Intended for healthcare professionals

Clinical Review

Difficult to treat asthma in adults

BMJ 2009; 338 doi: (Published 24 February 2009) Cite this as: BMJ 2009;338:b494
  1. Graeme P Currie, consultant chest physician1,
  2. J Graham Douglas, consultant chest physician1,
  3. Liam G Heaney, consultant chest physician2
  1. 1Aberdeen Royal Infirmary, Aberdeen AB25 2ZN
  2. 2Belfast City Hospital, Belfast BT9 7AB
  1. Correspondence to: G P Currie Graeme.currie{at}

    Summary points

    • Difficult asthma is present when patients using treatment at steps 4 or 5 of the British Thoracic Society and Scottish Intercollegiate Guideline Network guidelines remain symptomatic and have exacerbations

    • Determine whether the patient truly has asthma, whether prescribed treatment is being taken, and whether an alternative or coexisting diagnosis or aggravating factors exist

    • After taking a detailed history and examination, further directed investigations may be needed

    • Assessment and further management should ideally take place within a multidisciplinary clinic setting

    There is no universally accepted definition of difficult asthma. However, it is reasonable to consider it present when people have persistent symptoms and frequent exacerbations, despite being treated at steps 4 or 5 of the British Thoracic Society and Scottish Intercollegiate Guideline Network (BTS/SIGN) guidelines (fig 1).1 Such patients typically receive high dose inhaled steroids (≥800 µg beclometasone equivalent), a long acting β2 agonist, plus add-on treatment. The prevalence of difficult asthma is uncertain, but it may account for 5-10% of adults with asthma.2 Morbidity and health costs are disproportionately high in these patients,w1 and they are at greater risk of fatal and near fatal exacerbations.w2 In addition, frequent, intermittent, or continuous courses of oral prednisolone (plus regular high dose inhaled steroids) increase the risk of steroid related adverse effects.

    Sources and selection criteria

    All authors performed a comprehensive search of articles published up to January 2009 using PubMed and Medline. Keywords and phrases used were “asthma”, “exacerbations”, “symptoms”, “difficult asthma”, “lung function”, “diagnosis”, “bronchial hyper-responsiveness”, “nitric oxide”, “sputum eosinophils”, “treatment”, “monitoring”, “inhaled steroids”, “long acting β2 agonists”, “leukotriene receptor antagonists”, “bronchial thermoplasty”, “immunoglobulin E therapy”, and “tumour necrosis factor”.

    Fig 1 Simplified diagram of the pharmacological management of chronic asthma in adults1 w1

    Why are some people with asthma difficult to treat?

    Several key questions must be considered before prescribing add-on treatments and higher …

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