Treating Severe Asthma: It's Personal

With asthma you may feel like control is out of reach. It can be frustrating to suffer from asthma symptoms such as chest tightness, shortness of breath, coughing and wheezing, even though you are using your quick-relief inhaler as prescribed and long-term controller medication daily. Unlike uncontrolled asthma, severe asthma is characterized by resistance to certain medication which is why your current medication may offer no relief.

But there is hope.

Severe asthma is personalized so treatment will depend on your specific type, biomarkers, individual triggers and individualized or targeted therapy. That is why it is essential to keep your doctor up-to-date on the challenges you face with managing your asthma. If you believe you have severe asthma, you can work together with your healthcare provider to create a personalized treatment plan and medications that fit your specific type and needs.

What to Expect at a Follow-Up Visit

When tackling your severe asthma, it is best to be prepared when you meet with your doctor. At a follow-up visit, your doctor will ask for a complete medical history and perform tests to ensure that your symptoms are linked to asthma and are not being caused by a different condition. Once conditions such as respiratory infection, acid reflux, chronic obstructive pulmonary disease (COPD), chronic cough, vocal cord issues or other rare conditions have been ruled out, your doctor may refer you to an asthma specialist (pulmonologist or allergist) to do more testing in order to determine your asthma type.

Possible Tests

There are a number of tests that a pulmonologist or allergist may use to help determine your type of severe asthma. These tests will help determine whether your severe asthma includes Type 2 or Non-Type 2 inflammation.

Breath Tests:

• Spirometry: This test measures how much air you can breathe in and out of your lungs, as well as how fast you can blow the air out of your lungs.
• Methacholine challenge test: This test evaluates how reactive your lungs are to things in the environment. By breathing in small amounts of Methacholine, a drug that can cause narrowing of the airways, your doctor will then perform a spirometry test to measure the degree of the narrowing contributing to your asthma symptoms.
• Exhaled nitric oxide test: This test measures droplets in your exhaled breath carrying nitric oxide, a colorless gas. Excess amounts of nitric oxide can cause increased inflammation of your airway contributing to your asthma symptoms.

Blood Test:

• This test measures levels of allergens or other cells that cause Type 2 inflammation in the body. This type of inflammation is an indicator of severe asthma.

Sputum (lung mucus) test:

• This test measures eosinophils (white blood cells) in the mixture of saliva and sputum (lung mucus) coughed up from your lungs. Excess eosinophils cause Type 2 inflammation indicating severe asthma. If the results from the testing confirms that you have severe asthma, your specialist will then recommend a personalized treatment plan, medication and/or lifestyle changes that can better control your asthma.

Working with Your Doctor to Find Personalized Treatment Options

Severe asthma can be debilitating because it commonly affects your daily life. Finding the right medication for your asthma will depend on your age, symptoms, biomarkers, asthma triggers, preferences and cost.

With the help of your doctor, you will want to start by identifying and avoiding known triggers. You can prepare for your appointment by keeping an asthma journal that details what conditions trigger your asthma. In addition, your doctor may reassess your medication technique, barriers to taking them regularly and recommend some changes including taking a higher-dose of a controller medication (inhaled corticosteroid) or possibly maintenance oral corticosteroids.

Depending on your kind of asthma, as well as what triggers your symptoms, your doctor may prescribe medication tailored to your condition. A prescribed medication called a biologic is a new treatment to manage severe asthma symptoms. These medications are administered as an injection (shot) or intravenously (IV) bi-weekly, bi-monthly or monthly depending on the dosing recommendation. Biologics work by identifying and targeting the cells or chemical messengers in the body causing the Type 2 inflammatory response in your lungs and airways.

In order to prescribe a biologic, your doctor will conduct tests that will help to recognize biomarkers (unique identifiers) in your body. These biomarkers will determine your asthma type and find your match to specific biologic medications, therefore personalizing your care. Depending on if your asthma is Type 2 or Non-Type 2, your doctor will either recommend one of several anti-inflammatory medications or will prescribe an antibiotic and/or lifestyle changes. Biologic medicines are relatively new and more are being developed, so cost and insurance coverage should be considered before making a decision.

Another option your doctor may consider is an outpatient procedure called Bronchial Thermoplasty (BT). BT is a procedure that involves using mild heat applied to smooth muscle tissue in the airway causing less airway constriction and reducing flareups. This procedure is approved for adults only and many restrictions apply.

Another treatment option your doctor may prescribe is oral corticosteroids. Though these medications are usually only prescribed for short-term use, if you have severe asthma your doctor may recommend them for longer term use. Caution should be taken with this treatment option, as side effects can be serious.

If you are diagnosed with severe asthma but with Non-Type 2 inflammation, your doctor may personalize your treatment to include macrolide antibiotics. These antibiotics work to control the number of white blood cells (neutrophils) found in your airways and reduce symptoms.

In addition to antibiotics, if you have Non-Type 2 inflammation, you may need to make some lifestyle changes. Commonly, people with this type of severe asthma will be advised to:

• Remove allergens from the home, such as pets and/or certain products, or reducing exposure to environmental allergens and chemicals.
• Lose weight under guidance of your doctor.
• Manage other health conditions with the help of your doctor.
• Quit smoking and avoid secondhand smoke.

Living with severe asthma can be challenging, but with help from your healthcare provider it can be manageable. Complete our new Severe Asthma Treatment Planning Tool online or download the Severe Asthma Treatment Planning Worksheet to help you start a discussion with your specialist. Not sure if your asthma is uncontrolled or think you may have severe asthma? Take our Asthma Control Assessment quiz.