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Diagnosis and management of asthma in older adults

Author: Sharmilee Maria Nyenhuis, MD, FAAAAI
Section Editors: Peter J Barnes, DM, DSc, FRCP, FRS, Kenneth E Schmader, MD
Deputy Editor: Paul Dieffenbach, MD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Feb 2023. | This topic last updated: Mar 16, 2023.
INTRODUCTION
Asthma is common in adults over age 65 years [1,2] and it substantially reduces both
psychologic and physical quality of life [2-5].
Some experts distinguish between older adults who previously had asthma in childhood or
early adulthood and those whose asthma is newly diagnosed at a more advanced age. The
diagnosis in the first category is usually reasonably clear. The diagnosis in the second category
may be challenging due to the higher incidence of chronic obstructive pulmonary disease
(COPD) and the longer list of differential diagnoses. We find these two categories helpful for the
discussion of the disease but acknowledge their limitations. The clinical course may be more
complex; for example, childhood asthma usually remits in adolescence but often reappears
later in adulthood. The therapeutic approach is the same in both categories.
The clinical manifestations, evaluation, and management of asthma in older adults will be
reviewed here. General topics on the evaluation, diagnosis, and management of asthma and
COPD are discussed separately.
● (See "Asthma in adolescents and adults: Evaluation and diagnosis".)

● (See "An overview of asthma management".)
● (See "Chronic obstructive pulmonary disease: Diagnosis and staging".)
● (See "Stable COPD: Initial pharmacologic management".)
The United States Centers for Disease Control and Prevention (CDC) have identified older adults
and persons with moderate to severe asthma as a potential at-risk group for severe illness in
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response to coronavirus disease 2019 (COVID-19; severe acute respiratory syndrome

coronavirus 2 [SARS-CoV-2]) [6]. Maintaining good asthma control and obtaining proper
vaccination are essential to reduce this risk. Additional details are discussed separately.
● (See "An overview of asthma management", section on 'Advice related to COVID-19

pandemic'.)
● (See "COVID-19: Questions and answers".)
EPIDEMIOLOGY
The prevalence of asthma in adults age 65 years and older is estimated at 4 to 8 percent [7,8]
compared with a prevalence of approximately 8 percent in all adults [9]. A separate report
estimated that over two million persons with asthma are aged ≥65 years, with this number
expected to rise to more than five million by 2030 [7,10]. The epidemiology of asthma in general
is discussed separately. (See "Epidemiology of asthma".)
RISK FACTORS AND TRIGGERS
Potential risk factors and triggers for asthma in older adults are generally similar to asthma
triggers in other age groups [11-17]. It is worthwhile to ask older patients with asthma about
triggers ( table 1) because more than one-third of older patients with asthma report exercise-
induced asthma symptoms; half report that animal contacts or exposure to dusts or fumes
trigger their respiratory symptoms; and over two-thirds report seasonal worsening [2,18].
Asthma risk factors and asthma triggers are discussed in greater detail separately. (See "Risk
factors for asthma" and "Trigger control to enhance asthma management".)
Specific risk factors and triggers that are common and well-studied in older populations
include:
● Atopy – Despite a decline in prevalence of atopic symptoms, immunoglobulin E (IgE)

levels, and positive allergen skin tests from childhood to older age [19], about one-fourth
of older adults have at least one positive allergen skin test and about three-fourths of
older patients with asthma are allergic to one or more common indoor allergens (eg,
cockroach, cat, dog, mites) [5,20,21].
Older, as well as younger, adults with high levels of total IgE or specific IgE to cat or mite
antigens are more likely to have bronchial hyperresponsiveness (BHR) or to develop BHR
during two to three years of follow-up [22,23]. Older patients with asthma who have
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become sensitized to cockroach have more severe asthma and may experience a faster
subsequent decline in lung function [24,25]. In Sweden and Finland, indoor dampness and
mold growth are risk factors for adult-onset asthma [26,27].
● Tobacco use – Up to half of older people with a diagnosis of asthma are current or former
smokers [2]. Tobacco smoking is not a major risk factor for development of asthma in
older adults but can contribute to worsened control. Cigarette smoking is the major cause
of chronic obstructive pulmonary disease (COPD) and emphysema but also increases
production of IgE antibodies, bronchial responsiveness, and production of inflammatory
markers in the sputum in older adults with asthma [28].
● Occupational, residential, and ambient air exposures – Cumulative airborne exposures

may also increase the risk of asthma in older adults. For example, wood burning stoves
and smoke from indoor use of biomass fuels (eg, wood, agricultural waste) are associated
with the development of asthma in adults [12,26,29].
Increases in outdoor air pollution, especially particulate matter, have been associated with
asthma exacerbations and increased hospital admissions for respiratory disorders [30-37].
In a study of the respiratory effects of air pollution in older adults, daily hospital
admissions for asthma were highly associated with increases in NO2 and SO2 in the cool
seasons and increases in black smoke year-around [38]. Ozone levels may also contribute
to the development of asthma in older adults [29].
Among adults with asthma, about one-fourth have work-related asthma [39-41]. Exposure
to dusts, gas, vapors, fumes, or sensitizers is also associated with asthma [41]. (See
"Occupational asthma: Definitions, epidemiology, causes, and risk factors".)
● Medications – Certain medications used to treat hypertension, coronary heart disease,

glaucoma, and arthritis (eg, topical or systemic beta blockers, aspirin, or nonsteroidal anti-
inflammatory drugs [NSAIDs]) can exacerbate underlying asthma [42-44]. The risk of
adult-onset asthma also increases among females taking postmenopausal hormone
replacement therapy [45,46]. Discontinuing the triggering medications may lead to
improved asthma control.
CLINICAL MANIFESTATIONS
The asthma symptoms of intermittent wheeze, cough, and chest tightness are no different in
older persons than in younger persons, but older individuals are less likely to report dyspnea
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related to airflow limitation [47-49]. This may be the result of adaptation to the long-term
presence of symptoms or lower health expectations [50].
Clues to the presence of asthma include symptoms of allergic disease (eg, nasal congestion,
rhinorrhea, sneezing, and ocular itching) or nasal polyposis (eg, nasal congestion, anosmia,
nonsteroidal anti-inflammatory drug [NSAID] sensitivity). Chronic cough may be suggestive of
asthma in nonsmoking older patients [51]. Like most patients with asthma, older patients with
asthma seen in the outpatient setting usually have a normal chest exam. Pale edematous nasal
mucosa and/or the presence of nasal polyps increase the likelihood of concomitant asthma.
(See "Asthma in adolescents and adults: Evaluation and diagnosis", section on 'Clinical
features'.)
EVALUATION
The diagnosis of asthma generally requires pulmonary function testing to establish the
presence of variable airflow obstruction. Pulmonary function testing, including spirometry with
bronchodilator reversibility and methacholine challenge testing (MCT), is reliable in older adults.
Home peak flow monitoring is not usually employed due to both measurement lability and
unreliability in older patients as well as its relatively poor predictive power for the diagnosis of
asthma [52-54]. (See "Peak expiratory flow monitoring in asthma".)
Chest radiographs are typically obtained to rule out alternative diagnoses. Laboratory studies,
such as skin or serologic tests for allergy, are helpful in selected patients.
Pulmonary function testing — This section focuses on the use of pulmonary function tests
(PFTs) in older adults; PFTs are discussed in more detail separately. (See "Overview of pulmonary
function testing in adults" and "Pulmonary function testing in asthma".)
Spirometry with bronchodilator response — Since older patients often have few physical
signs of asthma and have a high pretest probability of chronic obstructive pulmonary disease
(COPD), spirometry before and after bronchodilator administration should be performed for all
patients with a history of dyspnea, chronic cough, reduced exercise tolerance, or asthma-like
symptoms [4,55-57]. However, because airflow limitation in asthma is intermittent and variable,
the absence of airflow limitation on a given day does not rule out the diagnosis.
Despite concerns that frailty or decreased cognitive function would impair performance, the
majority of older individuals are able to perform spirometry reliably with standard office
spirometers [58-61]. For those who are highly physically frail, adequacy of spirometry can be
less clear. There is a need to develop age-appropriate criteria regarding adequacy of
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spirometric test performance, as well as validation of alternative approaches, such as

