Management of Severe Asthma: a European Respiratory Society/American Thoracic Society Guideline,European Respiratory Journal

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Management of Severe Asthma: a European Respiratory Society/American Thoracic Society Guideline
European Respiratory Journal ( IF 16.6 ) Pub Date : 2019-09-26 , DOI: 10.1183/13993003.00588-2019
Fernando Holguin _{1,

2} , Juan Carlos Cardet ₃ , Kian Fan Chung ₄ , Sarah Diver ₅ , Diogenes S Ferreira _{6,

7} , Anne Fitzpatrick ₈ , Mina Gaga ₉ , Liz Kellermeyer ₁₀ , Sandhya Khurana ₁₁ , Shandra Knight ₁₀ , Vanessa M McDonald ₁₂ , Rebecca L Morgan ₁₃ , Victor E Ortega ₁₄ , David Rigau ₁₅ , Padmaja Subbarao ₁₆ , Thomy Tonia ₁₇ , Ian M Adcock ₁₈ , Eugene R Bleecker ₁₉ , Chris Brightling ₂₀ , Louis-Philippe Boulet ₂₁ , Michael Cabana ₂₂ , Mario Castro ₂₃ , Pascal Chanez ₂₄ , Adnan Custovic ₂₅ , Ratko Djukanovic ₂₆ , Urs Frey ₂₇ , Betty Frankemölle ₂₈ , Peter Gibson ₂₉ , Dominique Hamerlijnck ₂₈ , Nizar Jarjour ₃₀ , Satoshi Konno ₃₁ , Huahao Shen ₃₂ , Cathy Vitary ₃₃ , Andy Bush _{34,

35}

Affiliation

Pulmonary Sciences and Critical Care Medicine, University of Colorado, Denver, CO, USA
F. Holguin is ATS co-chair.
Allergy and Immunology, University of South Florida, Tampa, FL, USA.
Experimental Studies Medicine, National Heart and Lung Institute, Imperial College London, London, UK.
Respiratory Biomedical Unit, University of Leicester, Leicester, UK.
Alergia e Imunologia, Complexo Hospital de Clinicas, Universidade Federal do Parana, Curitiba, Brazil.
School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.
Division of Pulmonology Allergy/Immunology, Cystic Fibrosis and Sleep, Emory University, Atlanta, GA, USA.
Respiratory Medicine Dept and Asthma Centre, Athens Chest Hospital, Athens, Greece.
Biomedical Library, National Jewish Health, Denver, CO, USA.
Pulmonary Diseases and Critical Care, University of Rochester, Rochester, NY, USA.
School of Nursing, University of Newcastle, Newcastle, Australia.
Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada.
Pulmonary, Critical Care, Allergy and Immunologic Diseases, Wake Forest School of Medicine, Winston-Salem, NC, USA.
Iberoamerican Cochrane Centre, Barcelona, Spain.
Dept of Pediatrics, SickKids, Toronto, ON, Canada.
Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland.
Molecular Cell Biology Group, National Heart and Lung Institute, Imperial College of London, London, UK.
Division of Genetics, Genomics and Precision Medicine, University of Arizona, Tucson, AZ, USA.
Dept of Respiratory Sciences, University of Leicester, Leicester, UK.
Respiratory Medicine, Laval University, Quebec, QC, Canada.
Division of General Pediatrics, University of California San Francisco, San Francisco, CA, USA.
Division of Pulmonary and Critical Care Medicine, Washington University, St Louis, MO, USA.
Dept of Respiratory Diseases, University of Aix-Marseille, Marseille, France.
Paediatric Allergy, National Heart and Lung Institute, Imperial College of London, London, UK.
Respiratory Biomedical Research, University of Southampton, Southampton, UK.
Dept of Pediatrics, University Children's Hospital, Basel, Switzerland.
European Lung Foundation, Lausanne, Switzerland.
School of Medicine and Public Health, University of Newcastle, Newcastle, Australia.
Division of Pulmonary and Critical Care, University of Wisconsin, Madison, WI, USA.
Dept of Respiratory Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Hokkaido, Japan.
Dept of Respiratory and Critical Care Medicine, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China.
Asthma Institute, University of Pittsburgh, Pittsburgh, PA, USA.
Dept of Paediatrics, Imperial College London, National Heart and Lung Institute, London, UK.
A. Bush is ERS co-chair.

