Controlling Severe Asthma

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Options When Asthma Doesn't Respond to Treatment

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Though there is no cure for asthma, the goal of treatment is to allow individuals to maintain normal activity levels and reduce exacerbations of symptoms, such as wheezing and shortness of breath. This generally involves the use of one or more long-term control medications and a quick-acting rescue medication. The control medications are used daily to reduce the airway inflammation that can lead to asthma symptoms. Inhaled corticosteroids (ICS) are considered the gold standard of control medication, but other medications, such as long-acting beta agonists (LABA) may be added as needed to achieve better results. In contrast, quick-acting medications, like albuterol, are used to open the airways when symptoms suddenly flare.

If you suffer from severe asthma, however, conventional asthma treatment may not be enough to provide relief. Thankfully, there are some other options to explore.

Option 1: Allergy shots may also work as an asthma treatment.

Allergies and asthma often go hand-in-hand.  With allergies, your immune system responds to a harmless substance, such as mold or pollen, as though it was harmful to your body. It sends antibodies, proteins that your body produces to defend against things like viruses and bacteria, to attack it. The chemicals that are released that cause the runny nose and itchy eyes for allergy-sufferers may also trigger airway inflammation and asthma symptoms for some. Because of this, allergy shots may also help these cases of asthma. Allergy shots are a form of immunotherapy, a treatment that stimulates the immune system to work against a disease.

When you receive an allergy shot, you are actually being injected with a very small amount of the substance you are allergic to. This allows your body to get used to the allergen over time, and eventually, stop having the allergic response. By default, this should also decrease your asthma symptoms in response to the allergen. This may take a period of 3 to 5 years before the full effect is achieved.

Option 2: Biologics target the inflammatory asthma response.

A newer approach to severe asthma treatment involves the use of biological therapy, or “biologics”. Biologics are created from a natural source, such as human or animal proteins. Researchers have learned a lot about how airway inflammation occurs at the cellular and molecular level. As a result, they have been able to develop biologics to act at these intricate points and stop the inflammation from happening. These biologics are known as monoclonal antibodies, meaning they are antibodies created in a lab, not your own immune system.

There are few monoclonal antibodies currently being used to treat asthma. Your doctor will look at the characteristics of your specific type of asthma to determine if a biologic may be appropriate for you.

  • Immunoglobulin E (IgE) inhibitors: IgE is an antibody that is released when your body is exposed to an allergen. It initiates a chain reaction in the body, leading to inflammation in the airways. Omalizumab (Xolair) blocks IgE and has been shown to be effective in treating patients with allergic asthma. It is given as an injection once or twice a month.

  • Anti-interleukin-5 (IL-5): Eosinophils are white blood cells that play a role in airway inflammation. The number of circulating eosinophils is controlled by an antibody, IL-5. Two injectable medications have been developed to block IL-5 and decrease inflammation- reslizumab (Cinqair) and mepolizumab (Nucala). Reslizumab is administered as an infusion into a vein, while mepolizumab is injected through the skin. Each are given monthly.

Option 3: Bronchial thermoplasty is a non-medication option for severe asthma.

A procedure known as bronchial thermoplasty may help severe asthma patients who don’t respond to ICS or LABA. The treatment is divided into three separate but short outpatient procedures. While the patient is sedated, a flexible tube called a bronchoscope is inserted into the airways and energy from a radiofrequency probe selectively heats the airway tissues-not lung tissue. This causes the amount of smooth airway muscle to decrease, and as a result, the airways are less able to constrict. Studies have found bronchial thermoplasty to be safe, and patients report improved quality of life and less exacerbations of their asthma. This procedure is not widely available and not covered by all insurance companies, but it may be another alternative to discuss with your doctor.

More options for severe asthma treatment are expected to be coming down the pipeline, especially with regards to biologic therapies. In the meantime, if you are trying to get your asthma under control, make sure to take your medication as directed and follow your asthma action plan. Don’t hesitate to call your doctor if you have concerns or go to the emergency room as needed.

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Medical Reviewer: William C. Lloyd III, MD, FACS
Last Review Date: 2019 May 12

  1. An Update on Biologic-based Therapy in Asthma. Medscape. http://www.medscape.com/viewarticle/817432

  2. Asthma. Cleveland Clinic. http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/allergy/bronchial-asthma/

  3. Asthma Treatments and Drugs. Mayo Clinic. http://www.mayoclinic.org/diseases-conditions/asthma/basics/treatment/con-20026992

  4. Bronchial Thermoplasty in Asthma: Current Perspectives. Journal of Asthma and Allergy. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4440435/

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