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7 - Cardiovascular Disorders |
197
84. Man-Son-Hing M, Nichol G, Lau A, et al. Choosing
antithrombotic therapy for elderly patients with atrial
brillation who are at risk for falls. Arch Intern Med.
1999;159:677–685.
85.
Beyth, RJ, Quinn LM, Landefeld CS. Prospective
evaluation of an index for predicting the risk of major
bleeding in outpatients treated with warfarin. Am J
Med. 1998;105(2):91–99.
86.
Lip GY. Implications of the CHA(2)DS(2)-VASc and
HAS-BLED Scores for thromboprophylaxis in atrial
brillation. Am J Med. 2011;124(2):111–114.
87.
Pradaxa [package insert]. Ridgeeld, CT. Boehringer
Ingelheim Pharmaceuticals, Inc.; 2013.
88.
Xarelto [package insert]. Titusville, NJ. Janssen Phar-
maceuticals; 2014.
89.
Eliquis [package insert]. Princeton, NJ. Bristol-Myers
Squibb; 2014.
90.
Jauch EC, Saver JL, Adams Jr. HP, et al. Guidelines
for the early management of patients with acute isch-
emic stroke: a guideline for healthcare professionals
from the American Heart Association/American
Stroke Association. Stroke. 2013;44:870–947.
91. Lansberg MG, O’Donnell M, Khatri P, et al. Anti-
thrombotic therapy for ischemic stroke: American
College of Chest Physicians evidence-based practice
guidelines (9th ed). Chest. 2012;141(2 Suppl):e601S–
e636S.
92. Adams R, Albers G, Alberts M, et al. Update to the
AHA/ASA recommendations for the prevention of
stroke in patients with stroke and transient ischemic
attack. Stroke. 2008;39:1647–1652.
93. Sacco R, Diener H, Yusuf S, et al. Aspirin and
extended release dipyridamole versus clopidogrel for
recurrent stroke. New Engl J Med. 2008;359:1238–
1251.
94.
Diener H, Bogousslavsky J, Brass L, et al. Aspirin and
clopidogrel compared with clopidogrel alone after
recent ischaemic stroke or transient ischaemic attack in
high risk patients (MATCH): randomized, double-
blind, placebo-controlled trial. Lancet. 2004;364:331–
337.
95. National Institute of Neurological Disorders and
Stroke rt-PA Stroke Study Group. Tissue plasminogen
activator for acute ischemic stroke. N Engl J Med.
1995;333:1581–1587.
96. Sylaja P, Cote R, Buchan A, et al. rombolysis in
patients older than 80 years with acute ischemic stroke:
Canadian Alteplase for Stroke Eectiveness Study. J
Neurol Neurosurg Psychiatr. 2006;77:826–829.
97. Berrouschot J, Rother J, Glahn J, et al. Outcome and
severe hemorrhagic complications of intravenous
thrombolysis with tissue plasminogen activator in very
old (≥80 years) stroke patients. Stroke. 2005;36:2421–
2425.
98.
Tanne D, Gorman M, Bates V, et al. Intravenous tissue
plasminogen activator for acute ischemic stroke in
patients aged 80 years and older. Stroke. 2000;31:370–
375.
99.
Engelter S, Bonati L, Lyrer P. Intravenous thrombol-
ysis in stroke patients of ≥80 versus <80 years of age:
a systematic review across cohort studies. Age Ageing.
2006;35:572–580.
100.
Chinese Acute Stroke Trial Collaborative Group.
CAST: randomized placebo controlled trial of early
aspirin use in 20,000 patients with acute ischemic
stroke. Lancet. 1997;349:1641–1649.
101.
International Stroke Trial Collaborative Group. IST:
a randomized trial of aspirin, subcutaneous heparin,
both, or neither among 19,435 patient with ischemic
stroke. Lancet. 1997;349:1569–1581.
102.
Oger E. Incidence of venous thromboembolism: a
community based study in western France. romb
Haemost. 2000;83:657–660.
103. Kahn SR, Lim W, Dunn AS, et al. Prevention of
venous thromboembolism in nonsurgical patients:
American College of Chest Physicians Evidence-
Based Clinical Practice Guideline (8th edition). Chest.
2012;141(2 Suppl):e195S–e226S.
