Page 43 - Comprehensive treatment of patients with glucocorticoid-dependent severe asthma

improved symptom control [150] and quality of life in these patients [151]. Large multicentre clinical trials with anti-IL5 agents are now ongoing and will hopefully lead to FDA approval of this important drug in the near future.
Late onset obese female preponderant asthma
This asthma phenotype has become increasingly prevalent during the last decade, which is probably due to the steady increase in subjects with morbid obesity [152;153]. The major marker of severity in this phenotype is the excess weight and large waist circumference of the patients [154]. Obesity is associated with more severe asthma symptoms [155;156], poor asthma-related quality of life [155;157], and more asthma-related unscheduled medical visits and hospitalizations [155] despite high doses of asthma treatment.
The association between obesity and severe asthma can be explained by several mechanisms [153] including flow limitation secondary to mechanical factors [158], pro-inflammatory effects of adipose tissue on the lungs [159] and a high prevalence of co-morbidities that may affect lung function, in particular sleep disordered breathing and gastro-esophageal reflux disease [160].
The primary treatment of patients with the obese phenotype of severe refractory asthma is weight reduction. In a randomized controlled trial, it was demonstrated that weight reduction led to an improvement in lung function and asthma symptoms and quality of life [161] and a decrease in asthma exacerbations [161]. Similar results were obtained with gastric surgery [162;163].
Obstructive sleep apnea is extremely prevalent in obese patients with severe asthma [164] and has been shown to be associated with frequent asthma exacerbations [120]. Since treatment with continuous positive airway pressure has been shown to improve asthma control [165-167] sleep-related symptoms should be routinely assessed, and a polysomnography should be performed.
Patients with morbid obesity often suffer from gastro-esophageal reflux [168], which has been suggested to contribute to asthma severity [169]. Unfortunately, improvement with treatment is not clear-cut [170-173]. Therefore, the current recommendation for patients with uncontrolled moderately severe asthma
Current treatment of severe asthma
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