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European Respiratory Societypulmonology2019advanced

Management of Severe Asthma

Published by European Respiratory Society/American Thoracic Society · GRADE

8Recommendations
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Summary

AI-generated

The guideline provides clinical recommendations for the management of severe asthma, focusing on the use of novel biological therapies for type 2 high asthma, antimuscarinic agents, macrolides, and the use of biomarkers for predicting treatment response.

severe asthmaanti-IL-5dupilumabtiotropiumERS/ATSpulmonologyguidelinesrecommendations

Key Takeaways

  • 1
    Use anti-IL-5 and anti-IL-5 receptor α for severe uncontrolled adult eosinophilic asthma phenotypes.
  • 2
    Use a blood eosinophil cut-point >=150 μL−1 to guide anti-IL-5 initiation in adult patients.
  • 3
    Consider specific eosinophil (>=260 μL−1) and FENO (>=19.5 ppb) cut-offs to identify adolescents or adults likely to respond to anti-IgE therapy.
  • 4
    Use inhaled tiotropium for adolescents and adults with severe uncontrolled asthma despite GINA step 4–5 or NAEPP step 5 therapies.
  • 5
    Consider a trial of chronic macrolide therapy to reduce asthma exacerbations in persistently symptomatic or uncontrolled patients on step 5 therapies.
  • 6
    Use anti-IL-4/13 (dupilumab) for adult patients with severe eosinophilic asthma and for those with severe corticosteroid-dependent asthma.

What's New in This Version

Unlike the 2014 first Task Force guidelines which considered general management strategies, this update focused specifically on six PICOs related to the rapid introduction of novel treatments (biologicals, antimuscarinic agents, and macrolides) and predictive biomarkers.

Key Recommendations

Question 1

  • 1

    We suggest an anti-IL-5 strategy as add-on therapy for adult patients with severe uncontrolled asthma with an eosinophilic phenotype and for those with severe corticosteroid-dependent asthma

    ConditionalEvidence: Lowtherapeutic

Question 2

  • 2

    We suggest that a blood eosinophil cut-point >=150 µL−1 can be used to guide anti-IL-5 initiation in adult patients with severe asthma and a history of prior asthma exacerbations

    ConditionalEvidence: Lowdiagnostic/therapeutic

Question 3

  • 3

    We suggest using a blood eosinophil cut-off >=260 µL−1 to identify adolescents (>12 years) and adults with severe allergic asthma more likely to benefit from anti-IgE treatment

    ConditionalEvidence: Lowdiagnostic/therapeutic
  • 4

    We suggest using a FENO cut-off >=19.5 ppb to identify adolescents (>12 years) and adults with severe allergic asthma more likely to benefit from anti-IgE treatment

    ConditionalEvidence: Lowdiagnostic/therapeutic

Question 4

  • 5

    For children, adolescents and adults with severe asthma uncontrolled despite GINA step 4–5 or NAEPP step 5 therapies, we recommend the addition of tiotropium

    StrongEvidence: Moderatetherapeutic

Question 5

  • 6

    We suggest a trial of macrolide treatment to reduce asthma exacerbations in adult asthma subjects on GINA/NAEPP step 5 therapy that remain persistently symptomatic or uncontrolled

    ConditionalEvidence: Lowtherapeutic
  • 7

    We suggest against the use of chronic macrolide treatment in children and adolescents with severe uncontrolled asthma

    ConditionalEvidence: Lowtherapeutic

Question 6

  • 8

    We suggest dupilumab as add-on therapy for adult patients with severe eosinophilic asthma and for those with severe corticosteroid-dependent asthma regardless of eosinophil levels

    ConditionalEvidence: Lowtherapeutic

Scope & Objectives

Clinical Topic

severe asthma

Objectives

This document provides clinical recommendations for the management of severe asthma.

Target Patient Population

adults and children (>5 years) with severe asthma

Diagnostic Criteria

Asthma that requires treatment with high dose inhaled corticosteroids plus a second controller (and/or systemic corticosteroids) to prevent it from becoming 'uncontrolled' or which remains 'uncontrolled' despite this therapy.

Target Providers

clinicianshealth professionals

Patient Criteria & Setting

Therapeutic Area

Respiratory

Guideline Scope

managementtreatment

Special Populations

adolescentschildrencorticosteroid-dependent asthma patientseosinophilic asthma patients

Evidence Grading

System: GRADE

Recommendation Strength

StrongA strong recommendation was made for or against an intervention when the panel was certain that the desirable consequences outweighed the undesirable consequences. It is one that most well-informed patients would follow.
ConditionalA conditional recommendation was made for or against an intervention when the panel was uncertain that the desirable consequences outweighed the undesirable consequences (due to low quality evidence, finely balanced consequences, underlying values/preferences, etc.). Well-informed patients may make different choices.

Authors & Contributors

Fernando HolguinJuan Carlos CardetKian Fan ChungSarah DiverDiogenes S. FerreiraAnne FitzpatrickMina GagaLiz KellermeyerSandhya KhuranaShandra KnightVanessa M. McDonaldRebecca L. MorganVictor E. OrtegaDavid RigauPadmaja SubbaraoThomy ToniaIan M. AdcockEugene R. BleeckerChris BrightlingLouis-Philippe BouletMichael CabanaMario CastroPascal ChanezAdnan CustovicRatko DjukanovicUrs FreyBetty FrankemöllePeter GibsonDominique HamerlijnckNizar JarjourSatoshi KonnoHuahao ShenCathy VitaryAndy Bush

Guideline Features

Dosing informationBased on systematic reviewMultidisciplinaryPatient involvement

Learning Context

Difficulty

advanced

Learning Paths

Severe AsthmaBiological TherapiesBiomarkersTiotropiumMacrolidesDupilumabType 2 AsthmaEosinophilic Asthma