oscillometry, for measuring lung function in this population [62]. (See "Office spirometry",
section on 'Equipment'.)
Airflow obstruction is characterized by a reduced ratio of forced expiratory volume in one

second (FEV1) to forced vital capacity (FVC). Because this ratio normally declines with age,
airflow limitation is defined by an FEV1/FVC ratio below the lower limit of normal (ie, less than
5th percentile or z-score <-1.645) using equations that normalize for age, sex, and height [63].
(See "Asthma in adolescents and adults: Evaluation and diagnosis", section on 'Diagnosis' and
"Overview of pulmonary function testing in adults", section on 'Spirometry' and "Overview of
pulmonary function testing in adults", section on 'Asthma'.)
While we advocate use of this definition for the diagnosis of all obstructive lung disease in older
adults, a definition of COPD based on a fixed postbronchodilator FEV1/FVC ratio <0.7 is still
suggested by some guidelines [57].
Once the presence of airflow limitation has been identified by a reduced FEV1/FVC ratio, the
FEV1 is used to determine the severity of the underlying obstruction ( algorithm 1). Use of the
recommended reference equations from the Global Lung function Initiative (GLI) are
particularly helpful in older adults due to their broad applicability (the age range has been
extended to 95 years compared with previous versions) [63,64]. Future work expanding the
sample sizes for those over age 75 to 80 years may further improve reference values [64]. (See
"Office spirometry", section on 'Interpretation' and "Selecting reference values for pulmonary
function tests".)
Although the presence of airflow limitation increases suspicion for asthma, bronchodilator
testing may greatly increase diagnostic certainty by ruling out other obstructive diseases
generally characterized by more fixed obstruction (eg, COPD, bronchiolitis obliterans,
bronchiectasis, and central airway obstruction). In patients with asthma, older age does not
alter the acute response to inhaled bronchodilator (BD) drugs [65,66]. The probability of asthma
is increased if the postbronchodilator FEV1 increases by more than 10 percent of its predicted
value [67]. Additionally, if the postbronchodilator FEV1 and ratio improve from obstruction into
the normal range, then the probability of asthma is greatly increased and COPD is by definition
ruled out. (See "Overview of pulmonary function testing in adults", section on 'Post-
bronchodilator'.)
Bronchoprovocation testing, if spirometry is normal — Bronchoprovocation testing, such

as an MCT, can occasionally be helpful in the differential diagnosis of dyspnea and cough in
older patients with normal spirometry who are not taking asthma medications [47,66,68].
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Having wheezing or coughing due to allergens has been shown to be an independent predictor
of a positive MCT in older adults with asthma [69]. With normal baseline spirometry, side effects
from MCTs are rare, even in older persons.
A low provocative methacholine concentration causing a 20 percent decline in FEV1 (PC-20) from
the MCT increases the probability of asthma in patients with asthma-like symptoms. The
prevalence of bronchial hyperresponsiveness (BHR) is higher in older compared with middle-
aged adults, even after correcting for the baseline degree of airways obstruction, smoking
status, and atopy [47]. Therefore, a PC-20 threshold of <4 mg/mL to define BHR in older patients
may be more appropriate than the traditional <8 mg/mL. (See "Bronchoprovocation testing",
section on 'Methacholine'.)
Assessment of atopy — We suggest assessing older adults with persistent asthma for
sensitivity to indoor allergens with either allergen skin testing or serologic testing. Conversely,
we do not typically perform such testing in mild or easily controlled disease. (See "Overview of
skin testing for IgE-mediated allergic disease" and "Overview of in vitro allergy tests".)
Among patients with symptoms of exertional dyspnea, cough, or wheeze, the presence of atopy
makes asthma more likely than COPD [70]. In one study, the rate of atopy was 37 percent
among patients with asthma and 8 percent among those with COPD [70]. Although the atopy
rate of the general population declines from middle age (30 percent) to older age (8 percent)
[19], about three-fourths of older patients with asthma have a positive allergen skin test to
aeroallergens, and about one-fourth of those with a cat or dog become sensitized to their pet
[5]. In another study, half of older patients with asthma living in urban areas were sensitized to
cockroach antigen, and this sensitivity was associated with more severe airways obstruction
and hyperinflation [24]. In addition, knowledge of the allergens to which a patient is sensitized
can help guide mitigation efforts.
Imaging — The chest radiograph is almost always normal in patients with asthma. However, a
chest radiograph is indicated when evaluating older adults for symptoms suggestive of new-
onset asthma to exclude alternative diagnoses. (See "Asthma in adolescents and adults:
Evaluation and diagnosis", section on 'Imaging'.)
DIAGNOSIS
Confirmation of the diagnosis of asthma in older adults is based on the presence of respiratory
symptoms suggestive of asthma and the demonstration of variable expiratory airflow
obstruction on pulmonary function testing in the absence of competing diagnoses. Variability in
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airflow obstruction may be apparent from measurements made at different points in time, in
response to an asthma trigger, or after asthma therapy. As an example, a patient's forced
expiratory volume in one second (FEV1) might vary from one visit to the next, before and after
inhalation of methacholine, or before and after inhaled bronchodilator. (See "Asthma in
adolescents and adults: Evaluation and diagnosis" and "Pulmonary function testing in asthma".)
DIFFERENTIAL DIAGNOSIS
The differential diagnosis of intermittent respiratory symptoms in older adults in many cases is
more difficult than in younger adults due to the higher prevalence of nonasthma conditions
among older patients with dyspnea ( table 2).
The three most common causes of chronic or intermittent dyspnea in older adults are chronic
obstructive pulmonary disease (COPD) and emphysema, heart failure (HF), and asthma [71].
(See "Approach to the patient with dyspnea", section on 'Initial testing in chronic dyspnea'.)
COPD and emphysema versus asthma — Differentiating COPD and emphysema from asthma
can be difficult; COPD and asthma may also coexist in some patients. The pretest probability of
COPD and emphysema in a patient with a substantial (particularly past) smoking history is
much higher than for asthma; in contrast, atopic symptoms and allergic rhinitis are suspicious
for asthma.
On pulmonary function testing, airflow limitation that is significantly or completely reversible