This document provides clinical recommendations for the management of severe asthma. Comprehensive evidence syntheses, including meta-analyses, were performed to summarise all available evidence relevant to the European Respiratory Society/American Thoracic Society Task Force's questions. The evidence was appraised using the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach and the results were summarised in evidence profiles. The evidence syntheses were discussed and recommendations formulated by a multidisciplinary Task Force of asthma experts, who made specific recommendations on six specific questions. After considering the balance of desirable and undesirable consequences, quality of evidence, feasibility, and acceptability of various interventions, the Task Force made the following recommendations: 1) suggest using anti-interleukin (IL)-5 and anti-IL-5 receptor α for severe uncontrolled adult eosinophilic asthma phenotypes; 2) suggest using a blood eosinophil cut-point ≥150 μL−1 to guide anti-IL-5 initiation in adult patients with severe asthma; 3) suggest considering specific eosinophil (≥260 μL−1) and exhaled nitric oxide fraction (≥19.5 ppb) cut-offs to identify adolescents or adults with the greatest likelihood of response to anti-IgE therapy; 4) suggest using inhaled tiotropium for adolescents and adults with severe uncontrolled asthma despite Global Initiative for Asthma (GINA) step 4–5 or National Asthma Education and Prevention Program (NAEPP) step 5 therapies; 5) suggest a trial of chronic macrolide therapy to reduce asthma exacerbations in persistently symptomatic or uncontrolled patients on GINA step 5 or NAEPP step 5 therapies, irrespective of asthma phenotype; and 6) suggest using anti-IL-4/13 for adult patients with severe eosinophilic asthma and for those with severe corticosteroid-dependent asthma regardless of blood eosinophil levels. These recommendations should be reconsidered as new evidence becomes available. The ERS/ATS Task Force makes recommendations on the use of novel therapies for severe asthma, specifically biologicals for type 2 high asthma, and antimuscarinic agents and macrolides, as well as on biomarkers for predicting treatment response http://bit.ly/2kZLRaD

中文翻译：

严重哮喘的管理：欧洲呼吸学会/美国胸科学会指南

本文件为严重哮喘的管理提供了临床建议。进行了全面的证据合成，包括荟萃分析，以总结与欧洲呼吸学会/美国胸科学会工作组的问题相关的所有可用证据。使用 GRADE（推荐、评估、制定和评价分级）方法对证据进行评估，并将结果总结在证据资料中。由哮喘专家组成的多学科工作组讨论了证据综合并制定了建议，他们针对六个具体问题提出了具体建议。在考虑了各种干预措施的理想和不良后果、证据质量、可行性和可接受性之间的平衡后，工作组提出了以下建议：1) 建议使用抗白细胞介素 (IL)-5 和抗 IL-5 受体 α 治疗严重不受控制的成人嗜酸性粒细胞哮喘表型；2) 建议使用≥150 μL−1 的血液嗜酸性粒细胞临界值来指导成人重度哮喘患者的抗 IL-5 启动；3) 建议考虑特定的嗜酸性粒细胞 (≥260 μL−1) 和呼出的一氧化氮分数 (≥19.5 ppb) 临界值，以确定对抗 IgE 治疗有最大反应可能性的青少年或成人；4) 建议对患有严重未控制哮喘的青少年和成人使用吸入噻托溴铵，尽管全球哮喘倡议 (GINA) 的第 4-5 步或国家哮喘教育和预防计划 (NAEPP) 的第 5 步治疗；5) 建议在接受 GINA 第 5 步或 NAEPP 第 5 步治疗的持续有症状或不受控制的患者中，进行慢性大环内酯治疗以减少哮喘恶化，与哮喘表型无关；6) 建议对患有严重嗜酸性粒细胞哮喘的成年患者和患有严重皮质类固醇依赖性哮喘的患者使用抗 IL-4/13，而不管血液嗜酸性粒细胞水平如何。随着新证据的出现，应重新考虑这些建议。ERS/ATS 工作组就严重哮喘的新疗法的使用提出建议，特别是 2 型高度哮喘的生物制剂、抗毒蕈碱药物和大环内酯类药物，以及用于预测治疗反应的生物标志物 http://bit.ly/2kZLRaD

更新日期：2019-09-26

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