Impact of aging on high-dose inhaled corticosteroid use and specialist care management in patients with asthma: a Danish nationwide cohort study
Abstract
Objective: Asthma is a common chronic respiratory disease affecting people of all ages, but little is known about age-related differences in treatment strategies. The present study aims to explore age-related differences in inhaled corticosteroid (ICS) use and place of asthma management. Methods: All Danish adults with a registered secondary care asthma diagnosis or active treatment (>1 redemption of ICS within 365 days) in 2021 were included. Individuals with chronic obstructive pulmonary disease and individuals who migrated or died during the observation period were excluded. Danish national registries provided all treatment data. Results: A total of 184,565 patients with asthma (median age 57 [IQR 43–69], 59% female) were included. Overall, 15.7% of the asthma population was treated with high (>800–1600 budesonide-equivalent ug/day) or supratherapeutic (>1600 budesonide-equivalent ug/day) doses of ICS, and the proportion increased with age before reaching a plateau from age 56 onwards (lowest: 18–45 years, 9.7%; highest: 66–75 years, 18.9%; p < .001). Significantly fewer of the patients in the oldest age group were seen in specialist care (highest: 56–65 years, 18.9%; lowest: >86 years, 11.4%; p < .001), and 77.3% of patients exposed to high or supratherapeutic doses of ICS were managed only in primary care. Conclusion: The prevalence of high- and supratherapeutic ICS exposure was higher among patients ≥56 years, and when exceeding 76 years of age, a smaller proportion were managed in secondary care. With an increased focus on adverse effects of high-dose ICS treatment and earlier initiation of other treatments, our findings will, hopefully, facilitate less age inequity in asthma management.
Plain Language Summary
Asthma treatment guidelines recommend adjusting the dose of steroid inhalers based on disease severity and control — stepping up when control is poor, and stepping down when it improves. But in practice, do older asthma patients receive different inhaler doses and specialist management compared to younger ones? In this Danish nationwide study, we explored age-related differences in treatment. Using national registry data, we identified asthma patients across a broad age range and examined the prevalence of high-dose steroid inhaler use and specialist follow-up according to age. We found that high-dose inhaler use and patterns of specialist versus primary care management differed significantly by age, with older patients showing distinct patterns that were not always aligned with guideline recommendations. Our findings raise questions about whether age-related differences in treatment reflect genuine clinical needs or whether they represent inappropriate variation — particularly for older asthma patients who may be systematically under- or over-treated. We call for age-stratified awareness in asthma management, ensuring that treatment is optimised across the full age spectrum and not inadvertently guided by assumptions about older patients' disease or treatment expectations.