with inhaled bronchodilator favors a diagnosis of asthma. However, many patients with COPD
have significant reversibility to inhaled bronchodilators (BDs) and some patients with
emphysema by computed tomography (CT) scan may have complete reversibility and/or no
airflow limitation. In current or former smokers with airflow limitation but without a large BD
response, a low diffusing capacity (DLCO) strongly suggests COPD and emphysema rather than
asthma [72,73]. Similarly, former or current smokers who carry the diagnosis of asthma but
have a reduced DLCO, hyperinflation on their chest radiograph, or hyperinflation on lung
volume testing may benefit from cross-sectional imaging to evaluate for emphysema [74]. (See
"Chronic obstructive pulmonary disease: Diagnosis and staging".)
Asthma and COPD overlap — While a formal definition has not been agreed upon, asthma and
COPD overlap is described as being "characterized by persistent airflow limitation with several
features usually associated with asthma and several features usually associated with COPD"
[75]. Recognizing such patients may help guide therapeutic choices and potentially identify the
need for a comprehensive geriatric assessment. (See "Asthma and COPD overlap (ACO)".)
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Investigations using standard epidemiologic definitions of obstructive airways disease and data
on a large sample of participants from the Medical Expenditure Panel Survey (United States)
have shown that a substantial proportion of persons aged 65 to 85 years (37 percent) meet the
description of asthma-COPD overlap [76]. Furthermore, compared with either COPD or asthma
alone, asthma-COPD overlap was significantly associated with increased mobility impairment
and health care utilization, suggesting that these patients may particularly benefit from
comprehensive geriatric assessment and management. (See 'Monitoring the geriatric patient'
below.)
Heart failure versus asthma — The differentiation of heart failure (HF) from asthma in the
ambulatory setting may be challenging, particularly when the disease is mild. It is also not
uncommon for older patients to suffer from both asthma and heart failure concomitantly.
Objective evidence of elevated jugular venous pressure, S3, peripheral edema, and vascular
congestion on chest radiograph all increase the probability of HF. Systolic dysfunction on
echocardiography makes the diagnosis of HF; signs of diastolic dysfunction (eg, increased E/A
ratio) on echocardiography are less definitive as they can be positive in states of left ventricular
underfilling due to low preload pressure, for example, from COPD and emphysema [77], among
other diagnoses. Evidence of airflow obstruction on spirometry defines obstructive airways
disease. (See 'Spirometry with bronchodilator response' above.)
Cardiovascular disease in ambulatory older persons usually causes only a mild reduction in the
forced expiratory volume in one second (FEV1) and forced vital capacity (FVC) of approximately
0.1 to 0.3 liters [78]. Substantial airflow limitation in a patient presenting to the emergency
department or in the hospital is much more likely due to asthma or COPD than HF [79]. (See
"Determining the etiology and severity of heart failure or cardiomyopathy".)
In patients with acute dyspnea, chest radiograph and measurement of B-type natriuretic
peptide (BNP) may also help differentiate these entities. (See "Approach to the adult with
dyspnea in the emergency department", section on 'Plain chest radiograph'.)
Other — Restrictive lung disease, pulmonary vascular disease, bronchiectasis, and upper
airway obstruction can also present with symptoms that mimic asthma ( table 2).
Consideration of these diseases in the context of a potential diagnosis of asthma is discussed
separately. (See "Asthma in adolescents and adults: Evaluation and diagnosis", section on
'Differential diagnosis'.)
TREATMENT
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Successful management of asthma in older adults is based on four essential components

(education, control of asthma triggers, monitoring, and pharmacologic therapy) used for
management of asthma at all ages. The comments below outline considerations that
specifically pertain to older adults; a general approach to asthma management is provided
separately. (See "An overview of asthma management".)
Patient education and adherence — Asthma education includes communicating the features
and mechanism of asthma, the appropriate role and use of asthma medications, and measures
to treat and prevent symptoms. As with younger patients, a written asthma action plan is
important to achieve optimal care [80-82]. (See "Asthma education and self-management".)
Some older patients have difficulty learning correct inhaler technique, which is essential for
optimal efficacy of inhaled medications. Observation of the patient’s technique is a key step in
ensuring that the patient is using inhalers properly. Cognitive impairment, which can be
established by a number of screening tests, predicts difficulty learning and retaining inhaler
technique [83-87]. Alternatively, simply requiring patients to "teach back" inhaler technique may
identify those with difficulty performing multistep commands [87]. Cognitive impairment often
leads to uncoordinated "press and breathe" use of inhalers as well as nonadherence [87]. (See
"Mental status scales to evaluate cognition" and "Evaluation of cognitive impairment and
dementia".)
Use of a hydrofluoroalkane (HFA) pressurized metered dose inhaler (MDI) with a valved holding
chamber, a breath-actuated dry powder inhaler, or a nebulizer may improve medication
delivery when technique is suboptimal [88,89]. (See "Delivery of inhaled medication in adults"
and "The use of inhaler devices in adults".)
Other health conditions may also impact asthma medication adherence, such as arthritis
leading to difficulty in the handling of inhalers, particularly metered dose inhalers (MDIs)
[90,91]. Further, older adults have lower inspiratory flow rates and may not be able to achieve
the higher inspiratory flow rates required for some dry powder inhalers [90]. The use of an
inspiratory flow meter may help in determining the appropriate inhaler type [92].
Control of asthma triggers — Allergen avoidance and mitigation (efforts to reduce indoor
allergen levels) is beneficial in children and is also recommended in adults, including older
adults ( table 3). (See "Trigger control to enhance asthma management".)
Cigarette smoke is an airway irritant, and smoking cessation is associated with improvement in
lung function [93]. (See "Trigger control to enhance asthma management", section on 'Irritants
(including cigarette smoke)' and "Overview of smoking cessation management in adults" and
"Pharmacotherapy for smoking cessation in adults".)
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Infectious triggers can be mitigated through reducing exposure (eg, handwashing, judicious
face mask use) and recommended vaccinations for older adults (eg, influenza, pneumococcus,
and COVID-19). (See "Pneumococcal vaccination in adults" and "Seasonal influenza vaccination
in adults" and "COVID-19: Vaccines".)
Monitoring the geriatric patient — Among older persons, apparent changes in asthma
control may result from comorbidities, polypharmacy, psychosocial changes, or geriatric health
conditions; conversely, other changes in clinical status may be consequences of under-
recognized worsening of asthma control.
Older persons often require a comprehensive geriatric assessment due to the their complex
clinical presentations [94]. Advancing age is associated with increased multimorbidity (62
percent of older Americans have two or more chronic conditions), medication-related adverse
effects (20 to 30 percent of older Americans use medications listed in drugs-to-avoid lists),
psychosocial factors (less education, sedentary lifestyle, social isolation), geriatric health
conditions (cognitive and sensory impairments, falls, incontinence, weight loss, dizziness, etc),
and reduced symptom awareness [47-50,94-100].
Training to estimate peak flow, followed by peak flow monitoring feedback and motivational
interviewing, may be able to improve underperception of airflow obstruction in older patients
[101].
Otherwise, routine monitoring of asthma control, lung function, exacerbations, inhaler

technique, adherence, medication adverse effects, quality of life, and patient satisfaction with
care is similar to that in other adult patients. (See "An overview of asthma management",
section on 'Follow-up monitoring'.)
Pharmacologic management — The National Asthma Education and Prevention Program

