Treatment Considerations in Severe Asthma

Severe asthma is a significant health burden, affecting patients’ activities of daily living, quality of life, morbidity, and mortality, as well as increasing healthcare utilization, and effective management is key in helping these patients. To this end, a session at the annual ACAAI meeting reviewed considerations in planning and managing treatment and an overview of new pharmacological agents.

The goals of treatment for severe asthma are to reduce current impairment and reduce future risks, said presenter Nicola A. Hanania, MD, MS, of Baylor College of Medicine in Houston. Clinicians aim to improve symptom control, manage comorbidities, increase lung function, and boost functional status and quality of life. Simultaneously, they seek to reduce exacerbations, hospitalizations, treatment-related adverse events, and visits to the emergency department, as well as avoid disease progression and mortality.

He offered the following initial components of asthma management:

  • Initial assessment and continuous monitoring should include monitoring of symptoms, exacerbations, and quality of life, along with periodic pulmonary function tests.
  • Clinicians should help patient avoid triggers at home, at work, and in public, such as cigarette smoke, irritants, air pollutants, and allergens. In addition, the healthcare team should stay alert for any exacerbating diseases, such as gastroesophageal reflux disease, allergic rhinitis, and sinusitis.
  • Determine medications.
  • The healthcare team must provide asthma education.

The Global Initiative for Asthma (GINA) frames asthma management in a three-step loop:

  • Assess: ensure accurate diagnosis, control symptoms and risk factors, coach proper inhaler technique and adherence, and learn patient preferences.
  • Review symptoms, exacerbations, side effects, patient satisfaction, and lung function.
  • Adjust treatment, including nonpharmacologic strategies.

For more information about the GINA recommendations, visit https://ginasthma.org/2018-pocket-guide-for-asthma-management-and-prevention/.

Conventional therapies for asthma include controllers such as inhaled corticosteroids (ICS), long-acting inhaled bronchodilators (LABAs), tiotropium, and leukotriene modifiers. Quick relivers for emergencies are quick-acting beta-agonist bronchodilators and systemic steroids.

Recent biologics targeting T2 airway inflammation in asthma have recently become available. Approved medications include omalizumab (targets IgE), mepolizumab and reslizumab (target interleukin (IL)-5), benralizumab (targets IL-5 receptors), and dupilumab (targets the IL-4 receptor). Investigational agent tezepelumab targets TSLP. Hanania also shared research demonstrating the approved agents’ effectiveness in controlling asthma, increasing FEV1, improving quality of life, decreasing use of oral corticosteroids, and decreasing exacerbations. Research into long-term effects and expanded uses is ongoing.

This session was provided by ACAAI and supported by an educational grant from GlaxoSmithKline.