Comorbidities in elderly patients with asthma: Association with control of the disease and concomitant treatment

Efficacy, Safety, and Continuation of Biological Therapy in Older Patients with Asthma in a Real-World Setting: A Retrospective Observational Study

Background

Major randomized clinical trials have shown that biological therapy can reduce the exacerbation rate and oral corticosteroid (OCS) dosage in patients with severe eosinophilic asthma. However, data on the continuation, efficacy, and safety of biological therapy in older patients with asthma are limited. Therefore, the aim of this study was to evaluate the differences in the continuation rate, efficacy, and safety of biological therapy between older (≥ 65 years) and younger (< 65 years) patients with asthma.

Methods

In this single-center retrospective observational study, we collected clinical data of patients with asthma who were administered biological drugs such as omalizumab, mepolizumab, benralizumab, and dupilumab between April 2009 and August 2022. We comparatively analyzed the continuation, efficacy, and safety of biological therapy between older (age ≥ 65 years) and younger patient (age < 65 years) groups. The reasons for discontinuation or switching of biological drugs were also evaluated.

Results

Sixty-two (31 older and 31 younger) patients were treated with 91 biologics during the observational period. The mean age of older patients was 74.3 ± 5.1 years and that of younger patients was 48.0 ± 14.0 years. The continuation rate of biological therapy was not significantly different between the groups. Social background was the most common reason for discontinuation of biological therapy in both groups, and insufficient effect was the most common reason for switching to biological drugs. Asthma exacerbations decreased in both groups within the first 12 months of biologic therapy. The dosage of OCS tended to decrease in the older group and significantly decrease in the younger group.

Conclusion

Biologic therapy for older patients with asthma can be continued, with efficacy and safety similar to those in younger patients with asthma.

Age-Related Clinical Characteristics, Inflammatory Features, Phenotypes, and Treatment Response in Asthma

BACKGROUND

Emerging evidence suggests that aging affects asthma outcomes, but the mechanism remains largely unexplored.

OBJECTIVE

To explore age-related clinical characteristics, inflammatory features, phenotypes, and treatment response in asthma.

METHODS

This was a prospective cohort study of asthmatic patients with a 12-month follow-up in a real-world setting. Clinical inflammatory and phenotypic characteristics, future risk for exacerbations, and treatment response were assessed across different age groups (young was defined as age 18 to 39 years; middle-aged, 40 to 64 years; and elderly, 65 years or older).

RESULTS

Compared with young (n = 106) and middle-aged (n = 179) asthmatic patients, elderly patients (n = 55) had worse airway obstruction, more comorbidities including chronic obstructive pulmonary disease and diabetes, less atopy, and lower levels of IgE and FeNO, and were more likely to have late-onset and fixed airflow obstruction asthma and a reduced risk for having type 2 profile asthma. Levels of IFN-gamma, IL-17A, and IL-8 in induced sputum were significantly increased in elderly asthmatic patients (all P < .05). Path analysis indicated that age directly and significantly led to future exacerbations in asthma, partially mediated by an upregulation of airway IFN-gamma. Moreover, elderly patients with asthma had a reduced treatment response (improvement in FEV₁ of 12% or greater, or 200 mL, and a reduction in Borg scores of 1 or greater) (adjusted odds ratio = 0.11; 95% CI, 0.02-0.52; and adjusted odds ratio = 0.12; 95% CI, 0.03-0.49, respectively).

CONCLUSIONS

This study confirms that asthma in the elderly population represents a specific phenotype and indicates that aging can influence asthma in terms of clinical characteristics, inflammatory features, exacerbations, and treatment response.

Diagnostic and therapeutic approaches for elderly asthma patients: the importance of multidisciplinary and multidimensional management

INTRODUCTION

Asthma is commonly considered a disease of younger ages; however, it is not infrequent to pose a diagnosis of the disease in older individuals. Although current recommendations do not distinguish between young and old asthmatics in terms of diagnostic and therapeutic approaches, asthma in the elderly may present with peculiar features that contribute to complicate its management.

AREAS COVERED

The current review focuses on the challenges that arise when approaching an older individual with suspected asthma. Age-associated changes of the lung may complicate the diagnostic approach. Measurement of the forced expiratory volume in the first 6 s (FEV6) in an easier and faster alternative to FVC estimation, and residual volume should always be assessed. Older individuals are often affected by concomitant diseases, both age- and drug-related, that need to be considered when approaching elderly asthmatics, since they can affect the efficacy of the treatment as well as the control of the disease.

EXPERT OPINION

The potential drug to drug interaction should be routinely investigated, and documented in medical records. The effect of aging on the response to pharmacological therapy in older asthmatics should be explored. Therefore, the need of a multidisciplinary and multidimensional approach to the elderly asthmatics is strongly encouraged.

