Treatment of Severe Asthma

In accordance with the motto of this year’s World Asthma Day, “Uncovering Asthma Misconceptions”, this is the seventh post of our mini-series about asthma based on our patient booklet “Fast Facts for Patients and their Supporters: Asthma”. Here, we focus on the treatment possibilities of severe asthma.

If you have severe asthma, you are likely to need a higher dose of your preventer along with another inhaled medication, such as a long-acting reliever. Long-acting relievers will help to keep your airways open, but they do not treat the inflammation, so keep taking your preventer medicine as prescribed.

Other treatments will depend on the type of severe asthma that you have. It may take some time to find the right combination of drugs and doses that work for you.

Add-On Treatments for Asthma

Drug type	About the drugs
Montelukast	• Reduces inflammation in the airways; tablets, swallowed with water, 1 hour before or 2 hours after food; also in syrup or powder form • Often used to treat difficult asthma in children • May cause sleep disturbance and, rarely, sudden depression
Theophylline	• Relaxes the airway muscles; tablets or capsules every 12 or 24 hours • May be given in hospital directly into a vein • Works well in smokers with difficult asthma • Drug levels monitored by regular blood tests • Suitable for children
Long-term steroids (for example, prednisone)	• Calm inflamed airways • High doses, taken as tablets daily • Near to last resort because of side effects • Rarely used in children
Antifungal drugs (for example, itraconazole, voriconazole)	• Attack fungus in the body • Taken as tablets or capsules • Monitored by regular blood tests as they can affect the liver and kidneys • Not usually used in children
Note: read the leaflet that comes with your medicine. Don’t be daunted by the long list of side effects. You may get some or none of them.

Monoclonal antibodies (MABS) are an exciting area of medication development known as biological therapy (or biologics). They are tailormade molecules that prevent inflammation in your airways by blocking the chemicals that cause it.

MABS are used as an add-on therapy for people with severe allergic asthma. MABS are also being tested in other forms of severe asthma.

Monoclonal antibody	Used to treat
Omalizumab (Xolair)	Severe allergic asthma
Mepolizumab (Nucala)	Eosinophilic asthma
Reslizumab (Cinqair, Cinqaero)	Eosinophilic asthma
Benralizumab (Fasenra)	Eosinophilic asthma

MABS can be very successful at reducing asthma attacks and symptoms. Some patients’ responses to MAB treatment have been so impressive that some specialists are talking about controlling severe asthma to the point of no symptoms at all (remission).

How do MABS work? Different MABS work in different ways, but ultimately they prevent or reduce inflammation.

How are MABS administered? MABS are usually injected under the skin in the upper arm, abdomen or thigh every 2–8 weeks. That may mean frequent hospital or clinic visits, although new preparations that you can inject yourself with are being developed.

Are there any side effects? Like all medicines, MABS have some side effects. But some MABS can be given to children as young as 6 years old. The most common problems are pain, redness, itching, swelling and/or burning around the injection site. These effects do not last for long. Although rare, some people can have a serious allergic reaction (anaphylaxis), so you will be carefully monitored after your injection.

Bronchial Thermoplasty

Bronchial thermoplasty (BT) is a form of surgery using a bronchoscope. It improves quality of life but not lung function. You will be given a sedative or general anesthetic before the procedure. A wire is passed down the bronchoscope and pulses of heat are delivered to the walls of the small airways to reduce the build-up of muscle around the airways.

The procedure is only suitable for adults in centers with specially trained staff. You will have three sessions with at least 3 weeks between each session. Each procedure takes 30–45 minutes, and you may need to be admitted for observation after the procedure.

You will need to take high-dose oral steroids to reduce the inflammation in the airways immediately after BT and sometimes before the procedure. Asthma attacks usually increase in the first 3 months after BT. Make sure you know how to manage your symptoms after the procedure.