104. Gould MK, Garcia DA, Wren SM, et al. Prevention of
venous thromboembolism in nonorthopedic surgical
patients: American College of Chest Physicians
Evidence-Based Clinical Practice Guideline (8th
edition). Chest. 2012;141(2 Suppl):e227S–e277S.
105. Falck-Ytter Y, Francis CW, Johnson NA, et al.
Prevention of venous thromboembolism in orthopedic
surgery patients: American College of Chest Physi-
cians Evidence-Based Clinical Practice Guideline (8th
edition). Chest. 2012;141(2 Suppl):e278S–e325S.
106. Kearon C, Akl EA, Comerota AJ, et al. Antithrom-
botic therapy for venous thromboembolic disease:
American College of Chest Physicians evidence-
based clinical practice guideline (9th edition). Chest.
2012;141(2 Suppl):e419S.
107.
Jacobs L. e use of oral anticoagulants (warfarin) in
older people. J Am Geriatr Soc. 2002;50:1439–1445.
108. Activase [package insert]. San Francisco, CA: Genen-
tech; December 2012.
109.
Ansell J, Hirsh J, Hylek E, et al. Pharmacology and
management of vitamin K antagonists: American
College of Chest Physicians evidence based
clinical practice guidelines (8th edition). Chest.
2008;133:160S–198S.
110. Garcia D, Regan S, Crowther M, et al. Warfarin
maintenance dosing patterns in clinical practice:
implications for safer anticoagulation in the elderly
population. Chest. 2005;127:2049–2056.
https://t.me/medicina_free
198
| Fundamentals of Geriatric Pharmacotherapy
111. Kearon C, Ginsberg JS, Kovacs MJ, et al. Comparison
of low-intensity warfarin therapy with conventional-
intensity warfarin therapy for long-term prevention
of recurrent venous thromboembolism. N Engl J Med.
2003;349:631–639.
112.
Centers for Medicare and Medicaid Services. Decision
memo for prothrombin time (INR) monitor for home
anticoagulation management (CAG-00087R). March
19, 2008. http://www.cms.gov/medicare-coverage-
database/details/nca-decision-memo.aspx?NCAId=2
09&NCDId=269&ncdver=2&NcaName=Prothrom
bin+Time+(INR)+Monitor+for+Home+Anticoagula
tion+Management&IsPopup=y&bc=AAAAAAAA
EAAA&. Accessed July 31, 2014.
113.
Shepherd A, Hewick D, Moreland T, et al. Age as a
determinant of sensitivity to warfarin. Br J Clin Phar-
macol. 1977;4:315–320.
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8
R
D
MICHAEL R. BRODEUR
L O
1. Critically review the medical literature representing treatment of chronic obstructive pulmonary disease (COPD),
asthma, and tuberculosis (TB) in older adults.
2.
Assess the applicability of general adult treatment guidelines for COPD, asthma, and TB to older adults.
3. Recommend appropriate drug therapy and treatment goals for various respiratory disorders in older adults.
4. Describe common problems encountered by older adults associated with therapies for respiratory disorders and
recommend solutions to these problems.
K T D
IMMUNOSENESCENCE: The waning of the immune system that occurs with age.
NEBULIZER: A device used to disperse liquid medicine in a mist of extremely fine particles; useful in delivering
medicine to the lower respiratory tract.
REACTIVATION: A TB stage that occurs from a previously dormant focus seeded at the time of primary infec-
tion. Symptoms of cough, weight loss, and fatigue develop insidiously over weeks to months before diagnosis.
SPIROMETRY: Study of air volume and flow rate within the lungs. Normal values are based on age, gender,
and height and are expressed as a percentage of a person’s predicted value. Key measurements include forced
vital capacity (FVC) and forced expiratory volume over the first second (FEV-1).
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| Fundamentals of Geriatric Pharmacotherapy
I
A
host of age-related changes occur in the
respiratory system. Although some of
these changes are normal in aging, most are
secondary to environmental effects or complica-
tions due to specific disease states. When pulmo-
nary insults occur in the elderly patient, such as
COPD, asthma, and infection, the loss of reserve
capacity in the lung prevents adequate response
to the stressors imposed. Pulmonary decompen-
sation can be rapid and difficult to reverse. This is
readily apparent in the frailest of patients.
