What is the recommended treatment for severe persistent asthma?

Treatment for Severe Persistent Asthma

The recommended treatment for severe persistent asthma consists of high-dose inhaled corticosteroids combined with long-acting beta2-agonists, with the addition of oral systemic corticosteroids if needed to achieve and maintain control. 1

First-Line Therapy

• High-dose inhaled corticosteroids (ICS) are the foundation of treatment for severe persistent asthma, providing the most effective anti-inflammatory action 1
• Long-acting beta2-agonists (LABAs) should be added to high-dose ICS as standard combination therapy for severe persistent asthma 1
• This combination provides superior control compared to increasing ICS doses alone 1

Additional Medications When Control Is Not Achieved

When patients cannot achieve or maintain control with high-dose ICS and LABAs:

• Oral systemic corticosteroids should be added (1-2 mg/kg/day, generally not exceeding 60 mg/day) 1
• Repeated attempts should be made to reduce systemic corticosteroids while maintaining control with high-dose ICS 1

Third-Line Medications

Limited evidence exists for adding a third long-term control medication to the combination of high-dose ICS and LABAs:

• Adding leukotriene receptor antagonists (LTRAs) as a third medication has not shown significant benefit in severe persistent asthma 1
• Other potential add-on therapies have not been adequately studied in severe persistent asthma 1

Biologics for Severe Asthma

For patients with severe persistent asthma who remain uncontrolled despite optimal therapy:

• Omalizumab (anti-IgE) may be considered as adjunctive therapy for patients ≥12 years with allergic asthma and sensitivity to relevant allergens 1, 2
• Other biologics targeting specific inflammatory pathways may be considered for appropriate phenotypes of severe asthma 2

Quick-Relief Medications

All patients with severe persistent asthma require:

• Short-acting beta2-agonists (SABAs) as needed for symptom relief 1
• Oral corticosteroids may be required for acute exacerbations 1
• Increasing use of SABAs (more than two days per week) indicates inadequate control and the need to adjust long-term control medications 1

Monitoring and Follow-Up

• Patients with severe persistent asthma should be monitored regularly for symptom control and medication side effects 1
• Consultation with an asthma specialist is strongly recommended for patients with severe persistent asthma 1, 3
• Written asthma action plans should be developed and reviewed at each visit 1

Special Considerations

• For children with severe persistent asthma, the approach is similar but with age-appropriate medication dosing 1
• Addressing comorbidities such as rhinitis, sinusitis, obesity, and sleep apnea may improve asthma control 1
• Environmental trigger identification and avoidance strategies should be implemented 4

Common Pitfalls to Avoid

• Using LABAs as monotherapy without ICS is contraindicated and can increase risk of severe exacerbations and death 1
• Failing to make repeated attempts to reduce oral corticosteroids once control is achieved 1
• Overlooking the need for specialist referral in severe persistent asthma 1, 3
• Inadequate assessment of medication adherence and inhaler technique before stepping up therapy 1

The treatment of severe persistent asthma requires an aggressive approach with combination therapy and close monitoring to achieve the best outcomes in terms of symptom control and prevention of exacerbations, while minimizing medication side effects.