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Severe Persistent Asthma
Aka: Severe Persistent Asthma, Severe Asthma, Difficult to Treat Asthma, Difficult-To-Treat Asthma
- See Also
- Asthma
- Asthma Evaluation
- Asthma Differential Diagnosis
- Asthma Education
- Asthma Management
- Mild Intermittent Asthma
- Mild Persistent Asthma
- Moderate Persistent Asthma
- Asthma Exacerbation
- Definitions
- Uncontrolled Asthma
- Frequent use and early refills of rescue Inhaler
- Rescue Inhaler use more than twice weekly
- Awakening with nighttime symptoms more than twice monthly (over age 5)
- Within last 12 months, two or more courses of oral Corticosteroids, or Asthma hospital admission
- Difficult-To-Treat Asthma
- Uncontrolled Asthma despite high-dose Inhaled Corticosteroid with second controller or
- Uncontrolled Asthma despite oral Corticosteroids
- Severe Asthma
- Subset of Difficult-To-Treat Asthma
- Uncontrolled Asthma despite medication and lifestyle compliance or unable to taper maximal medical therapy
- Criteria: Severe Asthma
- Continuous symptoms throughout the day, interfering with sleep and activity
- Frequent exacerbations (several times daily)
- Daily symptoms throughout the day
- Nightly symptoms
- For age <5 years, night awakenings more than once per week
- Beta Agonist use several times daily
- Oral Corticosteroids required 2 or more times per year
- Pulmonary Function Tests
- FEV1 or PEF <60% of predicted
- PEF variability > 30%
- FEV1 to FVC Ratio decreased >5% (<75% for age 5-19, <70% for age 20-39, <65% for age 40-59, then <60%)
- Management: General
- See Asthma Stepped Care
- Evaluate for Non-compliance with medical therapy or lifestyle changes
- See Asthma Education
- Evaluate Inhaler technique
- See Asthma Inhaler Education
- Review Asthma Action Plan at every visit
- Consider Environmental Allergen exposures
- Tobacco Cessation and eliminate Secondhand Smoke exposure
- Consider Allergic Occupational Asthma
- Confirm filling of prescriptions and use as directed
- Ask about barriers to use (e.g. excessive cost)
- Consider medication adverse effects (e.g. NSAIDs, Aspirin, Beta Blockers)
- Consider comorbid conditions (e.g. Congestive Heart Failure, Coronary Artery Disease)
- Rule out Other Causes
- See Asthma Differential Diagnosis (e.g. Cystic Fibrosis)
- Repeat Spirometry or full Pulmonary Function Tests
- Consider high resolution CT Chest (e.g. chronic Pulmonary Embolism, Interstitial Lung Disease)
- Consider bronchoscopy
- Long-term daily control medication
- Inhaled Corticosteroid (High dose) and
- Long acting beta agonist Bronchodilator (LABA) and
- Formoterol when used as maintenance LABA, may be used as rescue Inhaler as well (2020 Asthma guidelines)
- See Single Maintenance and Reliever Therapy (SMART Asthma Management Protocol)
- Leukotriene Receptor Antagonist (Montelukast)
- Montelukast is associated with increased risk of Major Depression and Suicide
- https://www.fda.gov/news-events/press-announcements/fda-requires-stronger-warning-about-risk-neuropsychiatric-events-associated-asthma-and-allergy
- Consider Zileuton (Zyflo)
- Consider Systemic Corticosteroids (2 mg/kg/day to 60 mg/day)
- Other measures
- Short term rescue with beta agonist
- See Asthma Biologic agents below
- See Breathing Exercises in Asthma
- Bronchial Thermoplasty
- Bronchoscopy delivered radiofrequency ablation to airway Smooth Muscle
- Decreases bronchoconstriction and airway hyperplasia
- Improves Asthma quality of life, but worsens Asthma in first 6 weeks after treatment
- Torrego (2014) Cochrane Database Syst Rev (3): CD009910 +PMID:24585221 [PubMed]
- Thomson (2019) J Asthma Allergy 12:375-87 +PMID:31819539 [PubMed]
- Management: Asthma Biologic Agents
- See Asthma Monoclonal Antibody
- Indicated in refractory, Type 2 Asthma (Allergic Asthma, represents 50% of Asthma)
- Indications: One of the following present
- Blood Eosinophils >150/uL
- Sputum Eosinophils >2%
- Ferrous Nitrous Oxide >20 parts per billion
- Maintenance oral Corticosteroids required
- Preparations: Anti-IgE
- Omalizumab (Xolair)
- May be used in age 6 years old and older
- Indicated in severe refractory (Step 5-6) Asthma with IgE levels >75
- Subcutaneous Injection every 2-4 weeks
- Preparations: Anti-IL5 (Interleukin 5)
- Mepolizumab (Nucala)
- May be used in age 12 years old and older
- Administered SQ every 4 weeks
- Benralizumab (Fesenra)
- May be used in age 12 years old and older
- Administered SQ every 4 weeks for 3 doses, then every 8 weeks
- Reslizumab (Cinqair)
- May be used in age 18 years old and older
- Administered IV every 4 weeks
- Preparations: Interleukin-4 Alpha Receptor Antagonist
- May be used in age >= 6 years old
- Dupilumab (Dupixent)
- Adult Dose: 600 mg SQ once, then 300 mg SQ every 2 weeks
- Monitoring
- Re-evaluate every 3-6 months
- Taper off oral Corticosteroids and other add-on management
- Management: Exacerbations
- See Asthma Exacerbation
- See Asthma Exacerbation Home Management
- See Emergency Management of Asthma Exacerbation
- See Asthma Inpatient Management
- See Status Asthmaticus
- See Asthma Exacerbation Severity Evaluation
- See Asthma-Related Death Risk Factors
- Prevention
- Asthma Education
- Influenza Vaccine
- Weight loss in Obesity
- Exercise
- References
- Park (2017) Asthma Updates, Mayo Clinical Reviews, Rochester, MN
- (1997) Management of Asthma, NIH 97-4053
- (1995) Global Strategy for Asthma, NIH 95-3659
- Kalister (2001) West J Med 174:415-20 [PubMed]
- Kemp (2001) Am Fam Physician 63(7):1341-54 [PubMed]
- Narasimhan (2021) Am Fam Physician 103(5): 286-90 [PubMed]
- Pollart (2009) Am Fam Physician 79(9):761-7 [PubMed]