Association of Depression, Poor Mental Health Status and Asthma Control Patterns in US Adults Using a Data-Reductive Latent Class Method

Objectives To explore the association between depression, poor mental health status, and asthma control patterns among US adults using a latent class analysis (LCA) approach. Methods We used data from 10,337 adults aged 18 years and above from the 2016 Behavioral Risk Factor Surveillance System (BRFSS) Asthma Call-back Survey. Data-reductive LCA was used to derive asthma control patterns in the population using class variables indicative of asthma control. Besides univariate analysis, adjusted and unadjusted logistic regression models were used to examine the association of depression and poor mental health on the derived asthma control patterns.  Results About 27.8% of adults aged <55 reported depression, while 27.3% aged ≥55 years were depressed. The latent class prevalence of asthma control patterns was 42.8%, 31.1%, and 26.1%, corresponding to good, fair, and poor asthma control patterns, respectively. In adults aged <55 years, odds of depression (OR=1.52, 95% CI=1.27-1.82) and poor mental health (OR=1.58, 95% CI=1.27-1.96) were higher in the poor asthma control group compared to the good asthma control group. Odds for depression (OR=1.28, 95% CI=1.06-1.53) were also higher in the moderate asthma control group compared to the good asthma control group. Among those aged ≥55 years, depression odds (OR=1.57, 95% CI=1.31-1.87) were higher in only the poor asthma control group. Conclusions These findings may have public health implications. Detecting, screening, and treating depression and mental health disorders may help improve asthma control in people with asthma.

Expert consensus recommendations for the management of asthma in older adults

Asthma is a public health problem in patients of any age, although there is still a tendency to erroneously assume that it is almost always confined to children and young people. Epidemiological studies indicate that, from the sixth decade of life, the prevalence of this disease in countries such as Spain reaches 6-10%, with a higher prevalence among women aged 64 to 75 years. In addition, two-thirds of asthma deaths occur at this stage of life, resulting in a substantial number of hospital admissions, longer hospital stays and, from a finance point of view, significant direct economic costs. Asthma in older adults (65 years or older) is now a matter of great concern, the reality of which is underestimated and undertreated. It is therefore essential to establish appropriate recommendations for the diagnosis and treatment of asthma in the aging population. This consensus, which brings together the latest evidence available, was conceived with this objective. The proposed recommendations/conclusions are the result of a nominal consensus developed throughout 2019 and validated by panellists in successive rounds of voting.

Circulating miRNA expression in asthmatics is age-related and associated with clinical asthma parameters, respiratory function and systemic inflammation

Background

The course of asthma may differ between elderly asthmatics (EA) and non-elderly asthmatics (nEA), which may be partially associated with an age-dependent aberrant immune response. The aim of the study was to determine the influence of serum miRNA expression on asthma characteristics and systemic inflammation markers in EA and nEA.

Methods

Control and severity of asthma, pulmonary function and FeNO were assessed in 28 EA and 31 nEA patients. The control group included 59 elderly and non-elderly healthy individuals. The expression of selected miRNAs in serum was measured with rt-PCR, and proinflammatory cytokine activity was assayed by ELISA or flow cytometry.

Results

No difference in serum miRNA expression was observed between the asthmatics and healthy controls. EA demonstrated lower expression of miRNA-106a and miRNA-126a than nEA (p = 0.003 and p = 0.02) and EC had lower expression of miRNA-146a, -126a, -106a and 19b than nEC (p = 0.001, p = 0.003, p = 0.005 and p < 0.001 respectively). Only nEA demonstrated a relationship between the expression of selected miRNAs and the level of asthma control (assessed with ACT) and with airway inflammation, measured by FeNO level. All patients with asthma demonstrated elevated TNFα, IL-6 and sTNF RI levels compared to controls (p = 0.026, p = 0.03 and p < 0.001 respectively). EA demonstrated a higher TNFα level than EC (p < 0.001), and EA had a higher level of sTNF RI than nEA (p < 0.001). A significant correlation was observed between serum levels of proinflammatory cytokines and selected miRNAs.

Conclusion

Serum miRNA expression was found to correlate with clinical characteristics of asthma and systemic inflammation in an age-dependent fashion, suggesting that miRNA may differentially contribute to asthma pathogenesis in elderly and non-elderly patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12931-021-01769-x.

Uncontrolled asthma across GINA treatment steps 2 - 5 in a large US patient cohort

OBJECTIVE

Despite advances in treatment, asthma remains uncontrolled in many patients, with increased risk of exacerbation and associated healthcare resource utilization (HCRU). We describe patient characteristics, exacerbations, asthma control, and HCRU using GINA treatment step (GS) as a proxy for asthma severity. .

METHODS

Using a large, US, health-claims database, 4 longitudinal cohorts of 517,738 patients in GS2-5, including a subgroup of patients with baseline eosinophil (EOS) counts, were analyzed retrospectively (study period 2010 - 2016). Index for each cohort was patients' first time entering the GS, determined by first claim of first regimen. Uncontrolled asthma was defined according to published criteria as a multi-dimensional measure that includes number of exacerbations. Key variables including, baseline characteristics, post-index exacerbations, and HCRU (all-cause and asthma-specific events) are summarized by descriptive statistics.