This chapter covers respiratory-related
illnesses common in the older population,
including COPD, asthma, and TB. Pneumonia
and influenza are discussed in Chapter 17. Insti-
tutionalized patients have important differences
from those in the community regarding treat-
ment of these diseases. However, in any setting,
adequate use of preventive measures and rapid
response when exacerbations occur can reduce
the morbidity and mortality associated with these
illnesses. Pharmacists must take a leading role in
ensuring patients, caregivers, and other health-
care professionals are educated to recognize
and implement optimal pharmacotherapy to
prevent and/or treat respiratory illnesses in the
older patient.
C O
P D
A
Etiology, Epidemiology, and
Clinical Presentation Specic to
Geriatrics
Respiratory diseases are common disorders in
older adults and account for significant morbidity
and mortality. COPD is the third leading cause
of death in the United States and affects
20% of adults.
1,2
The prevalence of asthma
in older adults is difficult to assess due to
underdiagnosis, misdiagnosis, and undertreat-
ment; however, most studies indicate a preva-
lence of approximately 7%. Differentiating the
two conditions can be problematic for the experi-
enced clinician, especially because asthma and
COPD may coexist in the same patient.
With respiratory disorders being so
common, special attention should focus on the
issues that are unique in the elderly: potential
for medication adverse effects, especially in
those patients with multiple medical comorbidi-
ties; drug interactions in patients receiving poly-
pharmacy, particularly medications that may
worsen asthma and COPD; and issues of effec-
tive medication delivery, specifically with refer-
ence to inhaled medications. In addition, many
age-related changes occur within the respiratory
system that can affect the course of both asthma
and COPD.
Age-related changes affecting the respira-
tory system include
•
loss of height secondary to osteoporosis,
leading to a decrease in lung volume,
• neurologic conditions affecting the swal-
lowing mechanism, leading to aspiration,
• decreased perception of bronchoconstric-
tion despite similar levels of decreases in
forced expiratory volume over 1 second
(FEV-1) after a methacholine challenge test,
and
•
decreased bronchodilator response to
inhaled beta agonists (no data to support
any age-related difference in response to
inhaled anticholinergic medications).
3
The misconception that asthma is a child-
hood disease causes symptoms to be overlooked
by both patients and physicians. A majority of
elderly patients who develop asthma after the
age of 65 have their first asthmatic symptoms
preceded immediately or concomitantly with
an upper respiratory tract infection. This may
delay the diagnosis of asthma, because patients
attribute their respiratory symptoms to lingering
effects from the upper respiratory tract infec-
tion. Other conditions and diseases may present
with respiratory symptoms, such as heart failure
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8 - Respiratory Disorders |
201
and gastroesophageal reflux, in which cough
is a common complaint as it is with asthma.
Treatment of asthma is more complicated in
older patients compared to younger patients.
Although younger patients may be managed
with medications as needed, older patients most
often require continuous therapy complicated by
frequent dosing with multiple medications.
Summary of Standard Treatment in
the General Adult Population
The management of COPD has been summa-
rized in national and international guidelines that
stress similar treatment modalities. The Global
Initiative for Chronic Obstructive Lung Disease
was designed to increase awareness of COPD
and improve prevention and management with
the ultimate goal of reducing disease-related
morbidity and mortality. The goals of treatment
for COPD are to improve quality of life, exercise
tolerance, sleep quality, and survival and to
reduce dyspnea, nocturnal symptoms, exacer-
bations, use of rescue medications, and hospi-
talizations. The diagnosis of COPD should be
considered in any patient who has dyspnea,
chronic cough, or sputum production, and/or a
history of exposure to risk factors for the disease.
The diagnosis should be confirmed by spirom-
etry.
2
A post-bronchodilator FEV-1/FVC ratio
<0.70 confirms the presence of airflow limitation
that is not fully reversible. The FEV-1/FVC ratio is
used to stratify the severity of airflow limitation.
Symptoms can be quantified using the Modified
British Medical Research Council questionnaire
on breathlessness or the COPD Assessment
Test. Assessment of a patient’s risk of COPD
exacerbation is based on his or her exacerbation
history. Treatment regimens include medications
with different mechanisms of action (Table 8-1).
