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Management of severe asthma: summary of the European Respiratory Society/American Thoracic Society task force report

Sandhya Khurana, Andrew Bush, Fernando Holguin on behalf of the European Respiratory Society/American Thoracic Society Severe Asthma Task Force
Breathe 2020 16: 200058; DOI: 10.1183/20734735.0058-2020
Sandhya Khurana
1University of Rochester School of Medicine and Dentistry, Pulmonary and Critical Care Medicine, Rochester, NY, USA
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  • For correspondence: sandhya_khurana@urmc.rochester.edu
Andrew Bush
2Dept of Paediatrics, National Heart & Lung Institute, Imperial College London, London, UK
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Fernando Holguin
3University of Colorado, Pulmonary Sciences and Critical Care Medicine, Denver, CO, USA
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  • ORCID record for Fernando Holguin
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  • Figure 1
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    Figure 1

    T2 inflammation in asthma and available biologics. DC: dendritic cell; Th0: naïve T-cell; Th2: T-helper 2 cell; B: B-cell; TSLP: thymic stromal lymphopoietin.

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    Figure 2

    Biomarkers in T2 asthma. Eos: Eosinophil; iNOS: inducible nitric oxide synthase.

Tables

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  • Table 1

    Currently available biologics for T2 asthma

    DrugMechanismRoute
    OmalizumabAnti-IgESubcutaneous
    MepolizumabAnti-IL-5Subcutaneous
    ReslizumabAnti-IL-5Intravenous
    BenralizumabAnti-IL-5RαSubcutaneous
    DupilumabAnti-IL-4RαSubcutaneous

    R: receptor.

    • Table 2

      Questions selected by the ERS/ATS Severe Asthma Task Force

      Should a monoclonal anti-IL-5 antibody be used in adults and children# with severe asthma?
      Should a measurement of a specific biomarker be used to guide initiation of treatment with a monoclonal anti-IL-5 or IL-5Rα antibody in adults and children with severe asthma? (Chosen biomarkers being FENO, peripheral or sputum eosinophils and serum periostin)
      Should a measurement of a specific biomarker be used, in addition to total IgE level, to guide initiation of treatment with a monoclonal anti-IgE antibody in adults and children with severe asthma? (Chosen biomarkers being FENO, peripheral or sputum eosinophils and serum periostin)
      Should an inhaled LAMA be used in adults and children with severe asthma?
      Should a macrolide (i.e. azithromycin, clarithromycin) be used in adults and children with severe asthma?
      Should a monoclonal anti-IL-4Rα be used in adults and children with severe asthma?

      R: receptor. #: for the purposes of this guideline, age >5 years. Reproduced and modified from [6].

      • Table 3

        Summary of ERS/ATS severe asthma task force recommendations

        QuestionRecommendationStrengthQuality of evidence
        1Suggest 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 asthmaConditionalLow
        2Suggest that a blood eosinophil cut-point ≥150 per µL can be used to guide anti-IL-5 initiation in adult patients with severe asthma and a history of prior asthma exacerbationsConditionalLow
        3Suggest using a blood eosinophil cut-off ≥260 per µL to identify adolescents (>12 years) and adults with severe allergic asthma more likely to benefit from anti-IgE treatmentConditionalLow
        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 treatmentConditionalLow 
        4For children, adolescents and adults with severe asthma uncontrolled despite GINA step 4–5 or NAEPP step 5 therapies, recommend the addition of tiotropiumStrongModerate
        5Suggest a trial of macrolide treatment to reduce asthma exacerbations in adult asthma subjects on GINA/NAEPP step 5 therapy that remain persistently symptomatic or uncontrolledConditionalLow
        Suggest against the use of chronic macrolide treatment in children and adolescents with severe uncontrolled asthmaConditionalLow
        6Suggest dupilumab as add-on therapy for adult patients with severe eosinophilic asthma and for those with severe corticosteroid-dependent asthma regardless of eosinophil levelsConditionalLow

        Reproduced and modified from [6].

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        Management of severe asthma: summary of the European Respiratory Society/American Thoracic Society task force report
        Sandhya Khurana, Andrew Bush, Fernando Holguin
        Breathe Jun 2020, 16 (2) 200058; DOI: 10.1183/20734735.0058-2020

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        Management of severe asthma: summary of the European Respiratory Society/American Thoracic Society task force report
        Sandhya Khurana, Andrew Bush, Fernando Holguin
        Breathe Jun 2020, 16 (2) 200058; DOI: 10.1183/20734735.0058-2020
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        • Article
          • Abstract
          • Abstract
          • Background
          • The Severe Asthma Task Force of the ERS/ATS
          • What questions did the task force consider?
          • Should a monoclonal anti-IL5 or antil-IL-5 receptor α-subunit antibody be used in adults and children with severe asthma?
          • Should a monoclonal anti-IL-4Rα be used in adults and children with severe asthma?
          • Should a LAMA be used in adults and children with severe asthma?
          • Should a macrolide be used in adults and children with severe asthma?
          • Biomarkers in severe asthma
          • Should a specific biomarker be used to initiate treatment with an anti-IL-5 therapy in severe asthma?
          • Should measurement of a specific biomarker, in addition to total IgE level, be used to guide initiation of treatment with anti-IgE antibody in severe asthma?
          • Conclusions and future perspectives
          • Footnotes
          • References
        • Figures & Data
        • Info & Metrics
        • PDF

        Subjects

        • Asthma and allergy
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