(NAEPP) and the Global Initiative for Asthma (GINA) recommend starting with a determination
of asthma severity to guide initial therapy ( table 4) [102,103]. The goal is to control
symptoms quickly and subsequently adjust therapy in a stepwise fashion as symptoms and
pulmonary function require. All patients should have access to a "quick-relief" fast-acting beta-
agonist. In addition, patients with frequent symptoms or exacerbations are candidates for
maintenance therapies, of which inhaled glucocorticoids are the initial preferred agent. (See "An
overview of asthma management", section on 'Initiating pharmacologic treatment'.)
Asthma therapy is adjusted using a stepwise approach ( table 4) based upon an assessment
of asthma control ( table 5) and any adverse effects of medications. The degree of asthma
control is determined by the most severe indicator of impairment ( table 5). Assessing asthma
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control is discussed in more detail separately. (See "An overview of asthma management",
section on 'Adjusting controller medication'.)
When asthma is not well-controlled, possible causes of poor adherence should first be
considered, such as the cost of the inhalers, difficulty using the inhaler, increased exposure to
triggers, depression, or worries about steroid side effects [104-106]. (See "Enhancing patient
adherence to asthma therapy", section on 'Reasons for nonadherence'.)
In general, management is not different for older versus younger adults. However, multiple
combinations of agents are reasonable for different tiers of therapy ( table 4), some of which
may be more useful in older patients. Specific considerations in older adults include:
● Inhaled glucocorticoid side effects – In older adults, we generally prefer to add a long-
acting beta-agonist (LABA), tiotropium, or an antileukotriene agent as step-up therapy
while maintaining a lower dose of inhaled glucocorticoids (GCs) to reduce the risk of
inhaled GC side effects ( table 4). Use of this approach is particularly helpful in those
with certain common comorbidities (eg, hoarseness, osteoporosis, or glaucoma).
High daily doses of inhaled GCs may decrease bone mineral density and increase the risk
of fracture, although data are conflicting [107-109]. To decrease the effects of
corticosteroids on bone resorption, patients should be encouraged to exercise (if
possible), avoid excess alcohol intake, and obtain a healthy dietary intake of calcium and
vitamin D [110]. Older adults on chronic therapy with inhaled GCs who have a moderate
risk of osteoporosis should undergo bone density measurement to assess the need for
preventive therapy. (See "Screening for osteoporosis in postmenopausal women and men"
and "Prevention and treatment of glucocorticoid-induced osteoporosis", section on
'General measures' and "Major side effects of inhaled glucocorticoids".)
In addition to effects on bone density, inhaled GCs are a common cause of oral candidiasis
and hoarseness in older adults, which can be mitigated by careful oral rinsing after use of
the inhaled GC. For hoarseness, sometimes use of a smaller particle size agent, such as
beclomethasone HFA rather than a fluticasone dry powder inhaler, can reduce laryngeal
deposition and dysphonia. (See "Major side effects of inhaled glucocorticoids".)
● Cardiovascular effects of beta-agonists – Although beta-agonists can increase heart rate

and reduce serum potassium concentration, they have generally been found to be safe in
older adults. For patients with known cardiovascular disease, especially atrial fibrillation,
we prefer to try a higher dose of inhaled GCs or an add-on antileukotriene agent to
achieve control before starting a LABA ( table 4).
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Among 12,090 patients age 55 years or older with chronic obstructive pulmonary disease
(COPD), beta-agonists were not associated with an increase in the risk of fatal or nonfatal
myocardial infarction [111]. Except for formoterol administration as part of single
maintenance and reliever therapy (SMART), fast-acting beta-agonists should be used only
when needed. Scheduled dosing does not confer additional benefit. (See "Treatment of
moderate persistent asthma in adolescents and adults", section on 'Reliever medications'.)
The safety of LABAs in older adults with asthma has not been directly assessed in large
groups of patients [112]. The most reassuring data regarding cardiovascular safety of
LABAs come from studies of older adults with COPD. As an example, patients with COPD
experience no greater morbidity when using salmeterol with fluticasone compared with
fluticasone alone. (See "Management of the patient with COPD and cardiovascular
disease", section on 'Long-acting beta agonists' and "Management of the patient with
COPD and cardiovascular disease", section on 'Combination inhaled bronchodilator plus
glucocorticoid'.)
● Reducing oral glucocorticoid exposure – Chronic prednisone therapy has multiple

potential side effects in older patients, especially older females, including hip and
vertebral fractures, cataracts, poor glycemic control, and herpes zoster [107]. We prefer
short courses (five to seven days) of oral GCs and avoidance of long-term therapy except
as a last resort. (See "Major side effects of systemic glucocorticoids" and "Screening for
osteoporosis in postmenopausal women and men" and "Prevention and treatment of
glucocorticoid-induced osteoporosis" and "Acute exacerbations of asthma in adults: Home
and office management" and "Acute exacerbations of asthma in adults: Emergency
department and inpatient management", section on 'Systemic glucocorticoids'.)
● Efficacy of biologic therapies in the older population – Anti-IgE, anti-interleukin (IL) 4,

anti-IL5/anti-IL5 receptor, and anti-thymic stromal lymphopoietin biologic therapies have
been found to reduce asthma exacerbations by approximately 50 percent in patients with
poorly controlled asthma despite maximal inhaled therapies. (See "Treatment of severe
asthma in adolescents and adults", section on 'Persistently uncontrolled asthma' and
"Anti-IgE therapy".)
Although these trials included some patients between the ages of 65 and 75 years, most
patients studied were middle-aged adults, making the risks and benefits less certain in the
older population. Mechanistically, there are physiologic changes in the immune system of
older persons that could impact biologic agent effectiveness. For example, age-associated
changes in eosinophils include decreased degranulation in response to IL-5 stimulation,
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and sputum cellularity is generally more neutrophilic in older versus younger patients with
asthma [113]. The implications of these changes remain uncertain.
Anti-IgE therapy, the oldest of the biologic agents, has been studied most extensively and
appears to have similar efficacy in older and younger populations. One study found that
patients age 50 years or older, compared with younger patients, experienced a
comparable reduction in exacerbation rate (69 versus 75 percent), slightly less of an
improvement in asthma symptoms and nocturnal awakenings (68 and 73 percent in the
older versus 79 and 82 percent in the younger patients), and a similar improvement in
lung function [114]. There was a higher rate of discontinuation of omalizumab therapy in
older patients (21 versus 11 percent). In a pooled analysis of placebo-controlled trials,
participants age 50 years and older on anti-IgE therapy showed reduced risk of asthma
exacerbations, improved asthma symptom scores, and reduced rescue medication use
compared with placebo [115].
The adverse effects associated with omalizumab have not been specifically examined in
older adults. Typical adverse effects of anti-IgE therapy are discussed separately. (See
"Anti-IgE therapy", section on 'Adverse effects'.)
Specific data on the benefits and adverse effects of other biologic agents in older
populations are lacking, but they are under active investigation.
● Theophylline toxicity – Theophylline is not suggested for treatment of asthma in most

older adults due to variable metabolism and multiple medication interactions. Chronic
overmedication with theophylline causes major toxic events, including death [116]. (See
"Theophylline poisoning" and "Theophylline use in asthma", section on 'Safe use of
theophylline'.)
PROGNOSIS
Adult-onset asthma is more likely to become life-long and to have morbidity when compared
with asthma beginning in childhood [11,117]. Compared with younger adults with asthma,
older adults have more hospitalizations, more comorbidities, and poorer lung function [117-
120]. In a large United States database examined from 2006 to 2008, older adults with asthma
had a fivefold increased risk of overall mortality compared with younger adults with asthma
even after adjustment for comorbidities [120]. However, a six-year observational study of 4756
patients with asthma, The Epidemiology and Natural History of Asthma: Outcomes and
Treatment Regimens (TENOR) study, reported that the hospitalization rate was actually lower
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among the cohort age 65 years and older than the younger cohort [80]. The explanation for the
lower hospitalization rate may have been more aggressive asthma care among the older adults
in this supervised population, suggesting that optimizing asthma care has the potential to
improve outcomes.
SOCIETY GUIDELINE LINKS
Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Asthma in adolescents
and adults" and "Society guideline links: Severe asthma in adolescents and adults".)
SUMMARY AND RECOMMENDATIONS
● Epidemiology – Asthma is common in adults over age 65 years. Some patients will have
had asthma since childhood and others may have developed asthma as adults. Asthma is
less likely to resolve spontaneously in older adults. (See 'Epidemiology' above.)
● Risk factors and triggers – Atopy remains a common finding on skin testing in older
adults. Smoking, animal dander, and occupational exposures are common asthma triggers
in this population. (See 'Risk factors and triggers' above and 'Assessment of atopy' above
and "Trigger control to enhance asthma management".)
● Evaluation, diagnosis, and differential diagnosis
• Spirometry, bronchodilator response, and methacholine responsiveness are accurate in

most older adults. (See 'Spirometry with bronchodilator response' above and
'Bronchoprovocation testing, if spirometry is normal' above and "Asthma in
adolescents and adults: Evaluation and diagnosis", section on 'Diagnosis'.)
• Distinguishing asthma from chronic obstructive pulmonary disease (COPD) is a

