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Characteristics, phenotypes, mechanisms and management of severe asthma

Chinese Medical Journal 2022年第10期135卷 1141-1155页

作者： Kian Fan Chung piers dixey Hisham Abubakar-Waziri Pankaj Bhavsari Pujan H.Patel Sujuan Guo Yang Ji National Heart&Lung Institute Imperial College LondonLondon SW36LYUK Royal Brompton&Harefield NHS Hospitals LondonUK Department of Respiratory Medicine University of Hong Kong Shenzhen HospitalShenzhenGuangdong 518053China.

Severe asthma is "asthma which requires treatment with high dose inhaled corticosteroids (ICS) plus a second controller (and/or systemic corticosteroids) to prevent it from becoming ’’uncontrolled’ or which remains ’’uncontrolled’ despite this therapy." The state of control was defined by symptoms, exacerbations and the degree of airflow obstruction. Therefore, for the diagnosis of severe asthma, it is important to have evidence for a diagnosis of asthma with an assessment of its severity, followed by a review of comorbidities, risk factors, triggers and an assessment of whether treatment is commensurate with severity, whether the prescribed treatments have been adhered to and whether inhaled therapy has been properly administered. Phenotyping of severe asthma has been introduced with the definition of a severe eosinophilic asthma phenotype characterized by recurrent exacerbations despite being on high dose ICS and sometimes oral corticosteroids, with a high blood eosinophil count and a raised level of nitric oxide in exhaled breath. This phenotype has been associated with a Type-2 (T2) inflammatory profile with expression of interleukin (IL)-4, IL-5, and IL-13. Molecular phenotyping has also revealed non-T2 inflammatory phenotypes such as Type-1 or Type-17 driven phenotypes. Antibody treatments targeted at the T2 targets such as anti-IL5, anti-IL5Rα, and anti-IL4Rα antibodies are now available for treating severe eosinophilic asthma, in addition to anti-immunoglobulin E antibody for severe allergic asthma. No targeted treatments are currently available for non-T2 inflammatory phenotypes. Long-term azithromycin and bronchial thermoplasty may be considered. The future lies with molecular phenotyping of the airway inflammatory process to refine asthma endotypes for precision medicine.

关键词： Severe asthma Biologic therapies Eosinophils Neutrophils Corticosteroid insensitivity Type 2-high inflammation

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