Pharmacotherapy of severe asthma

Abstract

Severe asthma is a complex and heterogeneous phenotype where management can be challenging. While many patients with severe asthma respond to high-dose inhaled corticosteroids in combination with a long-acting beta-agonist, there remains a significant subset of patients that require oral corticosteroids to control symptoms. Alternative therapies are needed to help reduce the need for continuous oral corticosteroids; however, there are currently very few effective options. Several new alternatives to oral corticosteroids have been evaluated in severe asthma as add-on to conventional therapy. These include macrolide antibiotics, omalizumab, tumor necrosis factor-alpha inhibitors, cytokine receptor antagonists, and bronchial thermoplasty. The challenge with these entities is determining the appropriate phenotype of severe asthma where effectiveness is demonstrated, given the significant heterogeneity of the disease. Therefore, there is a crucial need to better understand the mechanisms and pathophysiology of severe asthma so more effective immunomodulators and biologic therapies can emerge.

Figure 1

(a) Change in Asthma Quality-of-Life Questionnaire (AQLQ) score over 12 months following treatment with bronchial thermoplasty (BT) compared to sham. *Posterior probability of superiority = 97.9%. (b) Rate of health care utilization events during the post-treatment period. Open bars, sham; shaded bars, bronchial thermoplasty. All values are means ± SEM. *Posterior probability of superiority 5 95.5%. ^†Posterior probability of superiority 5 99.9%.Figure adapted from reference [49••].