What is the recommended treatment for asthma in older adults?

Asthma Management in Older Adults

For older adults with asthma, treatment should follow a stepwise approach based on disease severity: intermittent asthma requires only as-needed short-acting beta-agonist (SABA) monotherapy, mild persistent asthma requires daily low-dose inhaled corticosteroids (ICS) with as-needed SABA (or alternatively as-needed ICS-SABA used concomitantly), and moderate-to-severe persistent asthma requires combination ICS plus long-acting beta-agonist (LABA) therapy. 1, 2, 3

Stepwise Treatment Algorithm

Step 1: Intermittent Asthma (Symptoms <2 days/week)

• Use as-needed SABA monotherapy only, typically albuterol 2 puffs every 4-6 hours when symptoms occur 2
• No daily controller medication is indicated at this severity level 2
• Critical monitoring parameter: SABA use frequency >2 days/week signals inadequate control and necessitates stepping up to daily ICS therapy 2, 3

Step 2: Mild Persistent Asthma (Symptoms ≥2 days/week)

• Preferred option: Daily low-dose ICS (200-250 μg/day beclomethasone equivalent) plus as-needed SABA 1, 3
• Alternative option for adherence concerns: As-needed ICS plus SABA used concomitantly (2-4 puffs albuterol followed by 80-250 μg beclomethasone equivalent every 4 hours as needed) 1, 3
• The intermittent ICS-SABA approach shows no differences in asthma control, quality of life, or exacerbation frequency compared to daily low-dose ICS 3, 4
• Leukotriene receptor antagonists (montelukast, zafirlukast) are less effective alternatives but may be considered for patients with compliance challenges 3, 5

Step 3-4: Moderate-to-Severe Persistent Asthma

• Add LABA to low-dose ICS rather than increasing ICS dose alone 1, 6, 3
• Combination low-to-medium-dose ICS/LABA provides superior symptom control, improved lung function, and reduced exacerbation rates 6
• For patients ≥12 years: ICS-formoterol (budesonide/formoterol) used as both maintenance and reliever therapy (SMART protocol) is strongly recommended over higher-dose ICS alone or same-dose ICS-LABA with separate SABA 1
• Critical safety warning: LABAs must never be used as monotherapy due to increased risk of asthma-related deaths; always combine with ICS 1, 6, 3, 7

Step 5: Severe Persistent Asthma

• Add long-acting muscarinic antagonist (LAMA) to ICS-LABA combination therapy 1
• For patients ≥12 years with uncontrolled asthma on ICS-LABA, adding LAMA provides additional efficacy 1

Age-Specific Considerations for Older Adults

• Pay particular attention to comorbidities that complicate asthma management in older adults, including COPD overlap, cardiovascular disease, and osteoporosis 3
• The fundamental stepwise approach remains appropriate regardless of age, but heightened vigilance for adverse effects is warranted 2, 3
• Assess bone mineral density initially and periodically with long-term ICS use 7
• Consider referral to ophthalmology for patients on long-term ICS therapy due to glaucoma and cataract risk 7

Optimal ICS Dosing Strategy

• Start with "standard daily dose" of 200-250 μg fluticasone propionate equivalent, which achieves 80-90% of maximum therapeutic benefit 8
• Moderate-to-high daily ICS doses (>200 μg) are associated with increased risk of major adverse cardiac events, arrhythmia, pulmonary embolism, and pneumonia 9
• Low-dose ICS (<200 μg daily) shows no association with adverse cardiovascular or pulmonary events 9
• Use the lowest effective ICS dose to minimize systemic adverse effects while maintaining control 9, 8

Critical Monitoring and Follow-Up

• Assess SABA use frequency at every visit—use >2 days/week indicates need to step up therapy 2, 3
• Evaluate medication adherence, inhaler technique, and environmental triggers at each encounter 3
• For patients on ICS therapy who are adherent, do not increase ICS dose during exacerbations, as controlled trials show no benefit 1
• Monitor for pneumonia in older adults on ICS therapy, particularly at higher doses 7, 9

Common Pitfalls to Avoid

• Failing to recognize SABA overuse (>2 days/week) as a signal for inadequate control requiring controller therapy 2, 3
• Prescribing daily controller medications for truly intermittent asthma, exposing patients to unnecessary side effects 2
• Using LABA monotherapy without concomitant ICS 1, 6, 3, 7
• Increasing ICS dose during exacerbations in adherent patients rather than optimizing baseline therapy 1
• Prescribing unnecessarily high ICS doses when standard doses (200-250 μg/day) provide near-maximal benefit 8

Allergen Mitigation and Adjunctive Therapies

• Routine allergen mitigation is not recommended without documented sensitization and symptom correlation 1
• For patients with confirmed allergen-related symptoms, use multicomponent allergen-specific interventions rather than single interventions 1
• Integrated pest management is conditionally recommended for patients with cockroach or rodent sensitization 1
• Subcutaneous allergen immunotherapy (SCIT) may be considered as adjunct therapy in patients ≥5 years with mild-to-moderate allergic asthma whose disease is controlled during all immunotherapy phases 1
• Sublingual immunotherapy (SLIT) is not recommended for asthma treatment 1
• Bronchial thermoplasty is not recommended outside of registry or research settings 1