In short: Not all uncontrolled asthma is severe asthma. In most cases the problem is "difficult-to-treat asthma": an unsuitable inhaler, incorrect inhaler technique, related conditions or an inaccurate diagnosis. Only when all of these have been addressed and the asthma is still not controlled is it severe asthma, and for severe asthma there are now also biologic therapies.
Difficult-to-treat asthma and severe asthma
Difficult-to-treat asthma is asthma that is not controlled despite medium- or high-dose inhalers, or that is controlled only at a high dose. It often has causes that can be corrected.
Severe asthma is a specific subset: the asthma remains uncontrolled even after treatment has been optimised, technique and adherence have been checked and related conditions have been treated, or it worsens when the dose is reduced. This applies to a small minority of patients with asthma.
The structured work-up
- Confirming the diagnosis and ruling out conditions that mimic asthma (such as vocal cord dysfunction) or complicate it (such as ABPA or EGPA)
- Checking that the inhaler and technique are suitable, including a demonstration during the visit, and checking adherence
- Treating related conditions: rhinitis and nasal polyps, reflux, obesity, sleep apnoea
- Identifying triggers at home and at work, and smoking
- Defining the type of inflammation: blood eosinophils, FeNO, IgE and allergy
Biologic therapies
A biologic therapy is an injection, usually once every few weeks, that blocks a specific mechanism in the inflammatory cascade. Available treatments:
- Xolair (omalizumab): anti-IgE, for allergic asthma
- Nucala (mepolizumab): anti-IL-5, for eosinophilic asthma
- Fasenra (benralizumab): targets the IL-5 receptor, for eosinophilic asthma
- Dupixent (dupilumab): blocks the IL-4 and IL-13 pathways, also suitable when nasal polyps are present
- Tezspire (tezepelumab): anti-TSLP, suitable for a wide range of asthma types
Depemokimab (Exdensur), an anti-IL-5 therapy given twice a year, has recently been approved in some countries.
The choice between them is individual, based on the type of inflammation, related conditions and your preferences. The response is assessed after at least four months.
A care team
In severe asthma, where needed, we work together with ear, nose and throat (ENT) specialists, for example in chronic sinusitis, nasal polyps or suspected vocal cord dysfunction, and with allergy and immunology specialists to investigate and treat allergies. This way treatment covers everything that affects your breathing.
The goal: remission
Today the goal in treating severe asthma is remission: no attacks, no oral steroids, minimal symptoms and stable lung function. With tailored treatment, many patients get there.
Frequently asked questions
Is biologic therapy suitable for everyone with severe asthma?
Not for everyone. These treatments are mainly suitable for asthma with a specific type of inflammation (T2). The work-up determines whether there is a suitable treatment, and which one.
Are biologic therapies covered by the Israeli health basket?
Biologic therapies for severe asthma are included in the Israeli national health basket according to defined criteria. We will help you check whether you meet them and assist with the application.
Can I stop taking oral steroids?
For many patients, yes. One of the main goals of treatment is to reduce and stop oral steroids, gradually and with follow-up.
Further reading: After years of life-threatening asthma, Tal can dream of becoming a mother (ynet, in Hebrew, Dr. Inbal Shafran)
Related topics
General information only; it does not replace a medical consultation. עברית