Asthma is a widespread breathing condition that affects many people today. It is a medical condition in which the airways become narrow, swelling up, and producing excessive mucus. This makes it difficult for a person to breathe and can also trigger wheezing, coughing and shortness of breath. On the other hand, severe asthma is a condition of asthma that is not responding well to regular treatments for asthma, including inhaled bronchodilator medications and inhaled corticosteroids. If you have severe asthma, meaning that you are unable to control your asthma with any type of treatment, then this means that you require a high dosage of either inhaled corticosteroids or you need to be on oral corticosteroids for the long term. Let us take a look at understanding treatment types for severe asthma.
Overview of Severe Asthma
Asthma is a type of inflammatory lung disease that can cause mild to severe symptoms. In a majority of cases, you will be able to control your asthma by avoiding the primary triggers, by taking your medications, and other treatment options.
However, if you find that you are unable to bring your asthma under control with any of the regular treatments, then this means that you are suffering from severe asthma. Having severe asthma means that you require a high dosage of either long term oral corticosteroids or inhaled corticosteroids, apart from your daily medications.
Many doctors have different opinions about the definition of severe asthma. The World Health Organization (WHO) classifies severe asthma into three separate categories.(1) These include:
- Untreated Asthma
- Therapy Resistant Asthma
- Difficult to Treat Asthma
Severe asthma is known to be challenging to treat, but it is still possible to get your condition under control.
Symptoms of Severe Asthma
The symptoms of severe asthma are quite similar to the symptoms of mild to moderate asthma, but the symptoms of severe asthma are more aggressive and more intense. They can even be potentially life-threatening. These symptoms are difficult to treat and manage with conventional asthma treatments.
Some of the signs and symptoms of severe asthma include:
- Wheezing that persists even after treatment
- Pain and tightness in your chest
- Shortness of breath that continues to worsen
Sometimes severe asthma symptoms can also become life-threatening, so make sure that you know when it’s time to seek emergency medical care. If you are experiencing shortness of breath that seems to occur even while doing the simplest of physical activities, or it tends to worsen easily, then you should seek emergency medical assistance at the earliest.
You might also need emergency treatment if your quick-relief inhaler does not seem to be helping.
Treatment Types For Severe Asthma
The basic definition of severe asthma is that either it is complicated to treat or it does not respond well to conventional treatments and medications. This total lack of positive response to drugs is known as therapy-resistant asthma. This may happen because your asthma has, over the years, finally become resistant to corticosteroids, or towards any of the other medications that were being used to treat your asthma.
If it is found that your asthma is not responding to the regular medications, then you need to visit your doctor for a diagnosis and look for alternative treatment methods. Your doctor will check to determine if you have any other conditions that might be getting mistaken for asthma – including heart failure and angina. Your doctor will also carry out a detailed examination to check for complications of severe asthma, such as allergic bronchopulmonary aspergillosis and other chronic infections.
If you are diagnosed with severe asthma, your doctor will then work together with you to develop a new treatment plan. This treatment plan will include lifestyle changes and some new medications, as well as natural treatments.(2)
Medications & Therapies
Here are the medications that are used for treating severe asthma:
- More frequent use of inhaled corticosteroids
- Corticosteroid injections
- Having a higher dose of inhaled corticosteroids
- Continuous inhaled nebulizer
- Biologic drugs
- Oral corticosteroids
- Montelukast or Leukotriene Modifiers
- Ipratropium bromide aerosols
- Long-acting beta-agonists (LABAs)
- Cromolyn sodium (Intal)
- Inhaled long-acting anticholinergics
- Bronchial thermoplasty
The medications that are listed here might either be prescribed alone or in combination in order to try to get the symptoms of severe asthma under control.
Let us take a look at some of these treatment options:
Biologic drugs are one of the more newer treatments for the treatment of severe asthma. These drugs work together with your immune system to treat severe asthma. They function by blocking the activity of the chemical released by your immune system, which makes your airways swell up. Biologics can prevent you from having asthma attacks and also make these attacks much milder.
There are four monoclonal antibodies that are presently approved for the treatment of severe asthma. These include:
- Benralizumab (brand name: Fasenra)
- Omalizumab (brand name: Xolair)
- Reslizumab (brand name: Cinqair)
- Mepolizumab (brand name: Nucala)
Omalizumab is known for treating severe asthma that gets triggered by allergies. Mepolizumab, benralizumab, and reslizumab, are useful in treating severe asthma that is caused by eosinophil, which is a type of white blood cell. This type of asthma is known as eosinophilic asthma.(3)
These biologic drugs are taken through injection or intravenously into a vein. There are also some new monoclonal antibodies, including tezepelumab, that are currently under investigation.
This is a type of inhaled drug that is also used in the treatment of chronic obstructive pulmonary disease (COPD) for over ten years now. In 2015, the US Food and Drug Administration (FDA) also approved the use of Spiriva for the treatment of severe asthma.(4)
Studies have shown that tiotropium helps improve a person’s asthma control when it is added to high doses of inhaled corticosteroids and well as short-acting beta-agonists.(5)
This is another group of asthma medications that works by blocking the action of leukotriene in this body. Leukotriene is a chemical that narrows and tightens the airways during any allergy-induced asthma attack.(6) There are three leukotriene modifiers that have been approved for the treatment of severe asthma. These include:
- Zileuton (brand name: Zyflo)
- Zafirlukast (brand name: Accolate)
- Montelukast (brand name: Singulair)
These medications can be taken orally by mouth for preventing or treating asthma attacks.
