What Are The Advanced Treatment Options For Asthma?

For many people, asthma can be effectively managed with daily controller inhalers and quick-relief rescue inhalers. However, for a subset of individuals with severe or difficult-to-control asthma, these standard treatments may not be enough to prevent frequent symptoms and exacerbations. Fortunately, medical advancements have led to a new generation of sophisticated therapies designed to target the specific underlying causes of severe asthma. These advanced options go beyond traditional approaches to offer personalized and more effective control.

Exploring these treatments is a crucial step for anyone who feels their asthma is still holding them back despite following their doctor's standard care plan. From biologic therapies that target specific inflammatory pathways to innovative procedures that physically alter the airways, the landscape of asthma management has expanded significantly, offering new hope for better breathing and improved quality of life.

Biologic Therapies (Monoclonal Antibodies)

Biologics represent one of the most significant breakthroughs in severe asthma treatment in recent years. These are not conventional chemical drugs but are lab-engineered proteins, specifically monoclonal antibodies, designed to identify and block particular cells or proteins in the immune system that drive asthma-related inflammation. Instead of providing broad anti-inflammatory effects like corticosteroids, biologics offer a highly targeted approach based on an individual's specific type of asthma, often referred to as their "phenotype."

These treatments are typically administered as an injection or infusion every few weeks or months. Different biologics target different pathways. For instance, medications like mepolizumab (Nucala), reslizumab (Cinqair), and benralizumab (Fasenra) are designed for people with severe eosinophilic asthma, a type characterized by high levels of inflammatory cells called eosinophils. Omalizumab (Xolair) targets Immunoglobulin E (IgE), an antibody involved in allergic asthma. Dupilumab (Dupixent) works by blocking pathways for multiple inflammatory proteins and can be used for both eosinophilic and allergic asthma.

Bronchial Thermoplasty

Bronchial thermoplasty is a unique, non-drug procedure for adults with severe, persistent asthma that is not well-controlled with standard medications. Unlike ongoing medication regimens, it involves a series of three outpatient procedures that aim to provide long-lasting relief. During the procedure, a specialist uses a bronchoscope to guide a small catheter into the lungs. This catheter delivers controlled thermal (heat) energy directly to the walls of the airways.

The primary goal of this heat application is to reduce the amount of excess airway smooth muscle. In people with asthma, this muscle is often enlarged and can constrict excessively during an asthma attack, narrowing the airways and making it difficult to breathe. By reducing the mass of this muscle, bronchial thermoplasty makes the airways less prone to constriction, which can lead to fewer severe asthma attacks, reduced emergency room visits, and an overall better quality of life for eligible patients.

Allergen Immunotherapy (Allergy Shots)

For individuals whose asthma is triggered or worsened by specific allergens like pollen, dust mites, or pet dander, allergen immunotherapy can be a game-changing advanced treatment. More commonly known as allergy shots, this therapy works by gradually desensitizing the immune system to the specific substances that cause allergic reactions. It involves administering regular injections with increasingly larger doses of the identified allergen over a period of several years.

The process helps the body build a tolerance, so it no longer overreacts when exposed to the trigger. This can lead to a significant reduction in both allergy and asthma symptoms. While it requires a long-term commitment, successful immunotherapy can provide lasting relief and may even reduce the need for daily asthma medications. In some cases, sublingual immunotherapy (tablets or drops placed under the tongue) may be an alternative to shots for certain types of allergies.

Leukotriene Modifiers

While not as new as biologics, leukotriene modifiers are an important advanced oral medication option used to manage persistent asthma. Leukotrienes are inflammatory chemicals released by the body in response to an allergic trigger. They are highly potent, causing the tightening of airway muscles and the production of excess mucus, both of which are hallmark features of an asthma attack.

Leukotriene modifiers, such as montelukast (Singulair), work by blocking the action of these chemicals. By interfering with the leukotriene pathway, these medications help reduce inflammation, relax the airways, and ease asthma symptoms. They are taken as a daily pill and are often used as an "add-on" therapy when inhaled corticosteroids alone are not providing adequate control, especially in patients who also have allergic rhinitis (hay fever).

Long-Acting Muscarinic Antagonists (LAMAs)

Long-acting muscarinic antagonists, or LAMAs, are a class of bronchodilators that help keep the airways open. For many years, these medications were primarily used to treat Chronic Obstructive Pulmonary Disease (COPD). However, research has shown they are also effective for asthma, and they are now approved as an add-on maintenance treatment for patients whose asthma is not well-controlled on an inhaled corticosteroid (ICS) and long-acting beta-agonist (LABA) combination therapy.

LAMAs work by blocking muscarinic receptors in the lungs, which prevents the muscles around the airways from tightening. This provides an additional mechanism for bronchodilation beyond what LABAs offer. Medications like tiotropium (Spiriva) and umeclidinium are delivered via an inhaler and can help improve lung function and reduce the frequency of severe asthma attacks when added to a standard controller regimen.

