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Severe asthma — Clinical Guidelines

Overview

Severe asthma is characterized by persistent symptoms despite high-dose inhaled corticosteroids and long-acting bronchodilators, often requiring biologic therapies for better control and reduced exacerbations 1 2.

Diagnosis

Persistent symptoms despite optimized standard therapy

Frequent exacerbations requiring systemic corticosteroids

Evidence of airflow limitation (reduced FEV1)

Elevated fractional exhaled nitric oxide (FeNO) or sputum eosinophilia in some cases

Regular monitoring of lung function and exacerbation frequency 1

Management

First-line treatments: High-dose inhaled corticosteroids combined with long-acting beta-agonists (LABA)

Adjunctive treatments:

- Anti-IL5 therapies: Benralizumab, Mepolizumab, Reslizumab (reduces exacerbation rates significantly) 2 - Anti-IL4Rα therapy: Dupilumab (improves FEV1 and reduces exacerbations, though specific dosing not detailed in abstracts) 2

Corticosteroid sparing: Biologic agents aim to reduce reliance on oral corticosteroids 2

Special Populations

Pregnancy: Specific guidance on biologic use in pregnancy not covered in abstracts 1 2

Pediatrics: Limited data on real-world efficacy in pediatric severe asthma; focus on benralizumab and mepolizumab in adults 2

Elderly: No specific considerations mentioned in abstracts 1 2

Comorbidities: Management strategies for comorbidities like obesity or GERD not detailed; focus on asthma control with biologics 1 2

Key Recommendations

Aim for clinical remission in severe asthma treated with biologics, considering variable definitions and correlates 1 (Evidence: Moderate)

Utilize anti-IL5 therapies (benralizumab, mepolizumab, reslizumab) to significantly reduce exacerbation rates in severe asthma 2 (Evidence: Strong)

Monitor and manage patients closely to assess improvements in FEV1 and reduction in oral corticosteroid usage alongside exacerbation frequency 2 (Evidence: Moderate)

References

1 Shackleford A, Heaney LG, Redmond C, McDowell PJ, Busby J. Clinical remission attainment, definitions, and correlates among patients with severe asthma treated with biologics: a systematic review and meta-analysis. The Lancet. Respiratory medicine 2025. link00293-5) 2 Charles D, Shanley J, Temple SN, Rattu A, Khaleva E, Roberts G. Real-world efficacy of treatment with benralizumab, dupilumab, mepolizumab and reslizumab for severe asthma: A systematic review and meta-analysis. Clinical and experimental allergy : journal of the British Society for Allergy and Clinical Immunology 2022. link

Severe asthma