International ERS/ATS guidelines on definition, evaluation and treatment of severe asthma

TLDR

Severe asthma is a growing unmet need, characterized by heterogeneity including eosinophilic phenotypes. The task force aimed to review and recommend definitions, evaluation, and treatment of severe asthma, while advocating coordinated research for biomarker‑driven therapy. The guideline was developed through a systematic literature review and expert committee discussion using the GRADE framework. Severe asthma is defined by the need for high‑dose inhaled corticosteroids plus a second controller or systemic steroids to prevent or treat uncontrolled disease, and the guideline recommends using sputum eosinophils, exhaled NO, and therapies such as anti‑IgE, methotrexate, macrolides, antifungals, and bronchial thermoplasty.

Abstract

Severe or therapy-resistant asthma is increasingly recognised as a major unmet need. A Task Force, supported by the European Respiratory Society and American Thoracic Society, reviewed the definition and provided recommendations and guidelines on the evaluation and treatment of severe asthma in children and adults. A literature review was performed, followed by discussion by an expert committee according to the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach for development of specific clinical recommendations. When the diagnosis of asthma is confirmed and comorbidities addressed, severe asthma is defined as asthma that requires treatment with high dose inhaled corticosteroids plus a second controller and/or systemic corticosteroids to prevent it from becoming "uncontrolled" or that remains "uncontrolled" despite this therapy. Severe asthma is a heterogeneous condition consisting of phenotypes such as eosinophilic asthma. Specific recommendations on the use of sputum eosinophil count and exhaled nitric oxide to guide therapy, as well as treatment with anti-IgE antibody, methotrexate, macrolide antibiotics, antifungal agents and bronchial thermoplasty are provided. Coordinated research efforts for improved phenotyping will provide safe and effective biomarker-driven approaches to severe asthma therapy.