RESULTS

Uncontrolled asthma was reported in 19.8% patients in GS2, 44.8% in GS3, 49.3% in GS4, and 58.6% in GS5. Annualized mean (SD) rates of exacerbation 12 months post-index generally increased across GS2-5 (0.26 [0.86], 0.32 [0.79], 0.36 [0.83], 0.29 [0.86], respectively). HCRU also increased with increasing GS, with higher HCRU among the uncontrolled cohort within each GS. In patients with EOS ≥300 cells/µL, uncontrolled asthma also increased with increasing GS (21.8%, 43.9%, 50.5%, 67.2% for GS2-5, respectively).

CONCLUSIONS

This large database study provides real-world evidence of the substantial degree of uncontrolled asthma in US clinical practice across GS, supporting calls for better asthma management. Healthcare burden tends to increase with lack of control in all groups, highlighting the need for improved patient education, adherence, access, and treatment optimization.

Supplemental data for this article can be accessed at publisher's website.

The effect of statins for asthma. A systematic review and meta-analysis

OBJECTIVE

To assess the effects of statins on asthma by systematically reviewing and conducting a meta-analysis on all clinical studies, including randomized controlled trials (RCTs) and observational studies, that examined the effects of statins on asthma.

METHODS

PubMed, EMBASE databases, and Cochrane reviews were searched to identify RCTs and observational studies, conducted through June 16, 2020, that assessed the effect of statins as a treatment for asthma. A meta-analysis was conducted using the following main outcomes: asthma control test (ACT), asthma control questionnaire (ACQ), pre- and post-bronchodilator forced expiratory volume in one second (FEV1), peak flow (PEF), and asthma exacerbation (asthma-related emergency department (ED) visits and hospitalization).

RESULTS

Our search revealed 11 RCTs and 8 observational studies that met the inclusion criteria. A meta-analysis demonstrated that statin treatment significantly improved ACT scores (mean difference: 1.61, P < 0.001) and ACQ scores (mean difference: -0.38, P < 0.001) compared to a placebo. Furthermore, statin treatment significantly reduced asthma-related ED visits (hazard ratio [HR], 95% confidence interval [CI], 0.83 [0.75-0.92], P < 0.001, number needed to treat [NNT], 5.9). However, statin treatment did not improve pulmonary function (FEV1 and PEF).

CONCLUSION

Our results suggest that statins have the potential to improve asthma control and reduce asthma exacerbation without any improvement in pulmonary function.

Supplemental data for this article can be accessed at publisher's website.

The Interplay Between Asthma and Other Diseases: Role of Ca2+/cAMP Signalling

OBJECTIVE

Asthma is correlated with a higher risk of manifesting other diseases, including hypertension, diabetes, obesity, psychiatric and neurological diseases, and cancer. Therefore, revealing this interplay between asthma and these illnesses may provide novel insights into their pathogenesis.

RESULTS

It is highly debated that dysregulation of Ca2+ homeostasis is involved in the pathogenesis of these maladies. Not surprisingly, calcium (Ca2+) channel blockers (CCBs), classically used as antihypertensive medicines, have been demonstrating off-label effects such as alleviating asthma symptoms, in addition to antidiabetic, antiobesity, anticancer and antineurodegenerative effects. Our studies about Ca2+/cAMP signalling may shed some new light on this field.

CONCLUSION

Thus, considering that asthma and associated illnesses such as hypertension, diabetes, obesity, cancer and neurodegenerative diseases have become highly prevalent medical problems in the world, the comprehension of this interplay between asthma and other disorders could improve drug therapy.

Pharmacotherapeutic management of asthma in the elderly patient

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.

Age- and sex-specific prevalence of chronic comorbidity in adult patients with asthma: A real-life study

The presence of comorbidity can be associated with poorer asthma outcomes. Previous prevalence studies focused on a limited selection of comorbid conditions in asthma only. We aimed to determine age- and sex-specific prevalence estimates for the full range of chronic comorbid conditions in adult asthma patients by performing a retrospective cohort study based on 32,787 medical records of patients aged ≥16 years with asthma from 179 general practices in the Netherlands. Age- and sex-specific prevalence estimates of 76 chronic comorbidities and 14 disease categories based on International Classification of Primary Care codes were determined. Chronic comorbidity was present in 65.3% of male asthma patients and 72.8% of female asthma patients, with female patients having a higher mean (SD) of 2.0 (2.1) comorbidities compared to male patients (1.7 (2.0)). This mean increased to 5.0 (2.7) conditions in the 75+ age group. Most prevalent comorbidities were hypertension (20.1%), osteoarthritis (11.5%), eczema (11.5%) and dyspepsia (10.7%). Compared to male asthma patients, female asthma patients showed higher odds for the presence of other chronic conditions in eight disease categories. Neurological (odds ratio [OR]; 95% confidence interval 2.01; 1.76-2.29), blood forming/lymphatics (OR 1.83; 1.38-2.42) and musculoskeletal diseases (OR 1.82; 1.69-1.95) showed the highest association with female sex. In conclusion, the presence of chronic comorbidity is the norm in adults with asthma and it is more prevalent in female than in male asthma patients. The odds of having a specific comorbid condition may differ between the sexes. Attention in guidelines on how to handle comorbidities may lead to a more targeted treatment for comorbidities and more patient-centred asthma management.

