People with asthma can experience recurring symptoms or flare-ups, despite preventer treatment. Only a small proportion of these people have severe asthma.
Note: Severe asthma is defined as asthma that is uncontrolled despite treatment with a high dose of an inhaled corticosteroid in combination with a long-acting beta2 agonist (with correct inhaler technique and good adherence) or maintenance oral corticosteroids, or that requires such treatment to prevent it becoming uncontrolled.1
The most common reasons for experiencing poorly controlled asthma are:
- not using preventer at a therapeutic dose and/or frequency (e.g. adherence is suboptimal)
- incorrect inhaler technique
- other medical conditions affecting asthma symptoms or risk of flare-ups
- psychosocial factors that affect asthma self-management (e.g. life events, financial problems or mental health conditions).
The term ‘difficult-to-treat asthma’ is used for asthma that remains uncontrolled despite treatment with a high dose of an inhaled corticosteroid combined with a long-acting beta2 agonist.1 ‘Difficult’ refers to the pattern of clinical findings – not the person.
Asthma management involves identifying the optimal treatment plan for each person and support them to achieve the best possible asthma control, through effective self-management (adults and older children), or effective asthma management by parents/carers (younger children).
When a person’s asthma is not well controlled despite treatment, working with the person (or parents/carers) to consider the possible reasons systematically, before adjusting the treatment, may avoid unnecessary or risky dose escalation. Consider:
- whether current treatment is appropriate
- inhaler technique
- frequency of preventer dosing
- whether the symptoms are due to asthma.
- the individual’s triggers
- any comorbid conditions that may affect asthma symptoms, risk or management.
Note: The order in which these considerations are best addressed may differ, depending on the setting, the patient and the circumstances. Because they are interrelated, they may each need to be addressed more than once.
If asthma is still not well controlled after working through these issues and optimising treatment, consider the possibility of severe asthma.
In this section
Comprehensive review when asthma is not controlled by preventer treatment
Checking whether current prescribed treatment is appropriate
Checking whether the person has problems taking their medicine
Checking whether current symptoms are due to asthma
Triggers and comorbidities
Considering triggers and comorbidities
Considering non-pharmacological strategies to manage difficult-to-treat asthma in adults and adolescents and providing general care
- Chung, K F, Wenzel, S E, Brozek, J L, et al. International ERS/ATS guidelines on definition, evaluation and treatment of severe asthma. Eur Respir J. 2014; 43: 343-73. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24337046