What are the management options for an asthma exacerbation in a 65-year-old patient with diabetes (Diabetes Mellitus) and chronic leukopenia (low white blood cell count), who has been evaluated by hematology and is not considered a concern?

From the Guidelines

For a 65-year-old patient with asthma exacerbation who also has diabetes and chronic leukopenia, I recommend prompt treatment with a short-acting beta-agonist such as albuterol via nebulizer (2.5 mg every 20 minutes for 3 doses) or metered-dose inhaler with spacer (4-8 puffs every 20 minutes for 3 doses), followed by systemic corticosteroids, typically prednisone 40-60 mg daily for 5-7 days, as the benefit outweighs the risk despite the patient's leukopenia, according to the guidelines for managing asthma exacerbations 1.

The patient's chronic leukopenia, which has been evaluated by hematology and deemed not concerning, should not significantly alter the standard approach to asthma management. However, it is crucial to monitor for signs of infection, which could be a trigger for the exacerbation, and consider empiric antibiotics after appropriate cultures if necessary.

Key considerations in managing this patient include:

• Monitoring blood glucose closely during steroid treatment due to the patient's diabetes, as steroids can cause significant hyperglycemia, and temporary adjustment of diabetes medications may be necessary.
• Providing supplemental oxygen to maintain oxygen saturation ≥92%.
• Ensuring the patient has an appropriate controller medication regimen and asthma action plan for ongoing management after the acute exacerbation.

The guidelines for managing asthma exacerbations emphasize the importance of prompt treatment, close observation, and repeated measurement of lung function, with primary treatment consisting of administration of oxygen, inhaled beta2-agonists, and systemic corticosteroids, as outlined in the National Asthma Education and Prevention Program Expert Panel Report 3 guidelines 1.

In terms of long-term management, combination therapy with inhaled corticosteroids and long-acting inhaled beta2-agonists may be considered for moderate persistent asthma, as suggested by the guidelines for combination therapy 1. However, the immediate priority is managing the acute exacerbation effectively to prevent morbidity, mortality, and to improve the patient's quality of life.

From the FDA Drug Label

Patients enrolled in this trial were required to have at least 1 of the following 4 pre-specified criteria in the previous 12 months: blood eosinophil count ≥300 cells/mcL, sputum eosinophil count ≥3%, exhaled nitric oxide concentration ≥50 ppb, or deterioration of asthma control after ≤25% reduction in regular maintenance ICS/OCS Efficacy was assessed in Trials 1 and 2 using an endpoint of the frequency of exacerbations defined as worsening of asthma requiring use of oral/systemic corticosteroids and/or hospitalization and/or emergency department visits Compared with placebo, patients receiving NUCALA 100 mg or mepolizumab 75 mg IV experienced significantly fewer exacerbations

The patient has asthma exacerbation and chronic leukopenia. The label does not provide information on the use of mepolizumab in patients with leukopenia. However, the label does show that mepolizumab can reduce the frequency of exacerbations in patients with severe asthma.

• Key considerations:
  • The patient's leukopenia may increase the risk of infections, and the use of mepolizumab may need to be carefully evaluated in this context.
  • The patient's diabetes should also be considered when evaluating the use of mepolizumab, as corticosteroids can affect blood sugar levels.
• Clinical decision: The use of mepolizumab in this patient should be approached with caution, and the potential benefits and risks should be carefully evaluated. The patient's leukopenia and diabetes should be taken into account when making a decision. 2

From the Research

Asthma Exacerbation Management

• The management of asthma exacerbations in older adults, such as a 65-year-old patient with diabetes and leukopenia, requires careful consideration of the patient's comorbidities and age-related changes 3.
• Inhaled corticosteroids (ICS) are the cornerstone of therapy for asthma, and their use has been shown to decrease the risk of asthma exacerbations 4.
• The addition of long-acting beta2-agonists (LABA) to ICS has been shown to be effective in reducing exacerbations and improving lung function in patients with asthma 5, 6.

Considerations for Older Adults

• Older adults with asthma may have different symptoms and characteristics than younger patients, and may be more likely to have comorbidities that can affect their respiratory symptoms and treatment outcomes 3.
• The use of ICS and LABA in older adults with asthma should be individualized, taking into account the patient's age, comorbidities, and other factors that may affect their response to treatment 3, 7.

Treatment Options

• The use of combination inhalers containing ICS and LABA has been shown to be effective in improving asthma outcomes and reducing exacerbations 5, 6.
• The choice of ICS and LABA should be based on the patient's individual needs and response to treatment, as well as the potential for adverse effects and interactions with other medications 5, 7, 6.