@article{d468da4193c14ad797d951c224d8709b,
title = "Workup of Severe Asthma",
abstract = "A 56-year-old man has difficult-to-control asthma and a history of four exacerbations in the prior 12 months despite high-dose inhaled corticosteroids (ICS) and additional controller therapies. Is he suitable for more advanced therapeutic options? To address this query, we herein review the clinical assessment of a patient with suspected severe asthma and discuss factors contributing to poor asthma control and how biomarkers assist in disease investigation and stratification. The key components of our multidisciplinary approach are to confirm an asthma diagnosis and adherence to treatment, to assess any contributing comorbidities or confounding factors, and to stratify what type of asthma the patient has. The combination of spirometry and repeated measures of key biomarkers of type 2 airway inflammation—the blood eosinophil count and fractional exhaled nitric oxide—identifies whether poor disease control is driven by uncontrolled, ICS-resistant type 2 airway inflammation or ongoing airflow obstruction. A failure to elicit evidence of either suggests an alternative driver for the patient's symptoms, including chronic airway infection and non-asthma causes. Each phenotype represents a treatable trait that requires a specific targeted approach. Critically, steroids can cause harm, and their use should be guided by objective evidence of inflammation rather than symptoms alone. To conclude, after assessment of treatment adherence and exclusion of relevant comorbidities, the patient was found to have severe asthma with ICS-resistant type 2 airway inflammation. We will consider additional treatment options at our next appointment in part 2/2 of this How I Do It series.",
keywords = "adherence, airways, asthma, biomarkers, eosinophils, exacerbations, FENO, multidisciplinary team, severe asthma, type 2 inflammation",
author = "Simon Couillard and Jackson, {David J.} and Wechsler, {Michael E.} and Pavord, {Ian D.}",
note = "Funding Information: Financial/nonfinancial disclosures: The authors have reported to CHEST the following: S. C. has received a nonrestricted research grant from Sanofi Genzyme for investigator-initiated type 2 innovation research; speaker honoraria from Sanofi Regeneron, AstraZeneca, and GlaxoSmithKline (GSK), outside the submitted work. D. J. J. has received advisory board and speaker's fees from AstraZeneca, Boehringer Ingelheim, Novartis, Teva, and GSK, Sanofi/Regeneron and Chiesi, outside of the submitted work. M. E. W. reports grants and personal fees from Novartis, Sanofi, GSK, and Cohero Health, personal fees from Regeneron, Genentech, Sentien, Restorbio, Equillium, Genzyme, grants, personal fees and nonfinancial support from Teva, personal fees and nonfinancial support from Boehringer Ingelheim, grants, personal fees and nonfinancial support from AstraZeneca. In the last 5 years, I. D. P. has received speaker's honoraria for speaking at sponsored meetings from AstraZeneca, Boehringer Ingelheim, Aerocrine AB, Almirall, Novartis, Teva, Chiesi, Sanofi/Regeneron, Menarini, and GSK, and payments for organizing educational events from AstraZeneca, GSK, Sanofi/Regeneron, and Teva. He has received honoraria for attending advisory panels with Genentech, Sanofi/Regeneron, AstraZeneca, Boehringer Ingelheim, GSK, Novartis, Teva, Merck, Circassia, Chiesi, and Knopp, and payments to support FDA approval meetings from GSK. He has received sponsorship to attend international scientific meetings from Boehringer Ingelheim, GSK, AstraZeneca, Teva, and Chiesi. He has received a grant from Chiesi to support a phase 2 clinical trial in Oxford. He is co-patent holder of the rights to the Leicester Cough Questionnaire and has received payments for its use in clinical trials from Merck, Bayer, and Insmed. In 2014-2015, he was an expert witness for a patent dispute involving AstraZeneca and Teva. Other contributions: The authors thank Dr Timothy SC Hinks for assistance in creating Figure 2. Funding Information: Financial/nonfinancial disclosures: The authors have reported to CHEST the following: S. C. has received a nonrestricted research grant from Sanofi Genzyme for investigator-initiated type 2 innovation research; speaker honoraria from Sanofi Regeneron , AstraZeneca , and GlaxoSmithKline (GSK), outside the submitted work. D. J. J. has received advisory board and speaker{\textquoteright}s fees from AstraZeneca , Boehringer Ingelheim, Novartis , Teva, and GSK, Sanofi / Regeneron and Chiesi , outside of the submitted work. M. E. W. reports grants and personal fees from Novartis , Sanofi , GSK, and Cohero Health, personal fees from Regeneron, Genentech, Sentien, Restorbio, Equillium, Genzyme, grants, personal fees and nonfinancial support from Teva, personal fees and nonfinancial support from Boehringer Ingelheim, grants, personal fees and nonfinancial support from AstraZeneca . In the last 5 years, I. D. P. has received speaker{\textquoteright}s honoraria for speaking at sponsored meetings from AstraZeneca , Boehringer Ingelheim, Aerocrine AB, Almirall, Novartis , Teva, Chiesi , Sanofi /Regeneron, Menarini, and GSK, and payments for organizing educational events from AstraZeneca , GSK, Sanofi /Regeneron, and Teva. He has received honoraria for attending advisory panels with Genentech, Sanofi /Regeneron, AstraZeneca , Boehringer Ingelheim, GSK, Novartis , Teva, Merck , Circassia, Chiesi , and Knopp, and payments to support FDA approval meetings from GSK. He has received sponsorship to attend international scientific meetings from Boehringer Ingelheim, GSK, AstraZeneca, Teva, and Chiesi. He has received a grant from Chiesi to support a phase 2 clinical trial in Oxford. He is co-patent holder of the rights to the Leicester Cough Questionnaire and has received payments for its use in clinical trials from Merck, Bayer, and Insmed. In 2014-2015, he was an expert witness for a patent dispute involving AstraZeneca and Teva. Publisher Copyright: {\textcopyright} 2021",
year = "2021",
month = dec,
doi = "10.1016/j.chest.2021.07.008",
language = "English",
volume = "160",
pages = "2019--2029",
journal = "Chest",
issn = "0012-3692",
publisher = "American College of Chest Physicians",
number = "6",
}