Asthma Across Age: Insights From Primary Care

Asthma is a heterogeneous disease comprising of multiple phenotypes and affects patients from childhood up to old age. In this review, we summarize the current knowledge on the similarities and differences in asthma across different age-groups, with emphasis on the perspective from primary care. Despite the similar disease presentation, phenotyping studies showed that there are differences in the distribution of phenotypes of asthma presenting in childhood compared to that in adulthood. Whereas, asthma with early age of onset tends to be of the atopic phenotype, the disease shifts toward the non-atopic phenotypes at later ages. Studies within primary care patients aiming to elucidate risk factors for future asthma exacerbation have shown pediatric and elderly patients to be at higher risk for future asthma attacks compared to other adult patients. Regardless, both pediatric and adult studies demonstrated previous asthma episodes and severity, along with high blood eosinophil to predict subsequent asthma attacks. Differences in childhood and adult asthma are not limited to the underlying phenotypes but also extends to the challenges in the diagnosis, treatment, and management of the disease. Diagnosis of asthma is complicated by age-specific differential diagnoses such as infectious wheezing and nasal obstruction in children, and aging-related problems such as heart disease and obesity in the elderly. There are also age-related issues leading to decreased disease control such as non-adherence, tobacco use, difficulty in using inhalers and corticosteroid-related side effects which hinder asthma control at different patient age-groups. Several clinical guidelines are available to guide the diagnosis and drug prescription of asthma in pediatric patients. However, there are conflicting recommendations for the diagnostic tools and treatment for pediatric patients, posing additional challenges for primary care physicians in working with multiple guidelines. While tools such as spirometry and peak flow variability are often available in primary care, their usage in preschool patients is not consistently recommended. FeNO measurement may be a valuable non-invasive tool which can be adopted by primary physicians to assist asthma diagnosis in preschool-age patients.

Efficacy and Safety of Sublingual Immunotherapy in Elderly Rhinitis Patients Sensitized to House Dust Mites

PURPOSE

This study aims to determine the efficacy and safety of house dust mite (HDM)-sublingual immunotherapy (SLIT) in elderly patients with AR.

METHODS

A total of 45 patients aged ≥ 60 years with HDM-induced AR who had ≥ 3 A/H ratio on skin prick test and/or ≥ 0.35 IU/L to both Dermatophagoides farinae and Dermatophagoides pteronyssinus by ImmunoCAP were enrolled in 4 university hospitals. To evaluate additional effects of HDM-SLIT, they were randomized to the SLIT-treated group (n = 30) or control group (n = 15). Rhinoconjunctivitis total symptom score (RTSS), rhinoscopy score, Korean rhinoconjunctivitis quality of life questionnaire, rhinitis control assessment test, asthma control test scores, and adverse reactions, were assessed at the first visit (V1) and after 1 year of treatment (V5); for immunological evaluation, serum levels of HDM-specific immunoglobulin A/IgE/IgG1/IgG4 antibodies and basophil response to HDMs were compared between V1 and V5 in both groups.

RESULTS

There were no significant differences in demographics, RTSS, skin reactivity to HDMs, or serum total/specific IgE levels to HDMs (P < 0.05, respectively) between the 2 groups. Nasal symptom score and RTSS decreased significantly at year 1 in the 2 groups (P < 0.05). There were no significant differences in percent decrease in nasal symptom score and RTSS at year 1 between the 2 groups (P < 0.05); however, rhinoscopic nasal symptom score decreased significantly in the SLIT-treated group (P < 0.05). Immunological studies showed that serum specific IgA levels (not specific IgE/IgG) and CD203c expression on basophils decreased significantly at V5 in the SLIT-treated group (P = 0.011 and P = 0.001, respectively), not in the control group. The control group required more medications compared to the treatment group, but there were no differences in adverse reactions.

CONCLUSIONS

It is suggested that HDM-SLIT for 1 year could induce symptom improvement and may induce immunomodulation in elderly rhinitis patients.

