Revisiting Late-Onset Asthma: Clinical Characteristics and Association with Allergy

Santiago Quirce,¹ Enrico Heffler,² Natalia Nenasheva,³ Pascal Demoly,⁴ Andrew Menzies-Gow,⁵ Ana Moreira-Jorge,⁶ Francis Nissen,⁷ Nicola A Hanania<sup>8

1</sup>Department of Allergy, La Paz University Hospital, IdiPAZ and Universidad Autónoma de Madrid, Madrid, Spain; ²Personalized Medicine, Asthma and Allergy, Humanitas Clinical and Research Center, IRCCS, Rozzano, MI, Italy; ³Department of Allergology and Immunology of Russian Medical Academy for Continuous Medical Education, Moscow, Russian Federation; ⁴Department of Pulmonology, Division of Allergy, Hôpital Arnaud de Villeneuve, University Hospital of Montpellier, Montpellier, France; ⁵Department of Respiratory Medicine, Royal Brompton Hospital, London, UK; ⁶Novartis Farmaceutica, S.A., Barcelona, Spain; ⁷London School of Hygiene and Tropical Medicine, London, UK; ⁸Section of Pulmonary and Critical Care Medicine, Baylor College of Medicine, Houston, TX, USA

Correspondence: Santiago Quirce
Hospital Universitario La Paz, P. La Castellana, 261, Madrid, 28046 Spain
Email squirce@gmail.com

Abstract: The Global Initiative for Asthma (GINA) 2020 defines late-onset asthma (LOA) as one of the clinical phenotypes of asthma wherein patients, particularly women, present with asthma for the first time in adult life, tend to be non-allergic and often require higher doses of inhaled corticosteroids (ICS) or are relatively refractory to corticosteroid treatment. In this review, we examine the published literature improve the understanding of the following aspects of LOA: 1) the age cut-off for its diagnosis; 2) its distinct clinical phenotypes, characteristics and risk factors; and 3) its association with allergic comorbidities and conditions. Overall, our review reveals that clinicians and researchers have used multiple age cut-offs to define LOA, with cut-off ages ranging from > 12 years to ≥ 65 years. LOA has also been classified into several distinct phenotypes, some of which drastically differ in their clinical characteristics, course and prognosis. Although LOA has traditionally been considered non-allergic in nature, our review indicates that it is commonly associated with allergic features and comorbidities. Our findings suggest that there is an urgent need for the development of more clear clinical practice guidelines that can provide more clarity on the definition and other aspects of LOA. In addition, the association of LOA and allergy needs to be re-examined to frame a more optimal treatment strategy for patients with LOA.

Keywords: asthma, diagnosis, age of onset, allergy, allergic asthma, asthma phenotypes