Scottish Airways Research Network (SARN) Delphi Consensus on pre-biologic assessment, clinical remission and post-remission management in severe asthma

Introduction Scotland's severe asthma multidisciplinary teams and prescribing recommendations may contribute to variation in biologic decisions. We sought expert consensus on pre-biologic assessment, clinical remission and post-remission management through the Scottish Airways Research Network (SARN). Methods A scientific committee developed 28 statements across these three domains. Thirty specialists from 15 centres rated statements using a five-point Likert scale. Consensus was predefined as >75% agreeing or strongly agreeing. Statements requiring revision were considered in Round 2. Results Twenty-four panellists completed Round 1 (80% response), achieving consensus on 15/28 statements (53.6%); 23 completed Round 2 (76.7% response), achieving consensus on 10/13 revised statements (76.9%). Pre-biologic assessment should include treatment optimisation, comprehensive phenotyping, type 2 biomarkers, exacerbation history, comorbidities and patient characteristics. Clinical remission should generally be assessed after at least 12 months and comprise freedom from maintenance oral corticosteroids, absent or minimal symptoms, no severe exacerbations, stable lung function, normalised asthma-related quality of life, and patient-healthcare professional agreement. Improved lung function, reduced airway inflammation and treatment burden, and normalised airway hyperresponsiveness were desirable but not mandatory. No consensus was reached on a specific Asthma Control Questionnaire threshold for remission or restricting biologic access among current smokers not participating in smoking cessation. Dosing-interval extension or discontinuation should not be routine but may be considered for selected patients with sustained remission under specialist supervision, shared decision-making, close monitoring and a rapid restart plan. Conclusion This Scottish Delphi study provides a pragmatic framework to support equitable, consistent decisions on pre-biologic assessment, remission and treatment de-escalation.