A proposed scheme to cope with comorbidities in asthma

The prevalence of non-communicable chronic diseases has been on the rise and the co-occurrence of morbidities is becoming more common. Multimorbidities are found more frequently among women, those with a history of mental disorders, lower level of schooling, and unfavorable socioeconomic condition. Physical inactivity, smoking and obesity are also associated with multimorbidities. Its occurrence is directly related to the age, affecting the majority of the individuals with more than 50 years old. It is important to consider the possibility of comorbid conditions that aggravate, complicate or simulate the symptoms of the disease in the face of a patient with asthma and poor response to treatment. Among subjects with asthma, some conditions stand out as the most frequent: chronic rhinitis or rhinosinusitis, gastroesophageal reflux disease, obstructive sleep apnea syndrome, obesity, and cardiovascular disorders. Comorbidities reduce the chances of optimal asthma control. It is essential to assess and manage properly these complex situations, choosing wisely preventive strategies and treatment options to avoid adverse events and optimize outcomes. Medications for asthma have the potential to worsen cardiovascular conditions, while beta-adrenergic receptor blockers and angiotensin conversion enzyme inhibitors used for cardiovascular conditions, can worsen asthma. Handling properly these cases will save lives and resources. However, there are multiple gaps in knowledge requiring investigation in this field to inform integrated care pathways and policies. It is likely information may be obtained from real life studies and electronic medical databases. Communications between the providers and patients may be facilitated by electronic technology, opening a large window for guided self-management.

Asthma control and adherence in newly diagnosed young and elderly adult patients with asthma in Turkey

OBJECTIVE

This study aimed to evaluate the factors that affect asthma control and adherence to treatment in newly diagnosed elderly asthmatics in Turkey compared with younger patients.

METHODS

This real-life prospective observational cohort study was conducted at 136 centers. A web-based questionnaire was administered to the patients who were followed up for 12 months.

RESULTS

Analysis included 1037 young adult asthma patients (age <65 years) and 79 elderly asthma patients (age ≥65 years). The percentage of patients with total control in the elderly and young groups were 33.9% and 37.1% at visit 1, 20.0% and 42.1% (p = 0.012) at visit 2, and 50.0% and 49.8% at visit 3, respectively. Adherence to treatment was similar for both groups. Visit compliance was better in the elderly group than in the young group at visit 1 (72.2% vs. 60.8%, p = 0.045), visit 2 (51.9% vs. 34.9%, p = 0.002), and visit 3 (32.9% vs. 19.4%, p = 0.004). Adherence to treatment increased with asthma control in both groups (both p < 0.001) but decreased with the presence of gastritis/ulcer, gastroesophageal reflux, and coronary artery disease in the elderly.

CONCLUSIONS

Asthma control and adherence to treatment were similar for the elderly and young asthma patients, though the follow-up rate was lower in young patients. The presence of gastritis/ulcer, gastroesophageal reflux and coronary artery disease had negative impacts on the adherence to treatment in elderly adult patients.

Clinical characteristics and comorbidities of elderly asthmatics who attend allergy clinics

Background

To date, few studies have focused on the clinical and allergic characteristics of asthma in the elderly, defined as asthma in people aged 60 or over. Thus, we propose to identify and study the clinical and allergic characteristics and comorbidities of patients with asthma among the elderly.

Methods

A retrospective, observational, descriptive study was developed in five clinics and hospitals in Argentina. Allergy Physicians analyzed their patients' medical records in 2014 and included those adults over the age of 60, who had been diagnosed with asthma according to the GINA guidelines. Clinical and allergic characteristics were analyzed.

Results

A total of 152 patients diagnosed with asthma, of whom 73% were women and 11% ex-smokers, were included in this study, with a mean age of 66 years. Only 10.5% of the participants had onset asthma past the age of 60. Regarding asthma severity, 74.3% were diagnosed with moderate persistent asthma, and 7.2% with severe persistent asthma. Eighty-four percent of the patients were treated with an inhaled corticosteroid (ICS) along with a long-acting β 2-adrenergic agent (LABA). More than half of the patients had two or more comorbidities simultaneously. Allergic comorbidities were the most frequent comorbidities, followed by arterial hypertension. Among allergic comorbidities, most patients presented allergies at the nasal level. There were no significant differences between the subpopulations of patients with late-onset asthma (LOA) and asthma with onset before the age of 60, i.e. early onset asthma (EOA) in most of their clinical characteristics. However, it was observed that EOA accounted for a higher percentage of patients with nasal allergies as compared to LOA (71% vs 46%, p <  0.05).It is worth mentioning that almost half of the patients with LOA had allergies at the nasal level.

Conclusion

These results may provide a better understanding of the clinical characteristics of asthma in the elderly in Argentina, thus, enabling the development of future therapeutic strategies and a better quality of life for our elderly asthma patients.

The impact of aging on outpatients with asthma in a real-world setting

BACKGROUND

Asthma is characterized by airway inflammation and bronchial hyperreactivity. It is conceived that aging may affect asthma characteristics, but this issue is still not completely clarified in clinical practice.

OBJECTIVE

The present study investigated whether aging may affect some clinical and functional factors in outpatients with asthma visited in a real-world setting, such as clinical practice.

METHODS

Globally, 391 outpatients (163 males, median age 47 years) with asthma were consecutively evaluated. The following parameters were assessed: history, including, smoking, comorbidity, and inhaled corticosteroids (ICS) use, physical examination, body mass index (BMI), lung function, level of asthma control, asthma control test (ACT), and fractional exhaled NO (FeNO).

