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Review
. 2020 Nov;12(6):910-933.
doi: 10.4168/aair.2020.12.6.910.

Evaluation and Management of Difficult-to-Treat and Severe Asthma: An Expert Opinion From the Korean Academy of Asthma, Allergy and Clinical Immunology, the Working Group on Severe Asthma

Byung Keun Kim #  1 , So Young Park #  2 , Ga Young Ban #  3 , Mi Ae Kim  4 , Ji Hyang Lee  5 , Jin An  5 , Ji Su Shim  6 , Youngsoo Lee  7 , Ha Kyeong Won  8 , Hwa Young Lee  9 , Kyoung Hee Sohn  10 , Sung Yoon Kang  11 , So Young Park  12 , Hyun Lee  13 , Min Hye Kim  6 , Jae Woo Kwon  14 , Sun Young Yoon  15 , Jae Hyun Lee  16 , Chin Kook Rhee  9 , Ji Yong Moon  13 , Taehoon Lee  17 , So Ri Kim  18 , Jong Sook Park  19 , Sang Heon Kim  20 , Heung Woo Park  21 , Jae Won Jeong  22 , Sang Hoon Kim  23 , Young Il Koh  24 , Yeon Mok Oh  25 , An Soo Jang  19 , Kwang Ha Yoo  2 , You Sook Cho  5 ; Korean Academy of Asthma, Allergy, and Clinical Immunology (KAACI), the Working Group on Severe Asthma
Affiliations
Review

Evaluation and Management of Difficult-to-Treat and Severe Asthma: An Expert Opinion From the Korean Academy of Asthma, Allergy and Clinical Immunology, the Working Group on Severe Asthma

Byung Keun Kim et al. Allergy Asthma Immunol Res. 2020 Nov.

Abstract

Severe asthma (SA) presents in about 3%-5% of adult asthmatics and is responsible for over 60% of asthma-related medical expenses, posing a heavy socioeconomic burden. However, to date, a precise definition of or clear diagnostic criteria for SA have not been established, and therefore, it has been challenging for clinicians to diagnose and treat this disease. Currently, novel biologics targeting several molecules, such as immunoglobulin E, interleukin (IL)5, and IL4/IL13, have emerged, and many new drugs are under development. These have brought a paradigm shift in understanding the mechanism of SA and have also provided new treatment options. However, we need to agree on a precise definition of and its diagnostic criteria for SA. Additionally, it is necessary to explain the diagnostic criteria and to summarize current standard and additional treatment options. This review is an experts' opinion on SA from the Korean Academy of Asthma, Allergy, and Clinical Immunology, the Working Group on Severe Asthma, and aims to provide a definition of and diagnostic criteria for SA, and propose future direction for SA diagnosis and management in Korea.

Keywords: IL4; IgE; Severe asthma; biologics; diagnosis; eosinophil; expert opinion; treatment, IL5.

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Conflict of interest statement

There are no financial or other issues that might lead to conflict of interest.

Figures

Fig. 1
Fig. 1. Approach to uncontrolled, difficult-to-treat, and severe asthma.
ANCA, anti-neutrophil cytoplasmic antibodies; FEV1, forced expiratory volume in 1 second; GINA, Global Initiative for Asthma; ICS, inhaled corticosteroids; CRS, chronic rhinosinusitis; GERD, gastroesophageal reflux disease; OSA, obstructive sleep apnea; FeNO, fractional exhaled nitric oxide; CT, computed tomography; IgE, immunoglobulin E.
Fig. 2
Fig. 2. Pharmacological treatment of severe asthma. Patients with uncontrolled asthma despite the use of a high-dose ICS–LABA combination and an add-on second controller (such as tiotropium, LTRA, or theophylline) should be referred to asthma specialists for phenotypic assessment and determination of the use of type 2 biologics. Those with type 2 high inflammation are eligible for type 2 biologics. Those with type 2 low inflammation need to be managed with unused second controller or an off-label treatment. Finally, OCS could be added as maintenance therapy for patients with severe asthma that is uncontrolled with the use of every medication available.
ICS, inhaled corticosteroids; LABA, long-acting β2 agonists; LTRA, leukotriene receptor antagonists; OCS, oral corticosteroids.
See this image and copyright information in PMC

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