Nordic consensus statement on the systematic assessment and management of possible severe asthma in adults

Abstract

Although a minority of asthma patients suffer from severe asthma, they represent a major clinical challenge in terms of poor symptom control despite high-dose treatment, risk of exacerbations, and side effects. Novel biological treatments may benefit patients with severe asthma, but are expensive, and are only effective in appropriately targeted patients. In some patients, symptoms are driven by other factors than asthma, and all patients with suspected severe asthma (‘difficult asthma’) should undergo systematic assessment, in order to differentiate between true severe asthma, and ‘difficult-to-treat’ patients, in whom poor control is related to factors such as poor adherence or co-morbidities. The Nordic Consensus Statement on severe asthma was developed by the Nordic Severe Asthma Network, consisting of members from Norway, Sweden, Finland, Denmark, Iceland and Estonia, including representatives from the respective national respiratory scientific societies with the aim to provide an overview and recommendations regarding the diagnosis, systematic assessment and management of severe asthma. Furthermore, the Consensus Statement proposes recommendations for the organization of severe asthma management in primary, secondary, and tertiary care.

How can we minimise the use of regular oral corticosteroids in asthma?

“…Moreover, the results of the ongoing trial with omalizumab, started 2 years ago, even in mild asthmatics with a positive modified Asthma Prediction Index are eagerly awaited, as well as strategies targeting viruses (vaccines, antiviral drugs) [106]. Similarly to what is currently claimed in adults, the usefulness of referral to expert centres is demonstrated but needs better implementation for routine procedures, especially in rural areas [107][108][109]. Flagging the yearly consumption of OCSs should be tested as a trigger for referral.…”

“…Once identified, these patients should be assessed for a number of issues addressed in secondary care environments. OCS overuse is frequent and can substantially benefit from a multidisciplinary approach towards asthma [107]: improved adhesion to prescribed maintenance therapy, removal of a persistent exposure to known triggers ( particularly allergens or pets), improving poor inhalation technique, or the discovery of untreated comorbidities. Still central and requiring multiple expertise (frequently including a psychologist/psychiatrist), OCS overuse may also result from misdiagnosis and interpretation of symptoms not necessarily caused by asthma [145].…”

Efficacy, adverse events, and inter-drug comparison of mepolizumab and reslizumab anti-IL-5 treatments of severe asthma – a systematic review and meta-analysis

“…Indeed, the subgroup analyses suggested a more pronounced effect in patients with higher eosinophil counts, a higher exacerbation rate at enrolment, and among patients on GINA step 5 treatment. Based on our results, prescribing anti-IL-5 treatment with either mepolizumab or reslizumab to patients correctly diagnosed with severe eosinophilic asthma according to published clinical guidelines [3] seems cost-effective as it will significantly reduce exacerbation rate and hospitalizations and may alleviate OCS-related systemic side effects.…”

“…Severe asthma is defined by frequent exacerbations despite treatment with high-dose inhaled corticosteroids (ICS) plus a second controller, or the need for daily oral corticosteroid treatment (OCS), to prevent exacerbations and achieve proper asthma control or stay uncontrolled on this treatment [2,3]. The prevalence of severe asthma is estimated 3–15% of all patients with asthma, depending on the method of identification [4] and is associated with a significant negative impact on quality of life for the affected patients [5], as well as an increased risk of morbidity and mortality [6].…”

Protocol for a multicentre randomised controlled trial to investigate the effect on asthma-related quality of life from breathing retraining in patients with incomplete asthma control attending specialist care in Denmark

“…More than 10% of the asthma population has difficult-to-treat asthma with poor asthma control despite substantial pharmacological treatment (ie, Global Initiative for Asthma, GINA, steps 4–5) 2 10 11. This subgroup uses high levels of asthma-related healthcare resources due to increased symptom burden, medication usage, prevalence of comorbidities, smoking, sick leave, higher exacerbation rates and emergency department visits compared with patients with asthma control 2 12.…”