common diagnostic challenge in older patients with intermittent dyspnea. Diffusing
capacity, lung volume measurement, and chest CT (in selected patients) may help to
differentiate these conditions. Asthma and COPD overlap is not uncommon, although
definitions vary. (See 'Pulmonary function testing' above and 'COPD and emphysema
versus asthma' above and 'Asthma and COPD overlap' above and "Asthma and COPD
overlap (ACO)".)
3/29/23, 12:02 PM 521
● Differences in the management of asthma in older persons – Successful management

of asthma in all patients is based on four essential components (education, control of
asthma triggers, monitoring, and pharmacologic therapy). (See "An overview of asthma
management".)
The comments below outline considerations that specifically pertain to older adults:
• Inhaler technique and adherence – Some older patients have difficulty learning
correct inhaler technique or develop difficulties with technique or adherence due to
cognitive impairment. Older adults also may not be able to activate some dry powder
inhalers due to low inspiratory flow rates. (See 'Patient education and adherence'
above.)
• Vaccination against respiratory illnesses – Older persons with asthma are at

increased risk for poor outcomes after infection with influenza, pneumococcus, and
COVID-19 and should receive vaccination against these pathogens. (See 'Control of
asthma triggers' above.)
• Monitoring the geriatric patient – Monitoring in older persons frequently includes a

comprehensive geriatric assessment due to multiple comorbid conditions,
deconditioning, nutritional status, and/or polypharmacy. (See 'Monitoring the geriatric
patient' above.)
• Pharmacologic management – The pharmacologic management of asthma in older

persons should be in concordance with international guidelines, which advise initial
therapy based on asthma severity ( table 4) followed by a stepwise adjustment
( table 4) based on asthma control ( table 5). (See 'Pharmacologic management'
above.)
Special considerations in older patients include:
- In older patients with poorly controlled asthma, we generally prefer to add a long-
acting beta-agonist (LABA), tiotropium, or an antileukotriene agent as step-up
therapy while maintaining a lower dose of inhaled glucocorticoids (GCs). This
strategy reduces the risk of inhaled GC side effects, some of which are more
common in older persons. Use of this approach is particularly helpful in those with
certain comorbidities (eg, hoarseness, osteoporosis, or glaucoma). (See
'Pharmacologic management' above and "Major side effects of inhaled
glucocorticoids".)
3/29/23, 12:02 PM 521
- For older patients with poorly controlled asthma and known cardiovascular
disease, especially atrial fibrillation, we prefer to use an add-on leukotriene or a
moderate dose of inhaled GCs to achieve control before starting a LABA.
- We minimize exposure to oral GCs and do not use theophylline in older patients
due to an increased risk of adverse effects.
- While anti-IgE therapy (omalizumab) appears to have comparable efficacy in older

adults who meet the usual indications, the specific risks and benefits of other
biologic agents in the older population require further study.
ACKNOWLEDGMENTS
The UpToDate editorial staff acknowledges Paul Enright, MD, R Graham Barr, MD, DrPH, and
Carlos A Vaz Fragoso, MD, who contributed to earlier versions of this topic review.
Use of UpToDate is subject to the Terms of Use.
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Topic 521 Version 30.0
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GRAPHICS
Questions to help identify asthma triggers*
Allergen exposures
Do you have asthma symptoms year-round or only certain times of year?
Do you have pets? Or birds? Are they indoors or outdoors most of the time?
Have you seen cockroaches at home/school/work in the past month? How about rodents?
Is there moisture, dampness, moldy odor, or visible mold in your home? ¶
For patients who live in dry climates, do you use an evaporative cooler (also known as a swamp
cooler)? These coolers are associated with increased humidity and increased mold/dust mites.
Do your asthma symptoms get worse during pollen seasons (eg, tree pollen in early spring in New
England) or more humid times of year (suggests molds and dust mites)?
Have you ever had allergy skin or IgE testing? If so, do you have the results?
Irritant exposures
Do you smoke cigarettes? If so, how many/day and how long have you smoked?
Does anyone at home/work/daycare smoke?
Do you smoke cannabis (marijuana), use electronic cigarettes, or vape?
Do you use a wood-burning stove or fireplace at home?
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Do you have any unvented/open fire stoves or heaters at home?
Are you exposed regularly to smells or fumes from perfumes, cleaning agents, or sprays?
Work and school

Do you cough, wheeze or need your inhaler more during the week at work/school than on
weekends or times away from work/school?
Do your eyes or nose itch or feel irritated at work/school?
Do coworkers or other students have similar symptoms?
Are you exposed to fumes, dusts, or vapors at work? If so, what?
Nasal problems
Do you have seasonal or persistent nasal congestion, runny nose, postnasal drip, or decreased
sense of smell?
Are your nasal symptoms worse at home/school/work?
Gastroesophageal reflux
Do you have heartburn (burning sensation in the chest); does food come back up into your mouth;
or do you sense/taste sour stomach acid coming up into your throat?
Medications that can worsen asthma

Do you use eye drops? If so, which? Do your asthma symptoms worsen after taking them?
Do you use any medications that contain beta-blockers or ACE inhibitors? Has your asthma
worsened since you started taking this medication?
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Do you take aspirin or other NSAIDs? Do your asthma symptoms flare when you take them?
Possible sulfite sensitivity Δ

Do you have wheezing, coughing, or shortness of breath after eating shrimp, dried fruit, or
processed potatoes or after drinking beer or wine?
IgE: immunoglobulin E; ACE: angiotensin-converting enzyme; NSAID: nonsteroidal anti-inflammatory

drug.
* These questions are examples and do not represent a standardized assessment or diagnostic
instrument. The validity and reliability of these questions have not been assessed.
¶ Higher humidity makes mold and mite exposure more likely. Visible mold suggests significant
mold exposure.
Δ Rare issue in children.
Adapted from: National Heart, Blood, and Lung Institute Expert Panel Report 3 (EPR 3): Guidelines for the Diagnosis and
Management of Asthma. NIH Publication no. 08-4051, 2007.
Graphic 80507 Version 12.0
3/29/23, 12:02 PM 521
Classification and grading of ventilatory impairments based on spirometry [1,2]
FEV1: forced expiratory volume in one second; FVC: forced vital capacity; LLN: lower limit of normal, the
5th percentile.
* Low refers to levels below the 5th percentile, or a z-score <–1.645; absolute values are not used due to
changes in spirometry with age and other factors.
¶ A reduced FVC does not prove a restrictive process. Confirmation of restriction requires evaluation of
lung volumes in a pulmonary function laboratory (ie, total lung capacity z-score <–1.645 or below fifth
percentile).
Δ A reduced FVC with normal FEV1/FVC and lung-volumes is a "nonspecific" pattern that may be followed
over time. One-third of patients with nonspecific patterns develop obstructive or restrictive disease in the
next three years.
◊ Many patients with reduced FEV1/FVC and low FVC have simple obstruction with air-trapping or failure
to complete exhalation.
§ The severity of obstructive and mixed obstructive/restrictive ventilatory impairments are physiologically
graded by decrement in FEV1. Patients with restriction should have restrictive impairment confirmed and
graded based on total lung capacity, but may be monitored by changes in FEV1. FEV1 may also be used as
an alternative method to grade severity of confirmed restriction when only spirometry or % predicted
values are available.
3/29/23, 12:02 PM 521
¥ Z-score is the preferred method for grading severity based on 2022 European Respiratory
Society/American Thoracic Society (ERS/ATS) guidelines because it reduces bias due to age, sex, and other
factors. Some spirometry software continues to report percent predicted, so we also include
categorization based on this reporting method. The percent predicted severity classification has been
adapted from earlier guidelines and modernized by reducing the number of distinct categories.
References:
1. Stanojevic S, Kaminsky DA, Miller MR, et al. ERS/ATS technical standard on interpretive strategies for routine lung function
tests. Eur Respir J 2022; 60:2101499.
2. Pellegrino R, Viegi G, Brusasco V, et al. Interpretative strategies for lung function tests. Eur Respir J 2005; 26:948.
3/29/23, 12:02 PM 521
Differential diagnosis of asthma in older adults
Potentially helpful diagnostic tests, in addition to clinical

