Finding the Right Treatment for Severe Asthma

Medically Reviewed By William C. Lloyd III, MD, FACS
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doctor placing stethoscope on patient's back

Anyone with asthma will tell you, it’s scary to feel like you are struggling to breathe. Thankfully, for many patients, these symptoms can be managed with typical treatments, such as inhaled corticosteroids (ICS) and quick-acting medicines like albuterol to open the airways. However, about 5-10% of asthma patients are classified as having severe asthma, meaning that their asthma is poorly controlled or uncontrolled even with high levels of inhaled corticosteroids. Finding the right treatment for this group may take a bit more investigation. Here are some things your doctor may address to help you find the relief you need.

5 Things You Didn't Know About Severe Asthma

Confirm your asthma diagnosis.

If your asthma isn’t responding to treatment, could it be because you don’t really have asthma at all? Sometimes what appears to be uncontrolled asthma is actually another medical condition instead. The misdiagnosis occurs because some conditions mimic asthma in terms of symptoms.

For this reason, it is important to confirm your diagnosis and rule out the alternatives, such as bronchiolitis, cystic fibrosis, or congestive heart failure.  Your doctor’s visit may include:

  • Evaluation of your symptoms

  • Spirometry tests: During this simple screening test, you breathe forcefully into a tube attached to a spirometer, a machine that measures how much air you inhale and exhale. This provides your doctor with information regarding how well your lungs are working. The test may be done both before and after taking a bronchodilator medication to open your lungs.

  • Pulmonary function tests: In addition to spirometry, more detailed tests can be performed to provide a more complete look at your lungs, including how well they transfer oxygen to your blood.

  • Chest CT: Computed tomography (CT) may be used to obtained detailed images of your airways, lungs and other structures inside your chest.

Consider factors that might be exacerbating your asthma.

Do you have other medical conditions or lifestyle factors that are making your asthma worse? Your doctor may assess for things that are associated with poorly controlled asthma, including:

  • Non-compliance with medication or improperly taking asthma medication

  • Obesity

  • Smoking

  • Exposure to allergens, such as mold

  • Sinus infections

Steps should be taken to remediate any of these factors. Quit smoking, try to maintain a healthy weight, and learn how to avoid allergens in your environment. Talk to your doctor if you have any questions about how to use your inhaler properly or when to take certain medications.

Determine your individual type of asthma.

If your doctor has confirmed that you do indeed have asthma and addressed any confounding factors that limit your treatment response, investigation should begin to identify your asthma phenotype, the characteristics of your individual type of asthma. This information helps guide your doctor’s treatment decisions. Your doctor may evaluate your asthma for the following characteristics:

  • Eosinophilic inflammation: Eosinophils are a type of white blood cell, and your doctor may test your sputum for the presence of these cells. High levels of eosinophils cause airway inflammation.

  • Allergic inflammation: Some asthma is triggered by an allergic response.

  • Early or late onset: Asthma that appears in childhood may be different than asthma that starts in adulthood.

Take a step-wise approach with severe asthma treatment.

A gradual approach, adding or adjusting medications along the way, is recommended when it comes to treating severe asthma. Your dose of inhaled corticosteroids (ICS) may need to be increased over time. Other medications that may need to be prescribed to your regimen include:

  • Systemic corticosteroids: Some cases of severe asthma require steroids that are taken by mouth or are injected. While ICS only treat inflammation in the airways, oral or injected steroids affect the whole body. They may be helpful for some patients who don’t respond to ICS, but there are more side effects.

  • Long-acting beta-adrenergic bronchodilators (LABA): LABAs such as salmeterol (Serevent) and formoterol (Peroforomist) can reduce airway swelling for up to 12 hours. However, ICS must be given along with LABAs because they have been linked to severe asthma attacks.

  • Leukotriene pathway modifiers: Motelulkast (Singulair) and zileuton (Zyflo) are two examples. These medications block chemicals in the immune system called leukotrienes that can cause asthma symptoms.

  • Long-acting muscarinic antagonist (LAMA): Tiotropium bromide (Spiriva) is a LAMA that can be used as another add-on therapy. It is taken once a day and reduces asthma flare ups for some patients with severe asthma.

  • Anti-Immunoglobulin E (IgE) therapy: Omalizumab (Xolair) is recommended for patients with allergies and asthma. Omalizumab blocks immunoglobulin-E, a protein that is released when you are having an allergic reaction and may cause airway inflammation.

  • Anti-Interleukin-5 (Antil-IL-5) therapy: This treatment is used for patients that have high levels of eosinophils in their sputum. IL-5 controls the number of eosinophils, so blocking IL-5 decreases the amount of eosinophils, reducing airway inflammation. Mepolizumab (Nucala) and reslizumab (Cinqair) both work against IL-5.

  • Antifungals: The small group of patients with severe asthma who also have allergic bronchopulmonary aspergillosis (ASBA), an allergy to a fungus found in soil, may benefit from adding an antifungal to their current asthma therapy.

It may be challenging to find the right treatment for your severe asthma, but it is not impossible. The more we learn about how to target specific patient populations and provide more personalized medicine, the more we can expect to better manage this condition.

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Medical Reviewer: William C. Lloyd III, MD, FACS
Last Review Date: 2021 May 24
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THIS TOOL DOES NOT PROVIDE MEDICAL ADVICE. It is intended for informational purposes only. It is not a substitute for professional medical advice, diagnosis or treatment. Never ignore professional medical advice in seeking treatment because of something you have read on the site. If you think you may have a medical emergency, immediately call your doctor or dial 911.
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    American Thoracic Society Journals.
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  4. International
    ERS/ATS Guidelines on Definition, Evaluation and Treatment of Severe Asthma.
    American Thoracic Society.