650, Hvidovre, Denmark. .,Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
| |
Collapse
|
6
|
Camargo CA, Davis KJ, Andrews EB, Stempel DA, Schatz M. Pharmacoepidemiological Study of Long-Acting β-agonist/Inhaled Corticosteroid Therapy and Asthma Mortality: Clinical Implications. Clin Drug Investig 2017; 36:993-999. [PMID: 27581247 DOI: 10.1007/s40261-016-0448-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
RATIONALE The increased risk of asthma mortality in association with long-acting β2-agonist (LABA) monotherapy is well documented but the risk associated with LABA plus inhaled corticosteroid (ICS) therapy remains unclear. OBJECTIVE We assessed the feasibility of a large pharmacoepidemiological study to compare the effect of combined LABA + ICS therapy with non-LABA maintenance therapy on the risk of asthma mortality. METHODS This observational retrospective study used electronic data from ten US data partners to construct a cohort of patients with persistent asthma (defined as: four or more asthma maintenance medication dispensings in 12 months and a code diagnosis of asthma). Asthma deaths were determined by linking patient data with the National Death Index. RESULTS From 5,881,438 asthma patients, a cohort of 994,627 met the criteria for persistent asthma and provided 2.4 million person-years of follow-up. The total number of deaths was 278 with only three of these occurring after incident exposure to an asthma maintenance medication. The overall pooled asthma mortality rate, standardized by age and data partner, was 1.16 [95 % confidence interval (CI) 0.98-1.34] per 10,000 person-years; crude mortality rates (per 10,000 person-years) increased with age and were higher in female individuals (1.34; 95 % CI 1.15-1.55) than in male individuals (0.92; 95 % CI 0.74-1.12). CONCLUSIONS Despite a cohort size of almost 1 million asthma patients, the asthma mortality risk associated with combined LABA + ICS therapy could not be determined. This study showed that very few patients with persistent asthma have asthma-related deaths, and confirmed that those who die are more likely to be older and female.
Collapse
Affiliation(s)
- Carlos A Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, 125 Nashua St, Suite 920, Boston, MA, 02114-1101, USA.
| | | | | | - David A Stempel
- US Medical Affairs, GlaxoSmithKline, Research Triangle Park, NC, USA
| | | |
Collapse
|
7
|
Li CY, Erickson SR, Wu CH. Metformin use and asthma outcomes among patients with concurrent asthma and diabetes. Respirology 2016; 21:1210-8. [DOI: 10.1111/resp.12818] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Revised: 01/28/2016] [Accepted: 02/22/2016] [Indexed: 01/07/2023]
Affiliation(s)
- Chun-Yi Li
- Medical Affairs; AstraZeneca Taiwan Limited; Taipei Taiwan
| | - Steven R. Erickson
- Department of Clinical, Social and Administrative Sciences, College of Pharmacy; University of Michigan; Ann Arbor Michigan USA
| | - Chung-Hsuen Wu
- School of Pharmacy, College of Pharmacy; Taipei Medical University; Taipei Taiwan
- Research Center for Pharmacoeconomics, College of Pharmacy; Taipei Medical University; Taipei Taiwan
| |
Collapse
|
8
|
Kim MY, Song WJ, Cho SH. Pharmacotherapy in the management of asthma in the elderly: a review of clinical studies. Asia Pac Allergy 2016; 6:3-15. [PMID: 26844215 PMCID: PMC4731478 DOI: 10.5415/apallergy.2016.6.1.3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2015] [Accepted: 01/12/2016] [Indexed: 12/29/2022] Open
Abstract
Asthma in the elderly is a disease with emerging concern. Despite some recent advances in our understanding of epidemiology and pathophysiology, there is a considerable lack of clinical evidence specific to elderly patients. Currently available high quality clinical evidence has been mostly obtained from younger adults, but rarely from elderly patients. Under-representation of elderly patients in previous randomized trials may have been due to being, old age, or having comorbidities. Thus, a question may be raised whether current clinical evidence could be well generalized into elderly patients. Further clinical trials should address clinical issues raised in elderly population. In this review, we aimed to overview the efficacy and safety of pharmacological management, and also to summarize the literature relevant to elderly asthma.
Collapse
Affiliation(s)
- Mi-Yeong Kim
- Department of Internal Medicine, Inje University Busan Paik Hospital, Inje University College of Medicine, Busan 47392, Korea
| | - Woo-Jung Song
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul 03080, Korea.; Institute of Allergy and Clinical Immunology, Seoul National University Medical Research Center, Seoul 03080, Korea
| | - Sang-Heon Cho
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul 03080, Korea.; Institute of Allergy and Clinical Immunology, Seoul National University Medical Research Center, Seoul 03080, Korea
| |
Collapse
|
9
|
Hernández G, Avila M, Pont A, Garin O, Alonso J, Laforest L, Cates CJ, Ferrer M. Long-acting beta-agonists plus inhaled corticosteroids safety: a systematic review and meta-analysis of non-randomized studies. Respir Res 2014; 15:83. [PMID: 25038591 PMCID: PMC4132190 DOI: 10.1186/1465-9921-15-83] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Accepted: 07/14/2014] [Indexed: 01/16/2023] Open
Abstract
Background Although several systematic reviews investigated the safety of long-acting beta–agonists (LABAs) in asthma, they mainly addressed randomized clinical trials while evidence from non-randomized studies has been mostly neglected. We aim to assess the risk of serious adverse events in adults and children with asthma treated with LABAs and Inhaled Corticosteroids (ICs), compared to patients treated only with ICs, from published non-randomized studies. Methods The protocol registration number was CRD42012003387 (http://www.crd.york.ac.uk/Prospero). Literature search for articles published since 1990 was performed in MEDLINE and EMBASE. Two authors selected studies independently for inclusion and extracted the data. A third reviewer resolved discrepancies. To assess the risk of serious adverse events, meta-analyses were performed calculating odds ratio summary estimators using random effect models when heterogeneity was found, and fixed effect models otherwise. Results Of 4,415 candidate articles, 1,759 abstracts were reviewed and 220 articles were fully read. Finally, 19 studies met the inclusion criteria. Most of them were retrospective observational cohorts. Sample sizes varied from 50 to 514,216. The meta-analyses performed (69,939-624,303 participants according to the outcome considered) showed that odds ratio of the LABAs and ICs combined treatment when compared with ICs alone was: 0.88 (95% CI 0.69-1.12) for asthma-related hospitalization; 0.75 (95% CI 0.66-0.84) for asthma-related emergency visits; 1.02 (95% CI 0.94-1.10) for systemic corticosteroids; and 0.95 (95% CI 0.9-1.0) for the combined outcome. Conclusions Evidence from observational studies shows that the combined treatment of LABAs and ICs is not associated with a higher risk of serious adverse events, compared to ICs alone. Major gaps identified were prospective design, paediatric population and inclusion of mortality as a primary outcome.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | - Montserrat Ferrer
- Health Services Research Group, IMIM (Hospital del Mar Medical Research Institute), Barcelona Biomedical Research Park, office 144, Doctor Aiguader, 88
- 08003, Barcelona, Spain.
| | | |
Collapse
|