A task force of the European Academy of Allergy and Clinical Immunology (EAACI) and the European Respiratory Society (ERS) have released a statement on severe asthma exacerbations in adult patients. The statement includes a definition of severe exacerbations, data regarding available and emerging therapies to prevent exacerbations, and priorities for future research. The full statement was published in the European Respiratory Journal.
Development of the EAACI/ERS Statement
Members of the EAACI/ERS task force convened to address 4 research questions related to severe exacerbations in asthma. These questions involved creating a clear definition of severe exacerbations, identifying triggers and risk factors for asthma-related exacerbations, finding the best strategies for management, and identifying optimal methods for preventing exacerbations. A literature review was performed to answer these questions and develop an evidence-based statement.
Statement Defines Severe Exacerbations of Asthma
The task force members agreed that severe exacerbations of asthma are primarily defined as a substantial worsening of asthma that necessitates the use of oral corticosteroids for ≥5 days vs 3 days, the latter duration recommended in the ERS/American Thoracic Society task force report of 2009. According to the EAACI/ERS committee members, a 5-day-based regimen of oral corticosteroids would make a better fit with the harmfulness of cumulative corticosteroids doses >0.5 grams/year.
And rather than relying only on clinical severity at presentation and peak expiratory flow or spirometry values to assess exacerbation risk, the task force emphasized the need for a composite score that takes into account a patient’s health history, the presence of comorbidities, psychosocial status, and adherence to therapy.
Triggers and Risk Factors
“Despite optimum maintenance therapy and appropriate prevention strategies,” the investigators wrote, “severe exacerbations occur, even in patients with mild disease or well-controlled asthma.” A major trigger for asthma exacerbations includes poor adherence to treatment. Inadequate inhalation technique may be an unintended contributor to poor adherence to inhaled corticosteroids in patients with asthma.
Another recognized risk factor for asthma exacerbations is high blood eosinophil count associated with type 2 (T2) inflammation. There is an unmet need to reduce severe exacerbations in non-T2 severe asthma. Macrolide antibiotics and bronchial thermoplasty may play a role that extends beyond medications used to reduce T2 inflammation, the committee wrote in their statement.
A modifiable risk factor for exacerbations, the task force adds, is viral infection. The most frequently detected viruses during an asthma exacerbation include rhinoviruses, particularly the rhinovirus A and rhinovirus C groups. Environmental allergens are also a preventable risk factor to some degree, and the task force suggests the possibility that access to air quality data records may help in the prevention of asthma exacerbations.
Acute Management and Prevention
In their statement, the task force members provided continued support for the use of systemic corticosteroids and bronchodilators in the acute management of asthma exacerbations. The statement also includes evidence of currently available therapies that work toward preventing exacerbations, including biological agents that are now in phase 3 clinical development (ie, omalizumab, mepolizumab and reslizumab, and benralizumab) and emerging therapies (ie, dupilumab and tezepelumab).
Further research is required to identify the best strategies for improving adherence to current treatment as a means of preventing asthma exacerbations. The EAACI/ERS members believe that the medications and treatment plans available are not sufficient for the prevention of exacerbations in all patients with asthma. Improving communication between the physician and the patient may be the most important facet of adherence and ultimate prevention.
Therapeutic educational programs, including E-health solutions that send electronic reminders to patients to use their inhalers, may be another effective option for managing and preventing the worsening of asthma. While E-health options may have a significant impact, it will only be effective “if these solutions are developed with patients and are sufficiently flexible and personalized.”
Disclosure: Several study authors declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.
Bourdin A, Bjermer L, Brightling C, et al. ERS/EAACI statement on severe exacerbations in asthma in adults: facts, priorities and key research questions. Eur Respir J. 2019;54(3).