A European Respiratory Society and American Thoracic Society (ERS/ ATS) Task Force of asthma experts has developed updated clinical recommendations for the management of severe asthma.
The guidelines were initiated in light of the rapid introduction of new treatments for severe asthma, including new biological treatments for the management of severe eosinophilic asthma.
Summary from the ERS/ ATS severe asthma guidelines:
After considering the balance of desirable and undesirable consequences, quality of evidence, feasibility, and acceptability of various interventions, the Task Force made the following recommendations:
1) Suggest using anti-interleukin (IL)-5 and anti-IL-5 receptor α for severe uncontrolled adult eosinophilic asthma phenotypes.
2) Suggest using a blood eosinophil cut-point ≥150 μL−1 to guide anti-IL-5 initiation in adult patients with severe asthma.
3) Suggest considering specific eosinophil (≥260 μL−1) and exhaled nitric oxide fraction (≥19.5 ppb) cut-offs to identify adolescents or adults with the greatest likelihood of response to anti-IgE therapy.
4) Suggest using inhaled tiotropium for adolescents and adults with severe uncontrolled asthma despite Global Initiative for Asthma (GINA) step 4–5 or National Asthma Education and Prevention Program (NAEPP) step 5 therapies.
5) Suggest a trial of chronic macrolide therapy to reduce asthma exacerbations in persistently symptomatic or uncontrolled patients on GINA step 5 or NAEPP step 5 therapies, irrespective of asthma phenotype.
6) Suggest using anti-IL-4/13 for adult patients with severe eosinophilic asthma and for those with severe corticosteroid-dependent asthma regardless of blood eosinophil levels.
These recommendations for the treatment of severe asthma should lead to modifications of guidelines and improvement in outcomes that are important to patients, namely reduction in oral corticosteroid dose and exacerbation frequency and improved quality of life. However, it is recognised that these recommendations will not be effective across all severe asthma subjects and that more precise phenotype-driven research is needed. Prior to adopting these novel and in many cases invasive and expensive approaches, every effort should be made to deploy standard medications to maximum benefit. However, for the minority of patients with asthma who, for whatever reason, do not respond to standard therapies and continue to experience frequent exacerbations, there is an exciting new and evolving world of novel, beneficial approaches.
Reference:
Management of severe asthma: a European Respiratory Society/American Thoracic Society guideline. Fernando Holguin, Juan Carlos Cardet, Kian Fan Chung, Sarah Diver, Diogenes S. Ferreira, Anne Fitzpatrick, Mina Gaga, Liz Kellermeyer, Sandhya Khurana, Shandra Knight, Vanessa M. McDonald, Rebecca L. Morgan, Victor E. Ortega, David Rigau, Padmaja Subbarao, Thomy Tonia, Ian M. Adcock, Eugene R. Bleecker, Chris Brightling, Louis-Philippe Boulet, Michael Cabana, Mario Castro, Pascal Chanez, Adnan Custovic, Ratko Djukanovic, Urs Frey, Betty Frankemölle, Peter Gibson, Dominique Hamerlijnck, Nizar Jarjour, Satoshi Konno, Huahao Shen, Cathy Vitary, Andy Bush
European Respiratory Journal 2020 55: 1900588; DOI: 10.1183/13993003.00588-2019