RESULTS

The elderly with asthma had: more frequently not controlled asthma, higher BMI, higher ICS dosages, more impaired lung function, including plethysmographic parameters, than adult asthmatics (p < 0.001 for all, but p = 0.002 for RV and p = 0.008 for FRC). Elderly asthmatics were also less frequently allergic (p < 0.001) and had less rhinitis comorbidity (p < 0.001) and less nasal symptoms (p < 0.05) than younger asthmatics.

CONCLUSIONS

The present study conducted in a real-world setting shows that aging significantly affects asthma, mainly concerning asthma control, lung function, and steroid-sensitivity.

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

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.

Routine Use of Budesonide/Formoterol Fixed Dose Combination in Elderly Asthmatic Patients: Practical Considerations

Asthma has been demonstrated to be as common in the elderly as in younger age groups. Although no specific recommendations exist to manage the disease differently in older individuals, functional features and clinical presentations may be affected by age per se, and by age-related conditions, such as comorbidities and polypharmacy. In this review article, we aimed to explore the efficacy and safety in elderly asthmatic patients of one of the most currently used inhaled treatments for asthma, that is, the fixed-dose combination of budesonide/formoterol. We attempted to address some practical questions that are relevant to the daily practice of clinicians. We focused on the efficacy and real-world effectiveness of inhaled corticosteroids and long-acting β-adrenergic bronchodilators (ICS/LABA) as treatment in the elderly population, since data are extrapolated from younger populations. We investigated whether a maintenance and reliever therapy approach is more effective in the elderly as opposed to maintenance regimens, from both the general practitioner's and the pulmonologist's perspective. To address these questions, we scanned electronic databases (PubMed, MEDLINE, Embase, Scopus and Google Scholar) from the date of inception up to October 2016 with a cross-search using the following keywords: 'asthma', 'elderly', 'SMART therapy', 'MART therapy', 'Turbuhaler', and 'budesonide/formoterol'. The available literature on the topic confirms that when the age-associated changes are properly managed in clinical practice, asthma in older populations can be optimally controlled with inhaled treatment including ICS/LABA. This also applies for the budesonide/formoterol fixed combination, thus allowing for the maintenance and reliever therapy approach.

Leukotriene Receptor Antagonists for the Treatment of Asthma in Elderly Patients

Elderly asthma (EA) is regarded as a distinct phenotype of asthma and is associated with age-related changes in airway structure and alterations in lung function and immune responses. EA is difficult to diagnose because of aging and co-morbidities, and overlaps with fixed airway obstructive disease. Novel modalities to differentiate between EA and chronic obstructive pulmonary disease (COPD) are necessary. A multifaceted approach, including clinical history, smoking habits, atopy, and measurement of lung function, is mandatory to differentiate asthma from COPD. There are a variety of co-morbidities with EA, of which COPD, upper airway diseases, depression, obesity, and hypertension are the most common, and these co-morbidities can affect the control status of EA. However, leukotriene receptor antagonists (LTRAs) can facilitate the management of EA, and thus addition of an LTRA to inhaled corticosteroid (ICS) monotherapy or ICS plus long-acting β₂-agonist therapy improves symptoms in EA patients. LTRA treatment is safe and beneficial in patients who are unable to use inhalation devices properly or who have co-morbid diseases. Therefore, clinical studies targeting a specific population of EA patients are warranted to help achieve a better therapeutic strategy in EA patients.

Predictors of asthma control in elderly patients

PURPOSE OF REVIEW

We are in the era of rapid aging of the global population. Elderly asthmatic patients have an increased frequency of hospitalization and a high mortality rate. In this review, we focus on comorbidities and treatment issues in terms of the predictors of asthma control in the elderly.

RECENT FINDINGS

Some frequent comorbidities, such as chronic obstructive pulmonary disease, chronic sinusitis, obesity, and depression, are associated with uncontrolled asthma in elderly asthmatic patients. Smoking status in elderly asthmatic patients was associated with more frequent exacerbations. Management of comorbidities should be taken into account when we treat elderly asthmatic patients. Low treatment adherence, which is common in elderly asthmatic patients, predicts poor asthma control status. A poor knowledge about asthma, cognitive function impairment, and inappropriate inhaler technique result in low treatment adherence. Polypharmacy is associated with low treatment adherence, adverse drug reactions, and drug-drug interactions, and it is supposed to be a predictor of asthma control.

SUMMARY

Multifactorial assessments, including comorbidities, treatment adherence, and polypharmacy, are important for better asthma control in elderly asthmatic patients. Further studies on the strategy for the management of elderly asthmatic patients in a real-world setting are warranted.