Disease
assessment
Asthma Spirometry pre and post-bronchodilator, methacholine inhalation

challenge
Atrial fibrillation Electrocardiogram
Bronchiectasis History of >1/4 cup of sputum per day, HRCT thorax
Chronic obstructive History of smoking, spirometry pre and post-bronchodilator, lung

pulmonary disease volumes, DLCO, CT thorax showing emphysema
Coronary heart disease Electrocardiogram, stress test
Deconditioning Ambulatory oximetry, cardiopulmonary exercise testing
Heart failure BNP, echocardiogram
Obesity Ambulatory oximetry, cardiopulmonary exercise testing
Pulmonary embolism ABG, D-dimer, CT pulmonary angiogram, electrocardiogram
Pulmonary vascular disease Echocardiogram, right heart catheterization
Restrictive lung disease Lung volumes, DLCO, HRCT thorax
Upper airway obstruction Flow volume loop, direct visualization
ABG: arterial blood gas; BNP: brain natriuretic peptide; DLCO: diffusing capacity; CT: computed
tomography; HRCT: high resolution computed tomography.
3/29/23, 12:02 PM 521
How to control things that make your asthma worse
You can help prevent asthma episodes by staying away Vacuum cleaning
from things that make your asthma worse. This guide
Try to get someone else to vacuum for
suggests many ways to help you do this.
you once or twice a week, if you can.
You need to find out what makes your asthma worse. Stay out of rooms while they are being
Some things that make asthma worse for some people vacuumed and for a short while
are not a problem for others. You do not need to do all of afterward.
the things listed in this guide.
If you vacuum, use a dust mask (from a
Look at the things listed in dark print below. Put a check hardware store), a central cleaner with
next to the ones that you know make your asthma worse, the collecting bag outside the home, or
particularly if you are allergic to the things. Then, decide a vacuum cleaner with a HEPA filter or
with your doctor what steps you will take. Start with the a double-layered bag.*
things in your bedroom that bother your asthma. Try
something simple first. Indoor mold
Tobacco smoke Fix leaking faucets, pipes, or other

sources of water.
If you smoke, ask your doctor for ways to help you quit.
Clean moldy surfaces.
Ask family members to quit smoking, too.
Do not allow smoking in your home, car, or around you. Dehumidify basements if possible.
Be sure no one smokes at a child's daycare center or Pollen and outdoor mold
school. During your allergy season (when
Dust mites pollen or mold spore counts are high):
Many people who have asthma are allergic to dust mites. Try to keep your windows closed.
Dust mites are like tiny "bugs" you cannot see that live in If possible, stay indoors with
cloth or carpet. windows closed during the midday
and afternoon, if you can. Pollen
Things that will help the most:
and some mold spore counts are
Encase your mattress in a special dust miteproof highest at that time.
cover.*
Ask your doctor whether you need
Encase your pillow in a special dust mite-proof cover* to take or increase anti-
or wash the pillow each week in hot water. Water must inflammatory medicine before your
be hotter than 130°F to kill the mites. Cooler water allergy season starts.
used with detergent and bleach can also be effective.
Smoke, strong odors, and sprays
Wash the sheets and blankets on your bed each week
in hot water. If possible, do not use a wood-burning
stove, kerosene heater, fireplace,
Other things that can help:
unvented gas stove, or heater.
Reduce indoor humidity to or below 60 percent;
Try to stay away from strong odors and
ideally 30-50 percent. Dehumidifiers or central air
sprays, such as perfume, talcum
conditioners can do this.
3/29/23, 12:02 PM 521
Try not to sleep or lie on cloth-covered cushions or powder, hair spray, paints, new carpet,
furniture. or particle board.
Remove carpets from your bedroom and those laid on Exercise or sports
concrete, if you can.
You should be able to be active without
Keep stuffed toys out of the bed, or wash the toys symptoms. See your doctor if you have
weekly in hot water or in cooler water with detergent asthma symptoms when you are
and bleach. Placing toys weekly in a dryer or freezer active-such as when you exercise, do
may help. Prolonged exposure to dry heat or freezing sports, play, or work hard.
can kill mites but does not remove allergen.
Ask your doctor about taking medicine
Animal dander before you exercise to prevent
symptoms.
Some people are allergic to the flakes of skin or dried
saliva from animals. Warm up for a period before you
exercise.
The best thing to do:
Check the air quality index and try not
Keep animals with fur or hair out of your home.
to work or play hard outside when the
If you can't keep the pet outdoors, then: air pollution or pollen levels (if you are
allergic to the pollen) are high.
Keep the pet out of your bedroom, and keep the
bedroom door closed. Other things that can make
Remove carpets and furniture covered with cloth from asthma worse
your home. If that is not possible, keep the pet out of Sulfites in foods: do not drink beer or
the rooms where these are. wine or eat shrimp, dried fruit, or
processed potatoes if they cause
Cockroach
asthma symptoms.
Many people with asthma are allergic to the dried
Cold air: cover your nose and mouth
droppings and remains of cockroaches.
with a scarf on cold or windy days.
Keep all food out of your bedroom.
Other medicines: tell your doctor about
Keep food and garbage in closed containers (never all the medicines you may take. Include
leave food out). cold medicines, aspirin, and even eye
Use poison baits, powders, gels, or paste (for drops.
example, boric acid). You can also use traps.
If a spray is used to kill roaches, stay out of the room

until the odor goes away.
* To find out where to get products mentioned in this guide, call:
Asthma and Allergy Foundation of America (800-727-8462).
Allergy and Asthma Network/Mothers of Asthmatics, Inc. (800-878-4403).
American Academy of Allergy, Asthma, and Immunology (800-822-2762).
National Jewish Medical and Research Center (Lung Line) (800-222-5864).
3/29/23, 12:02 PM 521
American College of Allergy, Asthma, and Immunology (800-842-7777).
Reproduced from: National Heart, Blood, and Lung Institute Expert Panel Report 3 (EPR 3): Guidelines for the Diagnosis and
Management of Asthma. NIH Publication no. 08-4051, 2007.
3/29/23, 12:02 PM 521
Approaches to asthma controller therapy in adolescents and adults
National Asthma Education and

Prevention Program: Expert Panel Global Initiative for Asthma (GINA)
Working Group (NAEPP 2020)
Asthma
symptoms/lung Therapy* Asthma symptoms Therapy
function
Intermittent asthma/step 1 Step 1
Daytime symptoms SABA, as needed Infrequent asthma Low-dose ICS with

≤2 days/week symptoms (eg, <2 rapid onset LABA
Nocturnal times/week) (eg, budesonide-
awakenings formoterol
≤2/month combination MDI
Normal FEV1 160 mcg-4.5
mcg/inhalation or
Exacerbations
DPI 200 mcg-6
≤1/year
mcg/inhalation) 1
inhalation, as
needed (preferred)
or
Low-dose ICS
whenever SABA
used or as-needed
low-dose ICS-SABA
Mild persistent asthma/step 2 Step 2
Daytime symptoms Low-dose ICS daily Asthma symptoms Low-dose ICS-

