Managing Asthma in Elderly Persons and Pregnant Women: Guidelines From the NIH

The special needs and concerns associated with the management of asthma in elderly persons and pregnant women are addressed in guidelines issued by the Expert Panel of the National Asthma Education and Prevention Program.¹ Highlights of those guidelines are presented here.

OLDER ADULTS

It is important to determine the extent of reversible airflow obstruction in elderly patients with asthma because of the high prevalence of other obstructive lung diseases, such as chronic bronchitis and emphysema. Careful evaluation is necessary because the precise cause of severe airflow obstruction can be difficult to establish. Consider a 2- to 3-week trial of systemic corticosteroid therapy to help detect significant reversibility of airway disease and to determine therapeutic benefit.

Because asthma medications may be associated with more adverse effects in elderly patients than in younger ones, the Expert Panel offers the following considerations:

•The response to bronchodilators may change with age. Older patients, especially those with preexisting ischemic heart disease, may also be more sensitive to side effects of ß₂-agonists, including tremor and tachycardia.

•Theophylline clearance is reduced in elderly patients. Furthermore, age is an independent risk factor for life-threatening events from chronic theophylline overdose. The potential for drug interaction—especially with antibiotics and H₂ antagonists—is higher because of the increased polypharmacy in this age group. Theophylline and epinephrine may exacerbate underlying heart conditions.

•Systemic corticosteroids can cause confusion, agitation, and changes in glucose metabolism.

•Inhaled corticosteroid use may be associated with a dose-dependent reduction in bone mineral content; low or medium doses are generally not associated with adverse events. Preexisting osteoporosis, changes in estrogen levels that affect calcium utilization, and a sedentary lifestyle may increase the risk in elderly patients, although the risk of inadequately controlled asthma may unnecessarily limit mobility and activities. Concurrent treatment with calcium supplements and vitamin D and bone-sparing medications (eg, bisphosphonates) is recommended.

•Medications being taken for other diseases may exacerbate asthma; dosages may need to be adjusted. NSAIDs used to treat arthritis, nonselective ß-blockers for hypertension, and ß-blockers found in some eye drops used for glaucoma may exacerbate asthma.

•The patient’s technique in using medications and devices should be observed. This is especially important in elderly patients because physical and cognitive impairments can make it difficult for them to learn and to consistently use the proper techniques.

PREGNANT WOMEN

Adequate control of asthma during pregnancy is crucial for the health and well-being of both the mother and her child. Maternal asthma increases the risk of perinatal mortality, preeclampsia, preterm birth, and low birth weight.

The Expert Panel offers the following recommendations for the treatment of asthma during pregnancy:

•Asthma status should be monitored during prenatal visits. The course of asthma improves for about one-third of women and worsens for about one-third of women during pregnancy.¹ Monthly assessments of asthma history and pulmonary function (preferably with spirometry, but measurement with a peak flow meter is usually sufficient) are recommended. This evaluation offers the opportunity to step down treatment, if possible, or to
increase treatment if necessary.

•The preferred short-acting ß₂-agonist is albuterol because it has an excellent safety profile and the most data related to safety during human pregnancy.

•Inhaled corticosteroids are the recommended long-term control medication. Budesonide is preferred because more safety data are available on its use in pregnant women than are available on other inhaled corticosteroids. Cromolyn has an excellent safety profile but has limited effectiveness compared with inhaled corticosteroids. Minimal published data are available on the use of leukotriene receptor antagonists during pregnancy; however, animal safety data are reassuring. Data are limited on the effectiveness and/or safety of long-acting ß₂-agonists during pregnancy, although these agents are likely to have a safety profile similar to that of albuterol, for which there are data related to safety during pregnancy.