Asthma in the elderly is poorly understood and vitamin D deficiency and insufficiency are very common in older individuals. We studied the role of vitamin D in elderly asthmatics.

METHODS: Asthmatics subjects, age 65 and older, were followed every 4 weeks for 12 weeks in the late fall and winter. During the study period they took 2,000 I.U. vitamin D3 daily. Serum 25-Hydroxyvitamin D and calcium were measured at baseline and study end.

RESULTS: Twenty nine percent of subjects were deficient and 50% insufficient in serum vitamin D at baseline. Serum vitamin D increased from 24.3±9.2 ng/ml (60.7±23 nmol/L) to 34±7.1 ng/ml (84.9±17.7 nmol/L) at the end of the study (p<0.001), whereas calcium was unchanged. We found no significant association between vitamin D and subjects' demographics. Vitamin D was similar in men and women. There was no association between serum vitamin D and inhaled steroid dose. Vitamin D was significantly lower in subjects with uncontrolled asthma (Asthma Control Test, ACT≤19) compared to the ones with well controlled symptoms (p<0.05). In subjects with uncontrolled asthma at baseline, ACT scores increased significantly at the end of the study (p<0.04), but not at 4 and 8 weeks. Spirometric values remained unchanged throughout the study.

CONCLUSIONS: Elderly asthmatics very commonly have vitamin D deficiency or insufficiency. Serum vitamin D levels were lower in subjects with uncontrolled asthma. In these subjects, vitamin D supplementation for 12 weeks led to improved ACT scores. Larger, randomized, placebo controlled studies are required to further evaluate whether vitamin D supplementation may improve asthma symptoms in this population.

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Comprehensive studies of the pathophysiologic characteristics of elderly asthma, including predominant site of disease, airway inflammation profiles, and airway hyperresponsiveness, are scarce despite their clinical importance.

OBJECTIVE: To clarify the pathophysiologic characteristics of elderly patients with asthma.

METHODS: Patients older than 65 years (elderly; n = 45) vs those no older than 65 years (nonelderly; n = 67) were retrospectively analyzed by spirometry, computed tomographic indices of large airway wall thickness and small airway involvement (air trapping), impulse oscillation measurements, exhaled nitric oxide levels, blood and induced sputum cell differentials, methacholine airway responsiveness, and total and specific serum IgE levels.

RESULTS: Elderly patients with asthma had significantly lower values for forced expiration volume in 1 second, mid-forced expiratory flow (percentage predicted), and ratio of forced expiration volume in 1 second to forced vital capacity than nonelderly patients with asthma (median 81.2% vs 88.8%, P = .02; 50.9% vs 78.6%, P = .03; 0.72 vs 0.78, P = .001, respectively). In computed tomographic measurements, elderly patients with asthma had significantly greater airway wall thickening and air trapping than nonelderly patients. Impulse oscillation measurements indicated that elderly patients with asthma showed significantly greater resistance at 5 Hz (used as an index of total airway resistance), greater decrease in resistance from 5 to 20 Hz, a higher ratio of decrease in resistance from 5 to 20 Hz to resistance at 5 Hz, higher integrated area between 5 Hz and frequency of resonance, greater frequency of resonance, and lower reactance at a frequency of 5 Hz (potential markers of small airway disease) than nonelderly patients. There were no significant differences in blood or sputum cell differentials, exhaled nitric oxide, or methacholine airway responsiveness between the 2 groups. Total serum IgE levels and positive rates of specific IgE antibodies against several allergens were significantly lower in elderly than in nonelderly patients with asthma.

CONCLUSION: Based on spirometric, computed tomographic, and impulse oscillation analyses, elderly patients with asthma have greater involvement of small and large airways than nonelderly patients with asthma.

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The onset of eosinophilic esophagitis (EoE) after oral immunotherapy (OIT) has been repeatedly described in patients with immunoglobulin E (IgE)-mediated food allergy in recent years, but the relation between the 2 conditions has not been fully assessed and quantified.

OBJECTIVE: To provide a systematic review of the evidence for an association between OIT and EoE.

METHODS: Electronic searches were performed with keywords relating to EoE and OIT in the MEDLINE, EMBASE, and SCOPUS databases. Summary estimates were calculated. A fixed-effects model was used depending on heterogeneity (I(2)). Risk of publication bias was assessed by funnel plot analysis and the Egger test.

RESULTS: The search yielded 118 documents, 15 of which were included in the quantitative summary. Most reported information came from children undergoing peanut, milk, and egg OIT. Significant publication bias in favor of studies reporting the development of EoE after OIT was documented. The overall prevalence of EoE after OIT was 2.7% (95% confidence interval 1.7%-4.0%, I(2) = 0%). Differences between medium-to high-quality studies and those of low quality were documented (3.5% vs 2.5%, respectively). EoE often resolved after OIT discontinuation; histologic remission of EoE achieved after allergen immunotherapy also was documented in 2 patients whose topical fluticasone treatment failed.

CONCLUSION: New onset of EoE after OIT occurs in up to 2.7% of patients with IgE-mediated food allergy undergoing this treatment strategy. The limited data on the utility of allergen immunotherapy as a therapy for EoE prevent a recommendation for this treatment option.

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QUESTION: A healthy woman with mild to moderate asthma came to my clinic today after learning that she was pregnant. She inquired about continuing her inhaled corticosteroid (ICS) medication and whether there would be any risks to her unborn child if she were to do so. What would you advise?

ANSWER: Given the published evidence, ICSs should be continued throughout pregnancy at low to moderate doses sufficient to control asthma symptoms and prevent exacerbations. However, caution must be taken with doses greater than 1000 µg/d (chlorofluorocarbon beclomethasone equivalent), although whether such doses cause adverse effects is currently still questionable. Patient education on proper ICS administration and adherence, including during the first trimester, must be ongoing. Well controlled asthma will reduce the need for higher ICS doses and possible exposure to systemic corticosteroids, and might decrease the risk of adverse pregnancy or perinatal outcomes.

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