NASHVILLE, TENN-- Although asthma is known to cause serious morbidity in the elderly, pharmacologic therapy in older patients with asthma has never been fully evaluated, in part because of the difficulties of defining asthma in this population. A new study of older persons who required hospital care for asthma suggests that these patients are often inappropriately medicated and receive suboptimal treatment.[1]

In an interview with RESPIRATORY REVIEWS, Tina V. Hartert, MD, MPH, noted that this study is unique because it was able to identify almost all of the patients enrolled in the Tennessee Medicaid program who required hospital care for asthma in one year. "All charts were reviewed to confirm the diagnosis of asthma," added Dr. Hartert, chief author of the study and Assistant Professor of Medicine in the Division of Allergy, Pulmonary, and Critical Care Medicine at the Center for Lung Research at Vanderbilt University School of Medicine in Nashville. "Detailed information on all prescription medications dispensed was available through the Medicaid pharmacy database."

The group meeting study criteria included 512 patients age 65 years or older with chronic asthma who were treated in an emergency department or admitted to a hospital for an asthma exacerbation. Eighty-one percent of these were classified as having either moderate-to-severe or potentially fatal asthma. The patients had a median of 15 outpatient visits in the prior year; over half had an outpatient visit in the 14 days before hospitalization.

ORAL CORTICOSTEROIDS ARE UNDERUSED

Five percent of patients, all of whom had potentially fatal asthma, were receiving oral corticosteroids at the time they presented to the hospital. Among the remaining patients, only 21% had used inhaled corticosteroids within the previous year--and only 10% had filled a prescription for one within 45 days before the hospital visit.

In contrast, 45% of patients had used an inhaled ß-agonist within the last year; another 18% had received an oral ß-agonist. Among those who used ß-agonists, a mean 9.4 units (defined as the equivalent of 200 actuations of albuterol) had been taken during the previous year.

Hartert et al described this as overuse, noting that when asthma is well controlled, ß-agonist use should be one to one and a half units per year or less.[2] "Excessive use of ß-agonists must be viewed as a surrogate marker for poorly controlled asthma," the investigators added. The medication prescribed most commonly was theophylline, which was used by 47% of the study subjects. The authors found the high frequency of ß-agonist and theophylline use worrisome, given that both drugs have been linked to an increased risk of cardiovascular disease.

Twenty-nine percent of patients had been given an antibiotic prescription in the 30 days before the hospital visit. Although some of these antibiotic prescriptions may have been justified, Hartert et al suggested that these prescriptions may represent "missed opportunities for intervention."

According to the researchers, these study results are significant in view of the increasing frequency of hospital care for asthma over the past decade. Nearly 50% of the direct costs of asthma care are for hospital visits, and appropriate medication--specifically, controller therapy with inhaled corticosteroids--decreases the risk of hospitalization.[3] Elderly patients, and the physicians who care for them, "would seem appropriate candidates to target for education in standard asthma practices," the authors concluded.

--Stanley Nelson

References
1. Hartert TV, Togias A, Mellen BG, et al. Underutilization of controller and rescue medications among older adults with asthma requiring hospital care. J Am Geriatr Soc. 2000;48:651-657.
2. National Asthma Education Program, National Heart Lung and Blood Institute. Expert panel report 2: Guidelines for the diagnosis and management of asthma. 1997;NIH 97-4051:iii-86 [Abstract].
3. Donahue JG, Weiss ST, Livingston JM, et al. Inhaled steroids and the risk of hospitalization for asthma. JAMA. 1997; 277: 887-891.