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Severe asthma

E.H. Bel
Breathe 2006 3: 128-139; DOI: 10.1183/18106838.0302.128
E.H. Bel
Dept of Pulmonology, C3-P, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, The Netherlands
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  • For correspondence: E.H.D.Bel@lumc.nl
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Abstract

Key points

  • Not all patients with “difficult-to-control” asthma have “severe asthma”. Many of them have either an incorrect diagnosis, or mild-moderate asthma with unrecognised aggravating factors, or are non-compliant with prescribed therapy.

  • For a diagnosis of severe asthma, it is necessary to confirm the diagnosis of asthma, to evaluate and treat endogenous and exogenous aggravating factors, and to closely follow the patient for ≥6 months.

  • Severe asthma is a heterogeneous condition with different phenotypes. Defining clinical phenotypes is necessary to improve understanding of underlying mechanisms, to help guide current treatment and to provide clues for novel therapeutic interventions.

  • Despite intensive multi-drug treatment with high-dose inhaled and oral corticosteroids, many patients with severe asthma remain uncontrolled. There is an urgent need for new, more-effective treatments.

Educational aims

  • To help the reader distinguish between “difficult-to-control”, “refractory” and “severe” asthma.

  • To discuss the initial approach to and assessment of a patient with difficult-to-control asthma.

  • To inform the reader how to recognise different clinical phenotypes of severe asthma.

  • To outline management strategies and discuss treatment modalities.

Summary “Severe asthma” refers to asthma that remains difficult to control despite intensive multidrug therapy, extensive assessment and management of comorbidity, and long-term observation by an asthma specialist.

The three main clinical phenotypes of severe asthma include asthma with frequent severe exacerbations, asthma with chronic airflow limitation, and steroid-resistant asthma.

Many patients with severe asthma are oral-steroid dependent. Classical steroid-sparing drugs (gold, methotrexate, cyclosporin) are only weakly effective and have unacceptable side-effects. Monoclonal antibodies against immunoglobulin (Ig)E and tumour necrosis factor (TNF)-α have shown clinical benefit in subgroups of patients with severe asthma, and large studies are under way to confirm these promising findings.

  • ©ERS 2006

Breathe articles are open access and distributed under the terms of the Creative Commons Attribution Non-Commercial Licence 4.0.

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Severe asthma
E.H. Bel
Breathe Dec 2006, 3 (2) 128-139; DOI: 10.1183/18106838.0302.128

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Severe asthma
E.H. Bel
Breathe Dec 2006, 3 (2) 128-139; DOI: 10.1183/18106838.0302.128
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