Asthma in Older Adults Guidelines

Updated: Dec 16, 2019
  • Author: Praveen Buddiga, MD, FAAAAI; Chief Editor: Michael A Kaliner, MD  more...
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Guidelines

Guidelines Summary

Asthma Clinical Practice Guidelines (GINA, 2019)

Guidelines for the management and prevention of asthma were published in 2019 by the Global Initiative for Asthma (GINA). [15] This is a quick summary of the guidelines without analysis or commentary. For more information, go directly to the guidelines.

For safety reasons, treatment with short-acting beta2-agonists (SABA) only is no longer recommended.

To reduce risk of serious exacerbations and to control symptoms, all adults and adolescents with asthma should receive controller treatment containing inhaled corticosteroids (ICS).

For mild asthma, as-needed low-dose ICS and low-dose formoterol are recommended. If formoterol is not available, the patient should take low-dose ICS whenever SABA is taken.

ICS-containing treatment should be initiated as soon as possible after asthma diagnosis.

Asthma medications should be added or deleted as the frequency and severity of the patient's symptoms change, as follows:

  • Step 1: As-needed low-dose ICS-formoterol

  • Step 2: Daily low-dose ICS plus as-needed SABA, or as-needed low-dose ICS-formoterol

  • Step 3: Low-dose ICS-LABA maintenance plus as-needed SABA, or low-dose ICS-formoterol maintenance and reliever therapy

  • Step 4: Low-dose ICS-formoterol as maintenance and reliever therapy, or medium-dose ICS-LABA maintenance plus as-needed SABA

  • Step 5: Refer for expert investigation and add-on treatment

2017 GINA Report, Global Strategy for Asthma Management and Prevention

In 2017, the Global Initiative for Asthma (GINA) and the Global Initiative for Obstructive Lung Disease (GOLD) released updated guidelines for the diagnosis and treatment of asthma, COPD and asthma-COPD overlap (ACO). The main goal of the consensus-based guidelines is to assist nonpulmonary specialists in the identification of chronic airway obstructive disease, distinguish between asthma, COPD and ACO, and determine initial treatment approach. [25]

GINA-GOLD no longer use the term asthma-COPD overlap syndrome (ACOS) as asthma-COPD overlap does not describe a single disease entity. Patients with combined features of both disorders more likely have several different phenotypes of airway disease caused by a variety of mechanisms.

The guidelines suggest a stepwise approach to diagnosis that includes the following steps [25] :

  • Step 1: Identifying patients at risk for chronic airway disease through clinical history, physical examination, radiology and screening questionnaires
  • Step 2: Differentiate asthma, COPD and asthma-COPD overlap based on a comparison of the number of features in favor of each possible diagnosis
  • Step 3: Perform spirometry and peak expiratory flow measurement to confirm of exclude diagnoses

Initial treatment recommendations include [25] :

  • For patients with characteristic features of asthma: adequate controller therapy with inhaled corticosteroids (ICS), but not long-acting bronchodilators as monotherapy
  • For patients with characteristic features of COPD: symptomatic treatment with bronchodilators or combination ICS-bronchodilator therapy, but not ICS monotherapy
  • For patients with characteristics of both asthma and COPD: ICS in a low or moderate dose depending on severity of symptoms; add on treatment with long-acting beta-antagonist (LABA) and/or long-acting muscarinic antagonist (LAMA). Do not treat with LABA monotherapy

For all three diagnoses of chronic airflow limitation, treat comorbidities, reduce modifiable risk factors (ie, smoking cessation, vaccinations), increase physical activity, encourage appropriate self-management strategies and perform regular follow-up. For COPD and asthma-COPD overlap, pulmonary rehabilitation is appropriate.

Referral to a pulmonary specialist is indicated for the following [25] :

  • Symptoms persist and/or exacerbations occur despite treatment
  • If diagnosis is uncertain or alternative diagnoses such as bronchiectasis, post-tuberculous scarring, bronchiolitis, pulmonary fibrosis, pulmonary hypertension need to be excluded
  • Atypical or additional signs and symptoms (eg, hemoptysis, weight loss, night sweats, signs of bronchiectasis or other structural lung disease)
  • Chronic airway disease is suspected but few features of asthma and COPD are present
  • Comorbidities are present that may interfere with assessment and management of airway disease

Resources

Go to Asthma and Chronic Obstructive Pulmonary Disease (COPD) for more information.

For more Clinical Practice Guidelines, go to Guidelines.