Why Standard Asthma Treatments Sometimes Aren't Enough

The standard approach to asthma management is a "step-up" model. Treatment typically begins with a quick-relief (rescue) inhaler. If symptoms persist, a low-dose inhaled corticosteroid (ICS) is added for daily control. For more severe cases, doctors may increase the ICS dose, add a long-acting beta-agonist (LABA), or introduce other controller medications. This approach is highly effective for the majority of people with asthma.

However, a small but significant percentage of patients have what is known as severe or refractory asthma. Their symptoms remain uncontrolled despite adhering to high-dose standard therapies, or they require high doses of oral corticosteroids to keep their symptoms at bay, which can lead to serious long-term side effects. This is where the standard approach falls short.

The development of advanced treatments stems from a deeper understanding that asthma is not a single disease. It is a complex syndrome with different underlying causes, or "phenotypes." For example, some people have asthma driven by an allergic response (allergic phenotype), while others have it driven by a specific type of white blood cell called an eosinophil (eosinophilic phenotype). By identifying these specific biological pathways, researchers have been able to develop targeted treatments, like biologics, that address the root cause of inflammation for a particular patient, offering a level of precision and effectiveness that standard one-size-fits-all therapies cannot provide.

Common Questions About Advanced Asthma Care

How Do I Know if I Need Advanced Asthma Treatment?

Determining if you are a candidate for advanced asthma treatment involves a careful evaluation of your symptoms and current medication use. Key signs that you may need to explore these options include experiencing frequent asthma attacks (exacerbations) that disrupt your daily life, requiring multiple visits to the emergency room or hospital for your asthma, and needing to use oral steroids (like prednisone) several times a year to get your symptoms under control.

Another major indicator is if you are using your high-dose controller medications exactly as prescribed but still rely heavily on your rescue inhaler multiple times a week or even daily. If you are experiencing any of these issues, it is essential to have a conversation with your doctor or a specialist, such as a pulmonologist or allergist. They can perform tests, including blood work or breathing tests, to determine your asthma phenotype and see if you are a suitable candidate for a targeted therapy.

What is the Difference Between Severe and Uncontrolled Asthma?

While the terms are often used interchangeably, there is a distinct clinical difference between "uncontrolled" and "severe" asthma. Uncontrolled asthma refers to a state where a person is experiencing frequent symptoms, limitations on activity, and/or exacerbations. However, this may be due to factors like incorrect inhaler technique, poor adherence to medication, or the need for a simple adjustment in their current treatment plan. In many cases, uncontrolled asthma can be brought under control by addressing these factors and optimizing standard therapies.

Severe asthma, on the other hand, is a specific subtype of asthma that remains uncontrolled despite a patient's adherence to maximal, optimized standard therapy. It is also defined as asthma that requires high-dose inhaled corticosteroids plus a second controller medication (or systemic corticosteroids) just to maintain control. It is this group of patients with diagnosed severe asthma who are the primary candidates for advanced treatments like biologics and bronchial thermoplasty.

Are There Risks Associated with These Advanced Treatments?

Like all medical interventions, advanced asthma treatments come with potential risks and side effects that should be thoroughly discussed with a healthcare provider. The specific risks vary depending on the treatment. For biologic therapies, common side effects include reactions at the injection site, such as pain, redness, or swelling. Headaches and fatigue can also occur. While rare, there is a risk of a serious allergic reaction (anaphylaxis), which is why the first few doses are often administered in a clinical setting.

With bronchial thermoplasty, it is common for patients to experience a temporary increase in respiratory symptoms, such as coughing, wheezing, or shortness of breath, in the days immediately following the procedure. For allergen immunotherapy, the most common risk is a local reaction at the injection site. There is also a small risk of a systemic allergic reaction, which is why patients are required to wait in the doctor’s office for a period of observation after receiving their shot. A specialist will weigh the potential benefits against these risks to help you make an informed decision.

Conclusion

The evolution of asthma care has moved far beyond the traditional one-size-fits-all model. The availability of advanced treatment options has provided new pathways for managing the most challenging cases of the disease. Therapies like biologics, bronchial thermoplasty, and targeted oral medications offer personalized solutions that address the specific underlying drivers of a person's asthma.

For individuals struggling with severe or difficult-to-control asthma, these innovations bring the promise of fewer attacks, better symptom control, and a significant improvement in day-to-day life. The key to accessing these benefits is working closely with a healthcare specialist who can accurately diagnose your type of asthma and guide you toward the most appropriate and effective treatment plan for your unique needs.

For more detailed information, you can visit these reputable sources:

• Asthma and Allergy Foundation of America
• American Lung Association