International ERS/ATS guidelines on definition, evaluation and treatment of severe asthma

Abstract

Severe or therapy-resistant asthma is increasingly recognised as a major unmet need. A Task Force, supported by the European Respiratory Society and American Thoracic Society, reviewed the definition and provided recommendations and guidelines on the evaluation and treatment of severe asthma in children and adults.A literature review was performed, followed by discussion by an expert committee according to the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach for development of specific clinical recommendations.When the diagnosis of asthma is confirmed and comorbidities addressed, severe asthma is defined as asthma that requires treatment with high dose inhaled corticosteroids plus a second controller and/or systemic corticosteroids to prevent it from becoming “uncontrolled” or that remains “uncontrolled” despite this therapy. Severe asthma is a heterogeneous condition consisting of phenotypes such as eosinophilic asthma. Specific recommendations on the use of sputum eosinophil count and exhaled nitric oxide to guide therapy, as well as treatment with anti-IgE antibody, methotrexate, macrolide antibiotics, antifungal agents and bronchial thermoplasty are provided.Coordinated research efforts for improved phenotyping will provide safe and effective biomarker-driven approaches to severe asthma therapy.

Nordic consensus statement on the systematic assessment and management of possible severe asthma in adults

“…The ERS/ATS guidelines on severe asthma published in 2014 define severe asthma as ‘ asthma which requires treatment with high dose inhaled corticosteroids (ICS) plus a second controller or systemic CS, which remains “uncontrolled” despite this therapy, or to prevent it from becoming “uncontrolled”’ [1]. Hence, this definition includes patients, who are well controlled on high-dose therapy, but lose symptom control when down-titrated [1].…”

“…Hence, this definition includes patients, who are well controlled on high-dose therapy, but lose symptom control when down-titrated [1]. The definitions of high dose ICS are summarized in Table 1.…”

“…Patients in whom poor asthma control is related to other factors, such as poor adherence or co-morbidities, are termed ‘difficult-to-treat asthma’ 1 (Figure 1).

Figure 1.Severe asthma: definition and systematic assessement.

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“…Although the majority of asthma patients have mild to moderate disease, a proportion of asthma patients have difficulty in achieving control on standard treatment or require very high doses of treatment to maintain asthma control, and risk of side effects [1,2]: In the patients with severe asthma, control is not obtained despite correction of comorbidities and correct use of high doses of asthma medications. Patients with severe asthma represent a major unmet need, as they experience frequent exacerbations, are hospitalized more often, and utilize the majority of health care expenses in asthma [3].…”

Health care resource utilization and characteristics of patients with eosinophilic asthma in secondary health care in Finland

“…In Finland and several European counties, improvements in asthma care during the last two decades have resulted in cost savings at both societal and patient levels, despite the increasing number of asthma patients [2–5]. However, many severe asthma patients are still uncontrolled [6,7], and asthma imposes a high burden on health care systems and on society [1,8]. …”