Addressing unmet needs in understanding asthma mechanisms: From the European Asthma Research and Innovation Partnership (EARIP) Work Package (WP)2 collaborators

Asthma is a heterogeneous, complex disease with clinical phenotypes that incorporate persistent symptoms and acute exacerbations. It affects many millions of Europeans throughout their education and working lives and puts a heavy cost on European productivity. There is a wide spectrum of disease severity and control. Therapeutic advances have been slow despite greater understanding of basic mechanisms and the lack of satisfactory preventative and disease modifying management for asthma constitutes a significant unmet clinical need. Preventing, treating and ultimately curing asthma requires co-ordinated research and innovation across Europe. The European Asthma Research and Innovation Partnership (EARIP) is an FP7-funded programme which has taken a co-ordinated and integrated approach to analysing the future of asthma research and development. This report aims to identify the mechanistic areas in which investment is required to bring about significant improvements in asthma outcomes.

Prevalence of comorbidities in chronic obstructive pulmonary disease patients: A meta-analysis

BACKGROUND

This study compares the prevalence rates of comorbidities between chronic obstructive pulmonary disease (COPD) and non-COPD control patients reported in literature.

METHOD

Literature was searched in several electronic databases. After the selection of studies by following précised eligibility criteria, meta-analyses of odds ratios (ORs) were carried out with subgroup and sensitivity analyses under random effects model.

RESULTS

Eleven studies (47,695,183 COPD and 47,924,876 non-COPD control patients' data) were used for meta-analysis. Average age of COPD patients was 66.66 ± 8.72 years of whom 55.4 ± 11.9% were males. The prevalence of cardiovascular comorbidities [OR 1.90, 95% confidence interval (95% CI) 1.59-2.28; P < .00001], cerebrovascular comorbidities (OR 1.84, 95% CI 1.47-2.31; P < .00001), hypertension (OR 1.45, 95% CI 1.31-1.61; P < .00001), diabetes mellitus (OR 1.22, 95% CI 1.07-1.38; P = .003), neurological and psychiatric disorders (OR 1.78, 95% CI 1.48-2.14; P < .00001), gut and renal disorders (OR 1.96, 95% CI 1.43-2.68; P < .00001), musculoskeletal disorders (OR 1.51, 95% CI 1.27-1.78; P < .00001), non-COPD respiratory comorbidities (OR 2.81, 95% CI 2.52-3.14; P < .00001), and cancer (OR 1.67, 95% CI 1.25-2.23; P = .0005) were significantly higher in COPD patients than in non-COPD controls.

CONCLUSION

COPD is associated with significantly higher comorbidities than in other diseases that should be taken into consideration in COPD control strategies.

Allergy and asthma medication use in home-dwelling U.S. older adults

BACKGROUND

Little is known about the use of allergy and asthma medications in older adults. This study aimed to assess the prevalence of use of these medications in older adults and evaluate predictors of their use.

METHODS

Cross-sectional study using data from the National Social Life, Health, and Aging Project (NSHAP), a nationally representative sample of community-dwelling, U.S. adults 57 to 85 years (n = 2976) collected in 2005-2006. We determined prevalence of medication use and used logistic regression to evaluate sociodemographic and health factors associated with their use.

RESULTS

Overall prevalence of allergy medication usage was 8.4% (most commonly antihistamines), and prevalence of asthma medication usage was 8.0% (most commonly bronchodilators). Allergy medication use was significantly associated with history of asthma (odds ratio [OR] 2.37; 95% confidence interval [CI], 1.52 to 3.69), chronic obstructive pulmonary disease (COPD) (OR 2.35; 95% CI, 1.58 to 3.51), or nasal surgery (OR 1.97; 95% CI, 1.00 to 3.86). Older age was associated with decreased allergy medication use (per decade, OR 0.80; 95% CI, 0.66 to 0.98). Although increased education was associated with increased overall allergy medication use, it was associated with decreased use of allergy medications generally contraindicated in the elderly. In contrast, the only significant predictors of asthma medication use were history of asthma (OR 19.66; 95% CI, 3.18 to 121.70) or COPD (OR 4.25; 95% CI, 0.88 to 20.44).

CONCLUSION

Allergy and asthma medication use is prevalent among older adults and driven mostly by history of asthma or COPD. Additional sociodemographic factors predict allergy (but not asthma) medication use. Further studies are needed to evaluate efficacy of these drugs in the elderly.

