brand logo

Am Fam Physician. 2021;103(5):286-290

Patient information: A handout on this topic is available at https://familydoctor.org/condition/asthma.

Published online December 7, 2020.

This clinical content conforms to AAFP criteria for CME.

Author disclosure: No relevant financial affiliations.

Asthma is a common chronic inflammatory disease in the United States. Up to 17% of asthma cases are classified as difficult to treat, and 3.7% of these are considered severe. Uncontrolled asthma is characterized by poor symptom control or frequent exacerbations. In difficult-to-treat asthma, the asthma is uncontrolled despite adherence to inhaled corticosteroid therapy in combination with a second controller, an oral corticosteroid is needed to achieve control, or it is uncontrolled despite oral corticosteroid therapy. Severe asthma is a subset of difficult-to-treat asthma in which the disease is uncontrolled despite adherence to optimal management or it worsens when high-intensity therapy is decreased. The diagnosis of asthma should be confirmed and modifiable factors and comorbidities addressed in patients with difficult-to-treat asthma. An adequate trial of an inhaled corticosteroid and long-acting beta agonist should be implemented with nonbiologic add-on therapies, such as a long-acting muscarinic agent or leukotriene receptor antagonist. Evaluation of severe asthma involves assessment of asthma phenotype. Evidence of type 2 inflammation indicates that the patient may benefit from newer biologic agents. Breathing exercises may improve quality of life, asthma symptoms, lung function, and number of exacerbations. Vitamin D and soy supplementation are ineffective. Bronchial thermoplasty is a procedural option that may be considered if there is inadequate response to other therapies.

Asthma is a common chronic inflammatory disease in the United States, affecting 40 million people in their lifetime.1 Primary care physicians manage most patients with asthma, with 22% regularly treated by a specialist.2 Up to 17% of asthma cases are classified as difficult to treat, and 3.7% of these are considered severe.3 Severe asthma accounts for up to 60% of the cost of asthma.4 The costs for individuals with severe asthma are approximately 1.7-fold to fivefold greater than that for individuals with mild asthma.5 Patients with severe asthma experience significant disruptions in work, school, family life, and activities.2

RecommendationSponsoring organization
Do not diagnose or manage asthma without spirometry.American Academy of Allergy, Asthma and Immunology

Difficult-to-treat asthma requires a coordinated holistic approach that addresses the disease and its impact on patients' lives. Recent advances have expanded the therapeutic options. A previous article in American Family Physician discusses classification of asthma severity and medications for chronic asthma.6

Definitions

Uncontrolled asthma is characterized by poor symptom control (frequent use of a rescue inhaler, activities limited by asthma, or nocturnal awakening because of asthma) or frequent exacerbations (two or more courses of oral corticosteroids in 12 months, or one or more asthma-related hospitalizations in 12 months).7

Asthma is considered difficult to treat if it is uncontrolled despite adherence to medium- or high-dose inhaled corticosteroid therapy in combination with a second controller, an oral corticosteroid is needed to achieve control, or it is uncontrolled despite oral corticosteroid therapy.7 Severe asthma is a subset of difficult-to-treat asthma in which the disease is uncontrolled despite adherence to optimal therapy and treatment of contributing factors and comorbidities or it worsens when high-intensity therapy is decreased.7

It is challenging to distinguish difficult-to-treat asthma alone from severe asthma in clinical practice. In a systematic assessment, only 12% of people with difficult-to-treat asthma met criteria for severe asthma.8 Suboptimal adherence to therapy and incorrect inhaler technique were common in patients with difficult-to-treat asthma. In addition, only one-half of asthma cases that were classified as severe were objectively confirmed, and treatment adherence and inhaler technique were often not assessed.8

Diagnosis and Management of Difficult-to-Treat Asthma

In 2019, the Global Initiative for Asthma guidelines outlined a multistep approach for the assessment and management of difficult-to-treat asthma in adults and adolescents (Figure 1).9

The first step is to confirm the diagnosis of asthma, including consideration of the differential diagnosis (Table 1).9 Current asthma can be ruled out after repeat testing in up to one-third of adults with physician-diagnosed asthma.10 Patient history, physical examination, and spirometry should be performed. Interpretation of office spirometry was reviewed previously in American Family Physician.11 If the diagnosis is still unclear, pulmonary function, diffusion capacity, and bronchoprovocation testing may be considered.9 Chest computed tomography may be required to rule out other conditions such as bronchiectasis or if the patient has atypical features.7

Bronchiectasis
Cardiac disease
Chronic obstructive pulmonary disease
Cough induced by angiotensin-converting enzyme inhibitor use
Deconditioning
Gastroesophageal reflux disease
Obesity
Postnasal drip
Tracheobronchomalacia
Vocal cord dysfunction

The second step is to address contributing factors, including modifiable factors (e.g., poor inhaler technique, smoking, treatment nonadherence, environmental exposures), and inadequately controlled comorbidities, such as gastroesophageal reflux, rhinosinusitis, sleep apnea, immunoglobulin deficiency, cardiac disease, and depression/anxiety.9

The third step is to optimize management. Patients should be educated on self-assessment of asthma control, understanding asthma medications, proper inhaler technique, and creating a home action plan. Asthma therapy should include a high-dose inhaled corticosteroid plus a long-acting beta agonist (LABA) and rescue therapy. Nonbiologic add-on therapies, such as a long-acting muscarinic agent (LAMA) or leukotriene receptor antagonist, should be considered. Nonpharmacologic interventions, such as exercise, healthy diet, weight loss, allergen avoidance, influenza vaccination, and breathing exercises, should also be implemented. Referral to an asthma specialist (allergist or pulmonologist) or clinic may be considered.9

Already a member/subscriber?  Log In

Subscribe

From $145
  • Immediate, unlimited access to all AFP content
  • More than 130 CME credits/year
  • AAFP app access
  • Print delivery available
Subscribe

Issue Access

$59.95
  • Immediate, unlimited access to this issue's content
  • CME credits
  • AAFP app access
  • Print delivery available

Article Only

$25.95
  • Immediate, unlimited access to just this article
  • CME credits
  • AAFP app access
  • Print delivery available
Purchase Access:  Learn More

Continue Reading

More in AFP

More in Pubmed

Copyright © 2021 by the American Academy of Family Physicians.

This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP.  See permissions for copyright questions and/or permission requests.