Managing Severe Asthma in Adults: Lessons From the ERS/ATS Guidelines

Kian Fan Chung


Curr Opin Pulm Med. 2015;21(1):8-15. 

In This Article

Abstract and Introduction


Purpose of review To review the latest guidelines on severe asthma.

Recent findings An updated definition of severe asthma is provided together with the evaluation steps necessary to reach a diagnosis of severe asthma. The importance of phenotyping is emphasized, and recommendations are provided for therapies specifically directed for severe asthma.

Summary Severe asthma is widely recognized as a major unmet need. It is defined as asthma that requires treatment with high-dose inhaled corticosteroids and a second controller and/or systemic corticosteroid to prevent it from becoming 'uncontrolled' or that remains 'uncontrolled' despite this therapy. Severe asthma is a heterogeneous condition that consists of phenotypes such as eosinophilic asthma. More phenotypes need to be defined. Evaluation of the patient referred to as having severe or difficult-to-control asthma must take into account adherence to treatment, comorbidities and associated factors including side effects from therapies. These need to be addressed. Recommendations on the use of sputum eosinophil count and exhaled nitric oxide to guide therapy are presented. Treatment with anti-IgE antibody, methotrexate, macrolide antibiotics, antifungal agents and bronchial thermoplasty is reviewed and recommendations made. Research efforts into phenotyping of severe asthma will provide both biomarker-driven approaches and newer effective therapies to severe asthma management.


Asthma can be considered a complex disease because it is likely to be caused by multi-factorial components and can present in different ways with varied long-term outcomes. The basis for this likely rests on the lack of a diagnostic marker of disease and the current diagnosis resting mostly on a history of intermittent wheeze. Another paradox is that although most patients with a diagnosis of asthma can be adequately treated with a combination therapy of inhaled corticosteroids (ICS) and a bronchodilator, usually long-acting β-agonists (LABAs), there is a core of patients whose asthma remains uncontrolled despite being on these treatments. These patients are generally termed having severe asthma or refractory asthma, particularly if addition of other controller medications on top of combination therapy does not lead to any improvement in asthma control. Such patients taking high-level treatments as exemplified by the steps 4 and 5 of the Global Initiative for Asthma (GINA) guidelines indeed experience the most morbidity, and although consisting of only 5–10% of the asthma population, consume the majority of the healthcare costs for asthma. In a recent study of patients with persistent asthma taken from 10 countries in Europe, the estimated costs for patients with uncontrolled asthma as defined in GINA that included expenses for drugs, doctor visits, tests and hospital admissions and costs linked to loss of productivity and days lost amounted to 2281 Euros compared to 509 Euros in a controlled asthma patient.[1] Clearly, there is an unmet need in this group of patients called severe. Not only do these patients need to benefit from more efficacious therapies, the whole condition called severe asthma needs to be understood more.