TABLE 2

European Respiratory Society (ERS)/American Thoracic Society (ATS) Severe Asthma Task Force recommendations for the management of severe asthma

QuestionRecommendationStrengthQuality of evidence
1We suggest an anti-IL-5 strategy as add-on therapy for adult patients with severe uncontrolled asthma with an eosinophilic phenotype and for those with severe corticosteroid-dependent asthmaConditionalLow
2We suggest that a blood eosinophil cut-point ≥150 µL−1 can be used to guide anti-IL-5 initiation in adult patients with severe asthma and a history of prior asthma exacerbationsConditionalLow
3We suggest using a blood eosinophil cut-off ≥260 µL−1 to identify adolescents (>12 years) and adults with severe allergic asthma more likely to benefit from anti-IgE treatmentConditionalLow
We suggest using a FENO cut-off ≥19.5 ppb to identify adolescents (>12 years) and adults with severe allergic asthma more likely to benefit from anti-IgE treatmentConditionalLow
4For children, adolescents and adults with severe asthma uncontrolled despite GINA step 4–5 or NAEPP step 5 therapies, we recommend the addition of tiotropiumStrongModerate
5We suggest a trial of macrolide treatment to reduce asthma exacerbations in adult asthma subjects on GINA/NAEPP step 5 therapy that remain persistently symptomatic or uncontrolledConditionalLow
We suggest against the use of chronic macrolide treatment in children and adolescents with severe uncontrolled asthmaConditionalLow
6We suggest dupilumab as add-on therapy for adult patients with severe eosinophilic asthma and for those with severe corticosteroid-dependent asthma regardless of eosinophil levelsConditionalLow

IL: interleukin; R: receptor; FENO: exhaled nitric oxide fraction; GINA: Global Initiative for Asthma; NAEPP: National Asthma Education and Prevention Program.