Dominick Shaw is an Associate Professor and honorary clinician at the University of Nottingham and Nottingham University NHS Hospital Trust. He leads the commissioned severe asthma service and performs clinical studies in asthma. He will be speaking at the upcoming BGS Spring Meeting in Nottingham.
Asthma still presents a major challenge to society. Although classically regarded as a disease of children and young adults, accumulating evidence suggests that late onset asthma carries a poorer prognosis. Moreover although the death rate from asthma has fallen over the last 10-15 years in people under 75, in those aged over 75 it has doubled. Consequently the overall mortality rate has not changed.
Asthma still causes significant social and financial problems for patients, with recurrent exacerbations needing oral steroids, hospital admissions, time off work and impact on families and carers. There is light at the end of the asthma tunnel however and asthma has advanced a long way from, in the words of a geriatrician colleague*, “one puff of the blue, two of the brown”.
Over the last few years the recognition that asthma is a heterogeneous group of diseases with different forms of airway inflammation has led to the successful development of a whole range of monoclonal antibody drugs targeting specific cytokines in the asthma inflammatory cascade. This has led to a step change in treatment and the era of the “mabs”- injectable monoclonal antibodies. Licensed drugs include Mepoluzimab and Reslizumab, which target Interleukin 5, others targeting separate cytokine pathways are not far behind. These add to the injectable asthma armamentarium which already includes Xolair- a mab targeting Immunoglobulin E.
Therapeutic advances in asthma do not stop at expensive monoclonal antibodies. The last few years have seen ground breaking studies in as required inhaled corticosteroid/Long acting beta agonist combination therapy, small particle inhaled corticosteroids, long acting muscarinic antagonists and the use of Azithromycin and bronchial thermoplasty. Challenges remain though. The recent publication of the NICE asthma guidance is welcome but they are at odds with the established BTS/SIGN guidance, an approach which may cause confusion. There are far too many drug device combinations available causing further confusion and potentially impacting upon compliance, which is still the biggest issue in asthma control.
The combination of asthma and the older person presents its own problems. The use of steroids has been linked to osteoporosis, manual dexterity is required to operate many of the inhaler devices and inspiratory flow rates generated need to match the device prescribed. Even establishing whether the underlying process is asthma or COPD can feel like untangling the Gordian knot.
At the BGS Meeting in Nottingham on Friday 13 April, we will discuss some if these issues faced by older people with asthma and run through some of the latest evidence. We hope to see you there.
*Coi; my wife.