Depending on the severity of COPD, the guide-
lines recommend first and alternative treatment
choices (Table 8-2). However, only smoking
cessation and supplemental oxygen therapies
have been proven to improve the course of
COPD. Smoking cessation is most effective in
early disease, but all patients who smoke should
be encouraged to quit.
Similar to COPD, a stepwise approach
to the treatment of asthma is recommended.
Step 1 utilizes short-acting beta agonists on an
as-needed basis; steps 2–4 emphasize inhaled
corticosteroids (ICS) as the preferred regimen,
with the daily dose of ICS increasing as the steps
progress. Alternative treatment options include
leukotriene receptor modifiers, cromolyn, and
theophylline. Omalizumab should be considered
in patients who have allergies, although there
are limited data on its efficacy in older adults.
These treatment steps have been designed for
the general adult population and may be applied
to older adults with some modifications.
For both COPD and asthma, proper inhaler
technique is critical to successful therapy. The
following strategies should be employed when
counseling patients using inhalers:
• Be familiar with various inhaler devices and
how to use them; placebo devices are a
valuable training aid
• Demonstrate the technique to the patient
• Encourage patients to demonstrate the use
of their inhaler
•
Re-check inhaler technique at each visit
until the patient has mastered the technique;
consider re-checking this every 2–3 months
thereafter
•
Reinforce that spacer devices are an essen-
tial tool
•
Minimize the number and types of inhaler
devices
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| Fundamentals of Geriatric Pharmacotherapy
Table 8-1. Commonly Used Drugs in the Management of COPD and Asthma
Class:
Medication
Examples
Indications for
Use
General Adult
Treatment Principles Geriatric Considerations
Short-acting β agonists
(SABA):
Inhaled and oral
bronchodilators
Albuterol
Pirbuterol terbutaline
sulfate (oral tablets
only)
Levalbuterol
hydrochloride
Levalbuterol tartrate
Asthma: Treatment
of choice for relief
of acute symptoms
and prevention of
exercise-induced
bronchospasm;
generally used as
needed.
COPD: For relief of
acute symptoms.
Asthma: Use of SABA >2
days a week for symptom
relief (not prevention of
EIB) generally indicates
inadequate asthma control
and need for initiating
or intensifying anti-
inflammatory therapy.
Chronic use of SABA not
recommended.
COPD: Improves
breathlessness but not
other patient-oriented
outcomes. In stable COPD
there is an associated
improvement in FEV-1.
Combinations of bronchodilators
improve efficacy and reduce
risk of AEs versus increasing
the dose of a single agent.
This sound strategy supports
combination therapy using
ipratropium and albuterol, for
example, rather than quadrupling
the dose of either one of those
agents alone.
Possible SE: tachycardia,
palpitations, tremor, feeling
nervous, insomnia, HA, N/V.
Geriatric patients may be more
susceptible to these effects.
Anticholinergics: Inhaled
bronchodilators
Ipratropium bromide
Tiotropium
Asthma: Ipratropium
may be used as
an alternative
bronchodilator for
patients intolerant of
SABA.
COPD: May be more
effective than long-
acting β agonist
(LABA) in relieving
the symptoms of
COPD.
Asthma: Effective as
bronchodilator but not
as potent as β agonists.
Ipratropium provides
additive benefit to SABA
in moderate or severe
exacerbations not
responding to β agonists
alone.
COPD: Improves symptoms
and quality of life and
decreases exacerbations,
hospitalizations, and
deaths; improves sleep.
Decreases rescue inhaler
use and office visits.
Inhaled ipratropium has an
excellent safety profile in
the elderly, and it should be
considered for use when
additional bronchodilator therapy
is necessary. Ipratropium has a
slow onset of action; it requires
30–60 min for maximal effect.
Possible AE: Dry mouth, abnormal
taste in mouth, bitter, nasal
congestion, dry nasal mucosa,
tachycardia.
Tiotropium: Ensure that patient
has the dexterity to place the
capsule in the HandiHaler; do
not swallow the capsule—for
inhalation use only.
