What is the step-up therapy approach for older adults with asthma?

Step-Up Therapy for Older Adults with Asthma

For older adults with asthma requiring step-up therapy, add a long-acting beta-agonist (LABA) to low-to-medium dose inhaled corticosteroids (ICS) as the preferred approach, rather than simply increasing the ICS dose alone. This combination provides superior asthma control while minimizing corticosteroid-related adverse effects that are particularly concerning in elderly patients 1.

Algorithmic Approach to Stepping Up Therapy

Step 3: Moderate Persistent Asthma (First Step-Up)

Preferred Strategy:

• Add a LABA to low-to-medium dose ICS (e.g., fluticasone/salmeterol 100-250/50 mcg twice daily) 1
• This combination is supported by Evidence A and provides better outcomes than doubling ICS dose alone 1

Alternative Options (if LABA contraindicated or not tolerated):

• Increase ICS to medium-dose range as monotherapy 1
• Add leukotriene receptor antagonist (montelukast 10 mg daily) to low-to-medium dose ICS 1
• Add theophylline to low-to-medium dose ICS (requires serum level monitoring) 1

Step 4: Severe Persistent Asthma (Second Step-Up)

Preferred Strategy:

• Medium-to-high dose ICS plus LABA (e.g., fluticasone/salmeterol 250-500/50 mcg twice daily) 1
• Consultation with asthma specialist is recommended at this level 1

Alternative Options:

• Medium-dose ICS plus LABA plus leukotriene receptor antagonist 1
• Medium-dose ICS plus LABA plus theophylline 1

Step 5: Very Severe Persistent Asthma (Third Step-Up)

Preferred Strategy:

• High-dose ICS plus LABA 1
• Consider omalizumab (anti-IgE therapy) for patients with documented allergic asthma and elevated IgE levels 1
• Omalizumab reduces exacerbations with NNT of 6-12 and decreases need for oral/inhaled steroids 1

Step 6: Refractory Severe Asthma (Final Step-Up)

Preferred Strategy:

• High-dose ICS plus LABA plus oral corticosteroids (1-2 mg/kg/day, maximum 60 mg/day) 1
• Continue omalizumab if allergic component present 1

Before initiating oral corticosteroids, consider trial of:

• Adding tiotropium (long-acting anticholinergic) to high-dose ICS/LABA 2, 3
• Adding leukotriene receptor antagonist as third agent 1

Critical Considerations for Older Adults

Before Any Step-Up, Always Verify:

• Inhaler technique - improper technique is common in elderly patients and mimics poor control 1, 4
• Medication adherence - assess barriers including cost, cognitive function, dexterity 1, 4
• Environmental triggers - new exposures or inadequate control measures 1, 4
• Comorbid conditions - GERD, heart failure, COPD overlap can worsen symptoms 1, 4

Age-Specific Safety Concerns:

Corticosteroid-Related Risks (particularly relevant in elderly):

• Bone mineral density loss - assess baseline and monitor periodically with high-dose ICS 1
• Cataracts and glaucoma - consider ophthalmology referral with long-term ICS use 1
• Adrenal suppression - more likely with high doses; taper slowly if reducing therapy 1
• Oral corticosteroid complications - avoid if possible due to increased risk of osteoporosis, diabetes, hypertension in elderly 5

LABA Safety:

• Never use LABA as monotherapy - associated with increased mortality risk 4, 6, 7
• Always combine with ICS - this is an absolute requirement 4, 6, 8
• A landmark study demonstrated that switching from ICS to LABA monotherapy resulted in 24% treatment failure rate versus 6% with continued ICS, plus increased exacerbations and airway inflammation 7

Cardiovascular Considerations:

• Use beta-agonists cautiously in patients with cardiovascular disease, arrhythmias, or hypertension 1, 5
• Theophylline requires careful monitoring due to narrow therapeutic window and drug interactions common in elderly 1, 5

Emerging Evidence for Older Adults

Tiotropium as Add-On Therapy:

• Real-world data shows adding tiotropium to ICS/LABA reduces exacerbation risk by 35% compared to increasing ICS/LABA dose 2
• Decreases emergency department visits by 47% and hospitalizations by 48% 2
• May be particularly valuable in elderly patients to avoid escalating corticosteroid doses 2, 3

Budesonide/Formoterol Maintenance and Reliever Therapy (MART):

• Effective approach in elderly when age-related factors are properly managed 9
• Allows single inhaler for both maintenance and rescue use 9

Common Pitfalls to Avoid

1. Do not increase ICS dose beyond medium range without adding LABA first - combination therapy is more effective than high-dose ICS alone 1

2. Do not add a third long-term controller medication to ICS/LABA in severe asthma without specialist consultation - limited evidence supports this approach 1

3. Do not prescribe additional LABA-containing medications - risk of overdose when combining products 1, 8

4. Do not use short-acting beta-agonists more than 2 days/week for symptom relief - this indicates inadequate control requiring step-up 1

5. Do not assume symptoms are solely asthma - elderly patients may have cardiac disease, COPD, or other conditions mimicking asthma 5

Monitoring After Step-Up

• Reassess control in 2-6 weeks after any therapy change 1
• Use validated tools: Asthma Control Test, Asthma Control Questionnaire, or Asthma Therapy Assessment Questionnaire 1
• Measure FEV₁ or peak flow - values <60% predicted indicate very poor control 1
• Step down therapy if well-controlled for at least 3 months to find minimum effective dose 1