Bronchial thermoplasty is a surgical procedure that is used for severe asthma that does not show any improvement with other treatments. During this procedure, radiofrequency energy is applied to the airway. The heat that is generated from the radiofrequency energy helps destroy some of the smooth muscle lining the airway, preventing these muscles from constricting and further narrowing the opening of the airway.(7)
Bronchial thermoplasty is typically delivered in three sessions, and each is administered within three weeks apart. So although this is not a cure for severe asthma, several studies have shown that bronchial thermoplasty helps reduce the symptoms of severe asthma.(8)
Apart from taking medications, it is also necessary for you to make specific lifestyle changes if you want to get relief from severe asthma. Here are certain recommended changes that you should consider incorporating in your life:
- If you are overweight or obese, try to lose weight gradually. Being overweight or obese puts a lot of pressure on all the systems of your body, making it more likely that you will suffer an asthma attack.
- Whenever possible, avoid or remove any known triggers such as allergens or exposure to environmental irritants such as chemicals and dust. You should basically avoid any known triggers that cause you to start feeling short of breath that may ultimately lead to an asthma attack.
- Avoid smoking and second-hand smoke.
Some people also recommend certain natural treatments for managing the symptoms of severe asthma. However, keep in mind that natural remedies are not a replacement for your asthma medications, but you may still benefit from trying out some of these, along with your prescribed treatments.
Some examples of natural treatments that may help in severe asthma include:
- Herbal remedies such as black seed, caffeine, and choline
- Breathing exercises that may reduce the amount of prescribed medication you require
- Mindfulness and yoga may help reduce stress, which is a known asthma trigger.
Nevertheless, more research is still required for supporting any alternative treatments and the effect they have on severe asthma symptoms. It is also necessary to discuss any type of supplements or herbs that you are thinking of taking with your doctor before you begin taking them.
Researchers are still looking for newer medications and therapies that will be able to prevent and also relieve symptoms of severe asthma. For instance, one such advanced drug that has created a lot of excitement is Fevipiprant (QAW039). Even though the experimental drug is still under development, it has still shown a drastic reduction in the symptoms of severe asthma and also helped improve lung function in patients with allergic asthma who were unable to experience any relief with inhaled corticosteroids.(9) If Fevipiprant receives approval, it will become the first new oral asthma medication to be introduced in the last two decades.
There are also many other studies and clinical trials going on that are investigating the factors that have a significant role to play in the very development of this disease. Identifying the triggers that trigger off asthma symptoms is going to allow researchers to stop the processes that trigger asthma and prevent an asthma attack even before it begins.
- Linkinghub.elsevier.com. (2019). Redirecting. [online] Available at: https://linkinghub.elsevier.com/retrieve/pii/S0091674910011267 [Accessed 23 Aug. 2019].
- Lommatzsch, M. and Virchow, C.J., 2014. Severe asthma: definition, diagnosis and treatment. Deutsches Ärzteblatt International, 111(50), p.847.
- Haldar, P., Brightling, C.E., Hargadon, B., Gupta, S., Monteiro, W., Sousa, A., Marshall, R.P., Bradding, P., Green, R.H., Wardlaw, A.J. and Pavord, I.D., 2009. Mepolizumab and exacerbations of refractory eosinophilic asthma. New England Journal of Medicine, 360(10), pp.973-984.
- Kerstjens, H.A., Disse, B., Schröder-Babo, W., Bantje, T.A., Gahlemann, M., Sigmund, R., Engel, M. and van Noord, J.A., 2011. Tiotropium improves lung function in patients with severe uncontrolled asthma: a randomized controlled trial. Journal of Allergy and Clinical Immunology, 128(2), pp.308-314.
- Halpin, D.M., 2016. Tiotropium in asthma: what is the evidence and how does it fit in?. World Allergy Organization Journal, 9(1), p.29.
- Montuschi, P. and Peters‐Golden, M.L., 2010. Leukotriene modifiers for asthma treatment. Clinical & Experimental Allergy, 40(12), pp.1732-1741.
- Cox, G., Miller, J.D., McWilliams, A., FitzGerald, J.M. and Lam, S., 2006. Bronchial thermoplasty for asthma. American journal of respiratory and critical care medicine, 173(9), pp.965-969.
- Mdedge.com. (2019). [online] Available at: https://www.mdedge.com/sites/default/files/issues/articles/media_d245962_477.pdf [Accessed 23 Aug. 2019].
- Bateman, E.D., Guerreros, A.G., Brockhaus, F., Holzhauer, B., Pethe, A., Kay, R.A. and Townley, R.G., 2017. Fevipiprant, an oral prostaglandin DP2 receptor (CRTh2) antagonist, in allergic asthma uncontrolled on low-dose inhaled corticosteroids. European Respiratory Journal, 50(2), p.1700670.
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