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203
Table 8-1. Commonly Used Drugs in the Management of COPD and Asthma (cont’d)
Class:
Medication
Examples
Indications for
Use
General Adult
Treatment Principles Geriatric Considerations
Inhaled corticosteroids:
Inhaled anti-
inflammatory
Beclomethasone
dipropionate
Budesonide
Ciclesonide
Flunisolide
Fluticasone propionate
Mometasone furoate
Triamcinolone
Asthma: The most
effective long-term
control therapy for
persistent asthma
regardless of
severity.
Patient should be started on
higher and more frequent
doses and then tapered
down once control has
been achieved. Response
is delayed with symptom
improvement occurring
within the first 1–2 wk
in most patients and full
therapeutic benefits in
4–8 wk.
Risk of systemic toxicity
minimal with low to
moderate doses and
increases with high doses
(>1000 mcg/day). Local
AEs (e.g., oropharyngeal
candidiasis, hoarseness,
cough, and dysphonia) can
be reduced by use of a
spacer device and rinsing
mouth after use.
Use the lowest dose that
maintains asthma control.
Assess patient’s inhaler
technique, adherence, and
environmental measures
before increasing dose.
Adding a LABA to a
low or medium dose of
inhaled corticosteroids
may be more effective
than doubling the dose
of steroids to maintain
asthma control.
COPD: Decreases
exacerbations in patients
with moderate to severe
disease. No effect on
mortality.
Long-term use of inhaled
corticosteroids at recommended
doses has been associated with
a good safety profile.
AEs are dose related. Local
effects of the mouth and
pharynx include candidiasis and
dysphonia. Systemic absorption
of inhaled corticosteroids has
been associated with skin
bruising, cataracts, and reduced
bone mineral density. An
increase risk of pneumonia has
been associated with high doses
(1000 mcg/day) of fluticasone.
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| Fundamentals of Geriatric Pharmacotherapy
Table 8-1. Commonly Used Drugs in the Management of COPD and Asthma (cont’d)
Class:
Medication
Examples
Indications for
Use
General Adult
Treatment Principles Geriatric Considerations
LABA
Inhaled bronchodilator
Formoterol
Salmeterol
Asthma: Used as
adjunctive long-term
therapy with
inhaled
corticosteroids,
which is more
effective than
increasing the dose
of corticosteroids
alone.
Can be used for
nocturnal asthma.
NOT used as monotherapy
due to absence of anti-
inflammatory properties.
NOT effective for acute severe
asthma due to slow onset
(20–30 min). Formoterol has
faster onset than salmeterol.
Need to continue short-
acting β agonist for acute
exacerbations while on
LABAs.
Use in the elderly should be
closely monitored.
Geriatric patients may be
more susceptible to SEs of β
agonists (e.g., tachycardia,
palpitations, tremor). This
risk is higher in patients with
pre-existing coronary artery
disease. Other SEs include
nervousness, insomnia, HA,
and N/V.
May cause dose-dependent
drop in serum potassium and
QT interval prolongation; use
cautiously in patients with
arrhythmia and pre-existing
coronary artery disease.
Although not clearly established,
airway responsiveness to
β-agonist medications may
also decrease with age.
Methylxanthine:
Oral bronchodilators
Theophylline
Asthma: Sustained-
release theophylline
may be used as
alternative, not
preferred, therapy
for step 2 (mild
persistent asthma).
It may be also used
as an adjunctive
with inhaled
corticosteroids.
Rarely used in practice.
Monitoring of theophylline
concentration is essential.
Severe cardiac arrhythmia,
seizures, and death
can occur at serum
concentration only twofold
greater than optimal
therapeutic concentration.
Use not recommended due to
safety concern. Patients over
age 75 have a 16-fold greater
risk of life-threatening events
or death than patients under
age 25 at comparable serum
theophylline level.
Dose should be reduced. Elderly
patients should be started with
a 25% reduction of the adult
dose.
Combined medication:
Inhaled bronchodilator
and steroid
Budesonide and
formoterol
Fluticasone and
salmeterol
Fluticasone and
vilanterol
Asthma: Use is
recommended for
step 3 (moderate
persistent asthma).
COPD: Use is
recommended
in Group D
patients with
many symptoms
and high risk for
exacerbations.
The combination gives
the advantage of
providing bronchodilation
while reducing airway
inflammation. LABA
also allows reduction in
corticosteroid dosage (by
50%).
