Benefit-risk Considerations Research Articles

Treatment of the Elderly Asthmatic Patient with Heart Disease

The medications that are prescribed for elderly asthmatic patients with heart disease must be carefully considered. β-Adrenergic agonists have the potential to produce clinically significant hemodynamic changes and cardiovascular events in asthmatic patients of all ages. On the basis of animal data, the concomitant administration of methylxanthines may potentiate this effect. Orally inhaled asthma medications may cause paradoxical bronchospasm, which can be profound and life-threatening. These effects could be devastating for some elderly asthmatics with compromised cardiac function. Such patients are at even greater risk, however, from exacerbations of asthma that are associated with hypoxia. Therefore, use of corticosteroids to prevent or treat such exacerbations is important in minimizing the cardiac risk for these patients. Approaches that will lessen the need for asthma medications also need to be considered carefully. This should include avoidance and treatment of extrinsic and intrinsic triggers, and possibly allergen immunotherapy. In addition, the elderly asthmatic patient with heart disease should understand the pathophysiology and symptoms of asthma, as well as appropriate treatment under varying circumstances. Because of multiple benefit-risk considerations in the elderly asthmatic patient with heart disease, it is appropriate to refer these patients to an allergist or pulmonologist for management assistance. Such specialists should work closely with the referring physician and the patient’s cardiologist to determine the potential respiratory impact of diuretics, β-adrenergic blocking agents, nonsteroidal anti-inflammatory drugs, and other medications used to treat patients with cardiac disease. Failure to consider the possibility of adverse effects from the administration of these medications can place the elderly asthmatic patient with heart disease at unnecessary risk.

Diagnosis and management of rhinitis during pregnancy.

Chronic nasal symptoms occur commonly in pregnant women. The most frequent causes of rhinitis during pregnancy are allergic rhinitis, bacterial rhinosinusitis and rhinitis medicamentosa. The appropriate diagnosis in the individual pregnant woman can usually be established on the basis of the history, physical examination and nasal cytology. Benefit-risk considerations in the management of gestational rhinitis are discussed in detail.

Benefit-risk considerations in preventive treatment for tuberculosis in elderly persons.

Of 2135 elderly residents of nursing homes in Arkansas (mean age, 79.4 years) who have been treated with isoniazid for prevention of tuberculosis, data from 1935 were suitable for analysis. About 12 months of therapy was successfully completed in 1600 persons. Therapy could not be completed in 84 persons (4.4%) because of incipient hepatic toxicity and in 116 (6.0%) because of other types of drug intolerance. Although 135 persons (7.0%) died during the course of therapy, no evidence was found that isoniazid contributed to any death. The ratio of benefit (reduction of risk for tuberculosis) to risk (for nonfatal isoniazid-related hepatitis) was clearly favorable in persons who had definite conversions (1.6 for women, 3.4 for men) but less so for persons who had tuberculin reactions of unknown duration and for persons with minor increases in size of tuberculin reaction (less than 12 mm increase from an initially negative reaction).