>2 but <7 and SABA as or need for reliever formoterol as
days/week needed inhaler ≥2 needed (preferred)
Nocturnal or times/week or
awakenings 3 to 4 Low-dose ICS-SABA Low-dose ICS daily
nights/month or ICS plus SABA, and SABA as
Minor interference concomitantly needed
with activities administered, as
Other options
FEV1 within the needed
Low-dose ICS-
normal range Alternative option(s) SABA or ICS plus
Exacerbations Daily LTRA and SABA,
≥2/year SABA as needed concomitantly
administered, as
needed
3/29/23, 12:02 PM 521
or (less
preferred)
LTRA daily and
SABA as needed
Moderate persistent asthma/step 3 Step 3
Daily symptoms Combination low- Troublesome Low-dose ICS-

Nocturnal dose ICS-formoterol asthma symptoms formoterol as
awakenings daily and 1 to 2 most days, maintenance and
>1/week inhalations as nocturnal reliever therapy (ie,
Daily need for SABA needed up to 12 awakening due to budesonide-
inhalations/day asthma ≥1 formoterol)
Some activity
(preferred option) time/month, risk (preferred)
limitation
factors for or
FEV1 60 to 80% Alternative option(s)
exacerbations ¶ Low-dose ICS-LABA
predicted Medium-dose ICS
daily and SABA as combination daily
Exacerbations
needed and SABA as
≥2/year
needed
or
Low-dose ICS- Other options
LABA Medium-dose ICS
combination daily daily and SABA as
or low-dose ICS needed
plus LAMA daily or
or low-dose ICS Low-dose ICS plus
plus LTRA daily LTRA daily and
and SABA as SABA as needed
needed
or
Low-dose ICS
daily plus zileuton
and SABA as
needed
Severe persistent asthma/steps 4 to 6 Steps 4 to 5
Symptoms all day Step 4: Severely Step 4:

Nocturnal Combination uncontrolled Medium-dose
awakenings nightly medium dose asthma with ≥3 of ICS-formoterol as
Need for SABA ICS-formoterol the following: maintenance and
several times/day daily and 1 to 2 daytime asthma reliever therapy
inhalations as symptoms >2 (preferred)
Extreme limitation
needed to 12 times/week; or
in activity
inhalations/day nocturnal Medium dose
FEV1 <60%
(preferred option) awakening due to ICS-LABA daily
predicted
asthma; reliever
Alternative option(s)
needed for
3/29/23, 12:02 PM 521
Exacerbations Medium-dose symptoms >2 and SABA as

≥2/year ICS-LABA daily or times/week, or needed
medium-dose ICS activity limitation
Other options
plus LAMA daily due to asthma
Possible add-on
and SABA as or
LAMA or switch to
needed An acute ICS-LAMA-LABA
or exacerbation
Possible add-on
Medium-dose ICS LTRA
daily plus LTRA or
High-dose ICS-
zileuton and
LABA trial (3 to 6
SABA as needed*
months) if other
add-ons
insufficient – May
need short course
of oral
glucocorticoids
Step 5: Step 5:
Medium to high- Medium-dose
dose ICS-LABA ICS-formoterol as
plus LAMA daily maintenance and
and SABA as reliever therapy
needed plus LAMA daily
(preferred) (preferred)
Alternative option(s) or
Medium-high Medium-dose
dose ICS-LABA ICS-LABA plus
daily or high-dose LAMA daily and
ICS + LTRA* daily SABA as needed
and SABA as Assess asthma
needed phenotype and
Possible addition evaluate for
of asthma possible addition
biologics Δ of asthma
biologics Δ
Other options
High-dose ICS-
LABA trial (3 to 6
months)
Possible add-on
LTRA or
azithromycin
Oral
glucocorticoids
3/29/23, 12:02 PM 521
titrated to
optimize asthma
control and
minimize adverse
effects
Step 6:
High-dose ICS-
LABA daily;
consider LAMA as
substitute for
LABA or as add-
on therapy if not
done previously ◊
Oral
glucocorticoids,
titrated to
optimize asthma
control and
minimize adverse
effects
Possible addition
of asthma
biologics Δ
Initial therapies are noted above. A higher level of initial therapy, sometimes with concurrent use of
oral glucocorticoids, may be chosen if the patient presents with an acute exacerbation. Treatment
may be stepped down if asthma is well controlled for at least three months, or stepped up 1 or 2
steps if asthma is not well controlled or is very poorly controlled. At follow-up visits, check
adherence, inhaler technique, environmental factors, and comorbid conditions. Subcutaneous
immunotherapy is suggested as an adjunct to standard pharmacotherapy in individuals who have
demonstrated allergy to the included allergens and whose asthma is well-controlled whenever
immunotherapy is administered. Consult with asthma specialist if step 4 or higher is required.
FEV1: forced expiratory volume in one second; SABA: short-acting beta-agonist; ICS: inhaled
corticosteroid (glucocorticoid); LABA: long-acting beta-agonist; MDI: metered dose inhaler; DPI: dry
powder inhaler; LTRA: leukotriene receptor antagonist; IgE: immunoglobulin E; IL: interleukin; LAMA:
long-acting muscarinic antagonist.
* Theophylline and cromolyn are not included in the table even though they were included in
NAEPP-EPR 3 (2007) and theophylline is included in NAEPP (2020). These agents are rarely used now,
due to availability of more effective options.
¶ Risk factors for exacerbations include: smoking, allergen exposure if sensitized, previous
intubation or intensive care unit stay for asthma, low FEV1 (especially <60% predicted), obesity, food
allergy, chronic rhinosinusitis, and poor adherence/inhaler technique.
3/29/23, 12:02 PM 521
Δ Asthma biologics include anti-immunoglobulin E, anti-interleukin (IL)-5, anti-IL-5R, anti-IL-4R (anti-

IL-4/IL-13), and anti-thymic stromal lymphopoietin (anti-TSLP). Refer to UpToDate graphic on our
approach to selection of biologic agents for add-on therapy for severe asthma in adolescents and
adults.
◊ The NAEPP 2020 Focused Updates included LAMA therapy in step 5 but not step 6; however, a trial
of add-on LAMA therapy is reasonable, if not previously assessed.
References:
1. National Asthma Education and Prevention Program: Expert panel report III: Guidelines for the diagnosis and
management of asthma. Bethesda, MD: National Heart, Lung, and Blood Institute, 2007. (NIH publication no. 08-
4051). https://www.nhlbi.nih.gov/health-topics/guidelines-for-diagnosis-management-of-asthma.
2. 2020 Focused Updates to the Asthma Management Guidelines: A Report from the National Asthma Education and
Prevention Program Coordinating Committee Expert Panel Working Group. J Allergy Clin Immunol 2020;146:1217-70.
https://www.nhlbi.nih.gov/health-topics/asthma-management-guidelines-2020-updates.
3. Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA). www.ginasthma.org.
3/29/23, 12:02 PM 521
Assessment of asthma symptom control and risk of exacerbations
A. Level of asthma symptom control

