II. Criteria

  1. Continuous symptoms throughout the day, interfering with sleep and activity
  2. Frequent exacerbations (several times daily)
    1. Daily symptoms throughout the day
    2. Nightly symptoms
      1. For age <5 years, night awakenings more than once per week
    3. Beta Agonist use several times daily
    4. Oral Corticosteroids required 2 or more times per year
  3. Pulmonary Function Tests
    1. FEV1 or PEF <60% of predicted
    2. PEF variability > 30%
    3. FEV1 to FVC ratio decreased >5% (<75% for age 5-19, <70% for age 20-39, <65% for age 40-59, then <60%)

III. Management

  1. See Asthma Stepped Care
  2. Rule out Other Etiologies
    1. Non-compliance
    2. Cystic Fibrosis
  3. Long-term daily control medication
    1. Inhaled Corticosteroid (High dose) and
    2. Long acting beta agonist Bronchodilator and
    3. Leukotriene Receptor Antagonist (Montelukast)
    4. Consider Zileuton (Zyflo)
    5. Consider Systemic Corticosteroids (2 mg/kg/day to 60 mg/day)
    6. Consider Anti-IgE Therapy (Omalizumab)
      1. Indicated in severe refractory (Step 5-6) Asthma with IgE levels >75
      2. Subcutaneous Injection every 2-4 weeks
    7. Consider Benralizumab/mepolizumab (Nucala)
      1. Interleukin 5 Inhibitor administered IM monthly
  4. Other measures
    1. Short term rescue with beta agonist
    2. Asthma Education

IV. References

  1. Park (2017) Asthma Updates, Mayo Clinical Reviews, Rochester, MN
  2. (1997) Management of Asthma, NIH 97-4053
  3. (1995) Global Strategy for Asthma, NIH 95-3659
  4. Kalister (2001) West J Med 174:415-20 [PubMed]
  5. Kemp (2001) Am Fam Physician 63(7):1341-54 [PubMed]
  6. Pollart (2009) Am Fam Physician 79(9):761-7 [PubMed]

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Ontology: Severe persistent asthma (C1960048)

Concepts Disease or Syndrome (T047)
ICD10 J45.50 , J45.5
SnomedCT 426656000
English Severe persistent asthma (disorder), Severe persistent asthma, severe persistent asthma (diagnosis), severe persistent asthma, Severe persistent asthma NOS
Spanish asma persistente severa (trastorno), asma persistente severa