JAMA Clinical Reviews Treatment of Severe Refractory Asthma
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Oct 1, 2025 Join Juan Carlos Cardet, an Associate Professor specializing in Allergy and Immunology, as he unpacks the complexities of managing severe refractory asthma. He explains the significance of Type 2 asthma and identifies key tests essential for accurate diagnosis. Dr. Cardet highlights the role of inhaled corticosteroids and outlines when to consider biologic therapies. He also discusses the promising impact of these therapies on reducing exacerbations and hospitalizations, while addressing disparities in access to specialized care.
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Definition Depends On Excluding Other Causes
- Severe refractory asthma is asthma uncontrolled despite high-dose inhaled corticosteroids plus a second controller and after correcting technique, adherence, and comorbidities.
- Only after addressing comorbid conditions like reflux and vocal cord dysfunction do we label asthma as severe refractory.
Th2 Biology And Practical Biomarkers
- Type 2 (Th2-high) asthma is driven by IL-4, IL-5, and IL-13 and involves Th2 cells and ILC2s.
- Blood eosinophils and fractional exhaled nitric oxide (FeNO) are practical biomarkers for identifying Th2-high asthma.
Comprehensive Diagnostic Workup
- Order full pulmonary function tests, including FEV1, FVC, bronchodilator response, TLC, and DLCO for severe refractory asthma evaluation.
- Use CT imaging, ENT laryngoscopy, rhinoscopy, and allergen testing to rule out mimics and address comorbid triggers.