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Eur Respir J. 2019 Sep 26. pii: 1900588. doi: 10.1183/13993003.00588-2019. [Epub ahead of print]

Management of Severe Asthma: a European Respiratory Society/American Thoracic Society Guideline.

Author information

1
University of Colorado, Pulmonary Sciences and Critical Care Medicine, Denver, CO, USA fernando.holguin@ucdenver.edu.
2
University of South Florida, Allergy and Immunology, Tampa, FL, USA.
3
Experimental Studies Medicine, Imperial College London, National Heart & Lung Institute, London, UK.
4
University of Leicester, Respiratory Biomedical Unit, Leicester, UK.
5
Alergia e Imunologia, Complexo Hospital de Clinicas, Universidade Federal do Parana, Curitiba, Brazil.
6
School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.
7
Emory University, Division of Pulmonology Allergy/Immunology, Cystic Fibrosis and Sleep, Atlanta, GA, USA.
8
Athens Chest Hospital, Respiratory Medicine Department and Asthma Centre, Athens, Greece.
9
Biomedical Library, National Jewish Health, Denver, CO, USA.
10
Pulmonary Diseases and Critical Care, University of Rochester, Rochester, NY, USA.
11
School of Nursing, University of Newcastle, Newcastle, Australia.
12
Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada.
13
Pulmonary, Critical Care, Allergy and Immunologic Diseases, Wake Forest School of Medicine, Winston-Salem, NC, USA.
14
Iberoamerican Cochrane Centre, Barcelona, Spain.
15
Department of Pediatrics, SickKids, Toronto, Ontario, Canada.
16
Institute of Social and Preventive Medicine, University of Bern, Switzerland.
17
Department of Molecular Cell Biology, Imperial College of London, National Heart & Lung Institute, London, UK.
18
Division of Genetics, Genomics and Precision Medicine, University of Arizona, Tucson, Arizona.
19
Department of Respiratory Sciences, University of Leicester, Leicester, UK.
20
Respiratory Medicine, Laval University, Quebec, Canada.
21
Division of General Pediatrics, University of California San Francisco, SF, USA.
22
Division of Pulmonary and Critical Care Medicine, Washington University, St. Louis, MO, USA.
23
Department of Respiratory Diseases, University of Aix-Marseille, Marseille, France.
24
Paediatric Allergy, Imperial College of London, National Heart & Lung Institute, London, UK.
25
Respiratory Biomedical Research, University of Southampton, Southampton, UK.
26
Department of Pediatrics, University Children's Hospital, Basel, Switzerland.
27
European Lung Foundation, Lausanne, Switzerland.
28
School of Medicine and Public Health, University of New Castle, New Castle, Australia.
29
Division of Pulmonary and Critical Care, University of Wisconsin, Madison, WI, USA.
30
Department of Respiratory Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Hokkaido, Japan.
31
Department of Respiratory and Critical Care Medicine, The second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China.
32
Asthma Institute, University of Pittsburgh, Pittsburgh, PA, USA.
33
Department of Paediatrics, National Heart & Lung Institute, Imperial College London, London, UK.

Abstract

This document provides clinical recommendations for the management of severe asthma. Comprehensive evidence syntheses, including meta-analyses, were performed to summarise all available evidence relevant to the Task Force's questions. The evidence was appraised using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach and the results were summarised in evidence profiles. The evidence syntheses were discussed and recommendations formulated by a multidisciplinary Task Force of asthma experts, who made specific recommendations on 6 specific questions. After considering the balance of desirable and undesirable consequences, quality of evidence, feasibility, and acceptability of various interventions, the Task Force made the following recommendations: 1) Suggest using anti-IL5 and anti IL-5Rα for severe uncontrolled adult eosinophilic asthma phenotypes; 2) suggest using blood eosinophil cut-point of ≥150/μL to guide anti-IL5 initiation in adult patients with severe asthma; and 3) Suggest considering specific eosinophil (≥260/μL) and FeNO (≥19.5 ppb) cutoffs to identify adolescents or adults with the greatest likelihood or response to anti-IgE therapy; 4) Suggest using inhaled tiotropium for adolescents and adults with severe uncontrolled asthma despite GINA step 4-5 or NAEPP step 5 therapies; 5) Suggest a trial of chronic macrolide therapy to reduce asthma exacerbations in persistently symptomatic or uncontrolled patients on GINA step 5 or NAEPP step 5 therapies, irrespective of asthma phenotype; 6) Suggest using anti-IL4/13 for adult patients with severe eosinophilic asthma, and for those with severe corticosteroid-dependent asthma regardless of blood eosinophil levels. These recommendations should be reconsidered as new evidence becomes available.

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