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Practice From Drug and Therapeutics Bulletin

What is the evidence for different management options for difficult to treat severe asthma?

BMJ 2017; 358 doi: (Published 14 August 2017) Cite this as: BMJ 2017;358:j3403
  1. Drug and Therapeutics Bulletin
  1. Drug and Therapeutics Bulletin Editorial Office, London WC1H 9JR, UK
  1. dtb{at}

What you need to know

  • Asthma causes 1000 deaths a year in the UK

  • The goals of treatment should be identified with the patient and agreed as part of an asthma action plan.

  • Assessment of people with difficult asthma should be facilitated through a dedicated multidisciplinary asthma service

  • Some patients are misdiagnosed with asthma, when they may not have asthma at all or there may be other pathology contributing to symptoms

  • Oral corticosteroids are the mainstay of treatment for patients with severe asthma and are effective for most patients, but should be used at the lowest dose that maintains asthma control

The management of adults with asthma that remains uncontrolled despite treatment with high dose therapies poses a challenge to clinicians and patients. National and international guidelines recommend intensification of treatment that typically involves the use of oral corticosteroids.12 The risks associated with long term systemic corticosteroid treatment are well documented and have led to the search for alternatives. Recent advances in the understanding of the pathology of asthma have prompted the development of other treatment options. Here, we consider the options available for people who require continuous or frequent use of oral corticosteroids and review the safety and efficacy of such treatments.

How common is it?

In the UK, over four million adults are being treated for asthma, and it remains responsible for more than 1000 deaths a year.34 Asthma exacerbations resulted in over 60 000 hospital admissions in 2013-14, with an estimated annual cost of £1bn to the NHS.34

The goals of asthma management are good symptom control with minimal exacerbations (see box 1).12

Box 1: Definition of complete control of asthma1

  • No daytime symptoms

  • No night time awakening due to asthma

  • No need for rescue medication

  • No asthma attacks

  • No limitations on activity, including exercise

  • Normal lung function

  • Minimal adverse effects from medication

The goals of treatment …

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