Onset is rapid (within 1
wk). Compliance can be
also improved with the
combination.
Refer to each component.
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8 - Respiratory Disorders |
205
Table 8-1. Commonly Used Drugs in the Management of COPD and Asthma (cont’d)
Class:
Medication
Examples
Indications for
Use
General Adult
Treatment Principles Geriatric Considerations
Corticosteroids:
Oral anti-inflammatory
Methylprednisolone
Prednisone
Dexamethasone
Asthma: Indicated in
patients with acute
severe asthma
not responding
completely to
aggressive inhaled β
agonists. Also used
long term to treat
patients with severe
persistent asthma.
COPD: Long-term
treatment with oral
corticosteroids is
not recommended in
COPD. Can be used
for short periods
for management of
COPD exacerbations.
May take 6–8 hr for pulmonary
function improvement.
Most patients achieve 70%
predicted FEV-1 within 48 hr
and 80% by day 6. Full dose
should be continued until
patient’s peak flow reaches
80% of predicted normal or
personal best. Tapering the
steroid dosage after short
course is unnecessary.
The following attempts
should be made: (1)
optimize therapy with
inhaled corticosteroids, (2)
keep oral steroids to the
minimum dose possible, (3)
use relatively short-acting
agents (e.g., prednisone
and methylprednisolone), (4)
attempt to control symptoms
with alternate-day dosing.
Long-term use of corticosteroids
may lead to or exacerbate
osteoarthritis, diabetes,
hypertension, cataracts,
and (rarely) depression of
the immune system and
susceptibility to infections. This
can be troublesome because
many of these complications
occur in the elderly even
without steroid use.
Myopathy, increased skin
fragility, loss of attention
span and memory, and mood
swings may also occur in
geriatric patients with long-
term steroid use.
Monitor closely with long-term
steroid use.
Leukotriene modifiers:
Oral anti-inflammatory
Montelukast
Zafirlukast
Zileuton
Asthma: Effective
in prevention of
allergen-induced,
exercise-induced,
and aspirin-induced
asthma.
Can also be used as
adjunctive therapy with
inhaled corticosteroids.
Can be used as daily
medication for mild
persistent asthma
but is less preferred
than low-dose inhaled
corticosteroids.
Liver function monitoring is
essential.
Possible AEs: headache,
nausea, diarrhea, infection.
Geriatric patients may be more
susceptible to some of the
AEs (e.g., headache, mild
infection).
Females >65 years of age
appear to be at an increased
risk for ALT elevations.
QT interval prolongation is
possible with zileuton.
Montelukast appears to be the
safest of the three.
Mast cell stabilizers:
Inhaled anti-
inflammatory
Cromolyn sodium
Nedocromil sodium
Asthma: Indicated for
prophylaxis of mild
persistent asthma
(step 2).
May be particularly effective
for allergic asthmatics
on a seasonal basis. May
also be used as preventive
therapy before exercise or
unavoidable exposure to
known allergens.
Coughing and wheezing are
possible after inhalation of
each agent; bad taste and
headache are possible after
nedocromil use.
Well tolerated.
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| Fundamentals of Geriatric Pharmacotherapy
Table 8-1. Commonly Used Drugs in the Management of COPD and Asthma (cont’d)
Class:
Medication
Examples
Indications for
Use
General Adult
Treatment Principles Geriatric Considerations
Monoclonal antibody:
Anti-allergen
Omalizumab
Asthma: Indicated
for treatment
of moderate to
severe persistent
allergic asthma
not well controlled
by high doses
of inhaled
corticosteroids.
Dose is based on IgE serum
levels prior to treatment
and body weight. Dosing
adjustment during
treatment should be
based on significant
changes in body weight,
NOT IgE levels during
or <1 year following
discontinuation of therapy.
Possible SE: Injection-site
reactions, anaphylaxis,
viral infection, upper
respiratory tract infection,
sinusitis, headache, sore
throat.
Specific geriatric
considerations have not
been established.
Elderly patients might be
more susceptible to AEs.
AE, adverse effect; ALT, alanine aminotransferase; EIB, exercise-induced bronchospasm; HA, headache;
IgE, immunoglobulin E; N/V, nausea and vomiting.
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