In the past 4 weeks, has the patient had: Well Partly Uncontrolled
controlled controlled
Daytime symptoms more than None of 1 to 2 of 3 to 4 of

twice/week? Yes No these these these
Any night waking due to

asthma? Yes No
Reliever needed more than

twice/week? Yes No
Any activity limitation due to

asthma? Yes No
B. Risk factors for poor asthma outcomes

Assess risk factors at diagnosis and periodically, at least every 1 to 2 years, particularly for patients
experiencing exacerbations.
Measure FEV1 at start of treatment, after 3 to 6 months of controller treatment to record personal
best lung function, then periodically for ongoing risk assessment.
Having uncontrolled asthma symptoms is an important risk factor for Having any of
exacerbations. these risk
factors
Additional potentially modifiable risk factors for exacerbations, even in patients
increases the
with few asthma symptoms, include:
patient's risk
Medications: ICS not prescribed; poor adherence; incorrect inhaler
of
technique; high SABA use (with increased mortality if
exacerbations
≥1×200-dose canister/month)*
even if they
Comorbidities: obesity; chronic rhinosinusitis; gastroesophageal reflux
have few
disease; confirmed food allergy; anxiety; depression; pregnancy
asthma
Exposures: smoking ¶ ; allergen exposure if sensitized; air pollution symptoms.
Setting: major socioeconomic problems
Lung function: low FEV1, especially if <60% predicted; higher reversibility
Other tests: sputum/blood eosinophilia; elevated FENO in allergic adults on
ICS
Other major independent risk factors for flare-ups (exacerbations) include:

Ever being intubated or in intensive care for asthma
Having 1 or more severe exacerbations in the last 12 months
Risk factors for developing fixed airflow limitation include preterm birth, low birth weight, and
greater infant weight gain; lack of ICS treatment; exposure to tobacco smoke, noxious chemicals,
3/29/23, 12:02 PM 521
or occupational exposures; low FEV1; chronic mucus hypersecretion; and sputum or blood
eosinophilia
Risk factors for medication side-effects include:

Systemic: frequent OCS; long-term, high dose and/or potent ICS; also taking cytochrome
P450 inhibitors
Local: high-dose or potent ICS; poor inhaler technique
Asthma control has two domains: symptom control and risk of future exacerbations. Assess the
symptom control domain by patient's recall of previous 4 weeks; assess risk of future exacerbations
by the presence of risk factors and by spirometry/or peak flow measures.
FEV1: forced expiratory volume in one second; ICS: inhaled corticosteroids; SABA: short-acting beta-2
agonist; FENO: fraction of expired nitric oxide; OCS: oral corticosteroid.
* 2022 guidelines note that use of ≥3 200-dose SABA canisters/year is also associated with
increased exacerbation risk.
¶ Smoking includes e-cigarette exposure.
For the most recent version of the GINA assessment of asthma control, please visit: Global Initiative for Asthma. Global
Strategy for Asthma Management and Prevention, 2022. Available at: https://ginasthma.org/gina-reports/ (Accessed on May
19, 2022). Reproduced with permission from: Global Initiative for Asthma. Asthma Management and Prevention (for Adults
and Children Older than 5 Years): A Pocket Guide for Health Professionals, Updated 2019. Available at:
https://ginasthma.org/pocket-guide-for-asthma-management-and-prevention/ (Accessed on July 19, 2019).
3/29/23, 12:02 PM 521
Contributor Disclosures
Sharmilee Maria Nyenhuis, MD, FAAAAI Consultant/Advisory Boards: Avillion/Astra Zeneca Ad Board
[Pediatric Asthma]; Prime Education [CME]. Other Financial Interest: Springer Nature [Royalties “Treatment
of Asthma in Older Adults”]. All of the relevant financial relationships listed have been mitigated. Peter J
Barnes, DM, DSc, FRCP, FRS Grant/Research/Clinical Trial Support: AstraZeneca [Asthma, COPD];
Boehringer [COPD]; Novartis [COPD]. Consultant/Advisory Boards: AstraZeneca [Asthma, COPD];
Boehringer [COPD]; Epi-Endo [Asthma, COPD]; Novartis [COPD]; Teva [COPD]. Speaker's Bureau:
AstraZeneca [Asthma]; Boehringer [COPD]; Novartis [COPD]; Teva [Asthma]. All of the relevant financial
relationships listed have been mitigated. Kenneth E Schmader, MD No relevant financial relationship(s)
with ineligible companies to disclose. Paul Dieffenbach, MD No relevant financial relationship(s) with
ineligible companies to disclose.
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must
conform to UpToDate standards of evidence.
Conflict of interest policy

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Official reprint from UpToDate®

Diagnosis and management of asthma in older adults

● (See "Asthma in adolescents and adults: Evaluation and diagnosis".)

response to coronavirus disease 2019 (COVID-19; severe acute respiratory syndrome

● (See "An overview of asthma management", section on 'Advice related to COVID-19

RISK FACTORS AND TRIGGERS

● Atopy – Despite a decline in prevalence of atopic symptoms, immunoglobulin E (IgE)

● Occupational, residential, and ambient air exposures – Cumulative airborne exposures

● Medications – Certain medications used to treat hypertension, coronary heart disease,

spirometric test performance, as well as validation of alternative approaches, such as

Airflow obstruction is characterized by a reduced ratio of forced expiratory volume in one

Bronchoprovocation testing, if spirometry is normal — Bronchoprovocation testing, such

On pulmonary function testing, airflow limitation that is significantly or completely reversible

Successful management of asthma in older adults is based on four essential components

Otherwise, routine monitoring of asthma control, lung function, exacerbations, inhaler

Pharmacologic management — The National Asthma Education and Prevention Program

● Cardiovascular effects of beta-agonists – Although beta-agonists can increase heart rate

● Reducing oral glucocorticoid exposure – Chronic prednisone therapy has multiple

● Efficacy of biologic therapies in the older population – Anti-IgE, anti-interleukin (IL) 4,

● Theophylline toxicity – Theophylline is not suggested for treatment of asthma in most

SOCIETY GUIDELINE LINKS

SUMMARY AND RECOMMENDATIONS

● Evaluation, diagnosis, and differential diagnosis

• Spirometry, bronchodilator response, and methacholine responsiveness are accurate in

• Distinguishing asthma from chronic obstructive pulmonary disease (COPD) is a

● Differences in the management of asthma in older persons – Successful management

• Vaccination against respiratory illnesses – Older persons with asthma are at

• Monitoring the geriatric patient – Monitoring in older persons frequently includes a

• Pharmacologic management – The pharmacologic management of asthma in older

Special considerations in older patients include:

- While anti-IgE therapy (omalizumab) appears to have comparable efficacy in older

Use of UpToDate is subject to the Terms of Use.

4. Dow L, Fowler L, Phelps L, et al. Prevalence of untreated asthma in a population sample of

47. Cuttitta G, Cibella F, Bellia V, et al. Changes in FVC during methacholine-induced

Study. Chest 2013; 144:1143.

Questions to help identify asthma triggers*

Is there moisture, dampness, moldy odor, or visible mold in your home? ¶

Does anyone at home/work/daycare smoke?

Do you smoke cannabis (marijuana), use electronic cigarettes, or vape?

Do you use a wood-burning stove or fireplace at home?

Do you have any unvented/open fire stoves or heaters at home?

Work and school

Do your eyes or nose itch or feel irritated at work/school?

Do coworkers or other students have similar symptoms?

Are you exposed to fumes, dusts, or vapors at work? If so, what?

Are your nasal symptoms worse at home/school/work?

Medications that can worsen asthma

Possible sulfite sensitivity Δ

IgE: immunoglobulin E; ACE: angiotensin-converting enzyme; NSAID: nonsteroidal anti-inflammatory

Δ Rare issue in children.

Graphic 80507 Version 12.0

Classification and grading of ventilatory impairments based on spirometry [1,2]

Graphic 139645 Version 2.0

Differential diagnosis of asthma in older adults

Potentially helpful diagnostic tests, in addition to clinical

Asthma Spirometry pre and post-bronchodilator, methacholine inhalation

Atrial fibrillation Electrocardiogram

Bronchiectasis History of >1/4 cup of sputum per day, HRCT thorax

Chronic obstructive History of smoking, spirometry pre and post-bronchodilator, lung

Coronary heart disease Electrocardiogram, stress test

Deconditioning Ambulatory oximetry, cardiopulmonary exercise testing

Heart failure BNP, echocardiogram