We welcome the important article delineating the difference between severity and control in asthma 1, but we wonder if, on reflection, a different nomenclature, with a broader scope, might be more useful in real life clinical practice. The authors' propose subgroups of severe asthma, where poor control for extraneous reasons (for example medication issues and/or associated co-morbidities) are included, although it was correctly pointed out that the term “severe” asthma should be reserved for those with a requirement for high intensity treatment. Typically, asthmatics come to a specialist clinic because of failure to respond to high dose therapy and, as discussed, there are many reasons for this.
We have proposed the umbrella term “problematic severe asthma” for these patients 2. They may have either or both of poor baseline control and severe exacerbations. The first step is a detailed multidisciplinary assessment, if possible including a home visit, reviewing records of dispensed prescription and a psychological assessment. This initial assessment leads to about half the patients being placed in the “difficult” category 3. Their problem (i.e. poor compliance) may not be easily resolved but they are clearly not candidates for potentially toxic therapies, such as cyclosporin or etanercept. The remainder then should have a detailed assessment of airway inflammation and an evaluation of the response to intramuscular triamcinolone (or another reliable method of administering corticosteroids which cuts out uncertainty of patient adherence) to determine steroid responsiveness. Most, but not all of this group, will turn out to be truly “severe, therapy-resistant”, whose exacerbations, poor baseline control or both, may need innovative therapies. Our view is that different names for specific categories will lead to a reduction in the current confusion in the literature which has been highlighted 1. Our suggestion, shown in figure 1⇓, emphasises the distinction between difficult-to-treat asthma and severe, therapy resistant asthma. In fact, the same concept applies at any level of asthma severity; poorly controlled asthma deserves consideration of the reason for the difficulty before costly treatment is increased.
Suggested nomenclature of subgroups of problematic severe asthma.
Statement of interest
Statements of interest for F.M. de Benedictis and G. Wennergren can be found at www.erj.ersjournals.com/misc/statements.shtml
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