The first part of the updated 2019 ERS/ATS asthma guidelines, discussed revising the stages of diagnosis for severe asthma, stresses the importance of distinguishing severe from milder disease (based on response to therapy) and to consider the “mimickers” for “difficult-to-treat asthma”. Dr Cardet has revised the news in the 2019 “Task Force of the 2019 ERS/ATS guidelines” on severe asthma. The panel of experts have developed key questions and rated the outcomes as “clinical or important” and established the evidence according to the GRADE approach. Six questions have been enunciated and the recommendations after an iterative consensus have been considered as either “strong”, that most well-informed patients would follow, or “conditional”, with uncertainty on whether the consequences are desirable or not: low-quality evidence, heterogeneous severity, patient values. The recommendations are:
- Anti-IL5 strategies: It is suggested using anti-IL5 strategies as an add-on therapy for adults with severe uncontrolled eosinophilic asthma. With a conditional remark.
- Biomarkers for anti-IL5 strategies: Also conditional, suggests using a blood eosinophilic cut-off of > 150/μL to guide anti-IL5 therapy initiation in adults with exacerbation prone severe asthma.
- Biomarkers for anti-IgE therapy: Again conditional, suggests using a blood eosinophilic cut-off of > 260/μL and a FeNO cut-off of > 19.5 ppb to identify adolescents (> 12 years) and adults with severe allergic asthma who are more likely to benefit from anti-IgE treatment.
- LAMA therapy: For children, adolescents and adults with severe uncontrolled asthma, despite GINA step 4-5/NAEPP step 5 therapies, recommends the addition of Tiotropio. This is the only strong recommendation.
- Macrolide therapy: A trial of macrolide treatment is suggested, to reduce asthma exacerbations in persistently symptomatic or uncontrolled adult asthmatics on GINA/NAEPP step 5 therapy. The use of chronic macrolide treatment in children and adolescents with severe uncontrolled asthma is contraindicated. The recommendation is conditional.
- Anti-IL4/IL13Ra therapy/dupilimab: Dupilumab as an add-on therapy for adult patients with severe eosinophilic asthma, and for those with severe costicosteroids-dependent asthma of eosinophil levels, is suggested (conditional).
In summary, the approach to severe asthma involves diagnostic confirmation, addressing asthma mimickers and comorbidities, and therapeutic optimisation.
This Task Force:
- Conditionally recommends the use of ant-IL5 and anti-ILA713 strategies and azythromycin, and strongly recommends tiotropio.
- Conditionally recommends the use of biomarkers for detecting those patients more likely to benefit from anti-IL5 strategies (blood eosinophils and FeNO).