Prevalence of Comorbidities in Asthma and Nonasthma Patients: A Meta-analysis

This study compares the prevalence rates of comorbidities between asthma and nonasthma control patients reported in the literature.Literature was searched in several electronic databases. After the selection of studies by following précised eligibility criteria, meta-analyses of odds ratios were carried out with subgroup and sensitivity analyses.Eleven studies studying 117,548 asthma patients compared with 443,948 non-asthma controls were included in the meta-analysis. The prevalence of cardiovascular comorbidities (odds ratio (OR): [95% CI] 1.90 [1.70, 2.14]; P < 0.00001), cerebrovascular comorbidities (OR 1.44 [1.29, 1.60]; P < 0.00001), obesity (OR 1.51 [1.14, 2.01]; P < 0.00001), hypertension (OR 1.66 [1.47, 1.88]; P < 0.00001, diabetes (OR 1.25 [1.08, 1.44]; P < 0.00001), other metabolic and endocrine comorbidities (OR 1.60 [1.40, 1.83]; P < 0.00001), psychiatric and neurological comorbidities (OR 1.62 [1.44, 1.82]; P < 0.00001), gut and urinary comorbidities (OR 1.91 [1.47, 2.49]; P < 0.00001),), cancer (OR 1.17 [1.10, 1.25]; P < 0.00001), and respiratory comorbidities (OR 5.60 [4.22, 7.44]; P < 0.00001) were significantly higher in the asthma patients in comparison with nonasthma controls.Asthma is associated with significantly higher comorbidities including cardio-/cerebrovascular diseases, obesity, hypertension, diabetes, psychiatric and neurological comorbidities, gut and urinary conditions, cancer, and respiratory problems other than asthma. Respiratory comorbidities are found 5 times more prevalent in asthma than in non-asthma patients.

Asthma in the elderly: a different disease?

KEY POINTS

Asthma in the elderly can be difficult to identify due to modifications of its clinical features and functional characteristics.Several comorbidities are associated with asthma in the elderly, and this association differs from that observed in younger patients.In clinical practice, physicians should treat comorbidities that are correlated with asthma (i.e. rhinitis or gastro-oesophageal reflux), assess comorbidities that may influence asthma outcomes (i.e. depression or cognitive impairment) and try to prevent comorbidities related to -'drug-associated side-effects (i.e. cataracts, arrhythmias or osteoporosis)."Geriatric asthma" should be the preferred term because it implies the comprehensive and multidimensional approach to the disease in the older populations, whereas "asthma in the elderly" is only descriptive of the occurrence of the disease in this age range.

EDUCATIONAL AIMS

To present critical issues in performing differential diagnosis of asthma in the elderly.To offer the instrument to implement the management of asthma in the most advanced ages. Asthma is a chronic airway disease that affects all ages, but does this definition also include the elderly? Traditionally, asthma has been considered a disease of younger age, but epidemiological studies and clinical experience support the concept that asthma is as prevalent in older age as it is in the young. With the ever-increasing elderly population worldwide, the detection and proper management of the disease in old age may have a great impact from the public health perspective. Whether asthma in the elderly maintains the same characteristics as in young populations is an interesting matter. The diagnostic process in older individuals with suspected asthma follows the same steps, namely a detailed history supported by clinical examination and laboratory investigations; however, it should be recognised that elderly patients may partially lose reversibility of airway obstruction. The correct interpretation of spirometric curves in the elderly should take into account the physiological changes in the respiratory system. Several factors contribute to delaying the diagnosis of asthma in the elderly, including the age-related impairment in perception of breathlessness. The management of asthma in advanced age is complicated by the comorbidities and polypharmacotherapy, which advocate for a comprehensive approach with a multidimensional assessment. It should be emphasised that older age frequently represents an exclusion criterion for eligibility in clinical trials, and current asthma medications have rarely been tested in elderly asthmatics. Ageing is associated with pharmacokinetic changes of the medications. As a consequence, absorption, distribution, metabolism and excretion of antiasthmatic medications can be variably affected. Similarly, drug-to-drug interactions may reduce the effectiveness of inhaled medications and increase the risk of side-effects. For this reason, we propose the term "geriatric asthma" be preferred to the more generic "asthma in the elderly".

Challenges in the pharmacological treatment of geriatric asthma

Asthma in older populations is characterized by frequent comorbid conditions, which increase the risk of side effects and of detrimental interactions between respiratory and non-respiratory drugs. These observations lead to the need to manage asthma in older populations by applying a multidimensional assessment and a multidisciplinary treatment; therefore, we favor the use of the 'geriatric' term to define asthma in the elderly. Geriatric asthma is a complex disease, which may not necessarily imply that it is also complicated, although the two conditions may often coexist. On this basis, the switch from an organ-driven management to the holistic approach may be the key factor to attain optimal control of the disease in this age range. The current review discusses the age-related factors affecting asthma treatment in the oldest individuals, such as the comorbid conditions, and age-related changes of metabolism and excretion that can impair the efficacy and safety of drugs.

Challenges in the management of severe allergic asthma in the elderly

Little is known about the features of asthma and allergy in the elderly. A significant number of elderly patients with asthma have uncontrolled and severe asthma. This review aims to provide an analysis of the literature on the assessment and phenotype of severe allergic asthma in the elderly. Gaps and pitfalls in diagnostic and therapeutic approaches, as well as management of severe allergic asthma in the elderly, are also discussed.

Challenges in the Management of Asthma in the Elderly

Recent literature has emphasized the clinical and socio-epidemiological significance of asthma in the elderly. However, why the disease burden remains high in this group is unclear. Elderly subjects usually have multiple chronic illnesses, and the role played by comorbidities in the context of asthma has been underappreciated. This review aims to summarize the literature associations between comorbidities and asthma in elderly patients. In addition, we discuss patient management issues.