Severe Asthma

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1 Diagnosis Table 1. Definition of Severe Asthma for Patients Aged ≥6 Years Asthma that requires treatment with guidelines-suggested medications for GINA steps 4 -5 asthma (high dose ICS a and LABA or leukotriene modifier/theophylline) for the previous year or systemic CS for ≥50% of the previous year to prevent it from becoming ''uncontrolled'' or which remains ''uncontrolled'' despite this therapy. • Uncontrolled asthma defined as at least one of the following : 1. Poor symptom control: ACQ consistently >1.5, ACT <20 (or ''not well controlled'' by NAEPP/GINA guidelines) 2. Frequent severe exacerbations: two or more bursts of systemic CS (>3 days each) in the previous year 3. Serious exacerbations: at least one hospitalization, ICU stay or mechanical ventilation in the previous year 4. Airflow limitation: after appropriate bronchodilator withhold FEV 1 <80% predicted (in the face of reduced FEV 1 /FVC defined as less than the lower limit of normal) • Controlled asthma that worsens on tapering of these high doses of ICS or systemic CS (or additional biologics) a e definition of high dose inhaled corticosteroids (ICS) is age-specific (Table 2). GINA, Global Initiative for Asthma; LABA, long-acting β2-agonists; CS, corticosteroids; ACQ, Asthma Control Questionnaire; ACT, Asthma Control Test; NAEPP, National Asthma Education and Prevention Program. Table 2. Definition of High Daily Dose of Various Inhaled Corticosteroids in Relation to Patient Age Inhaled corticosteroid Threshold daily dose in μg considered as high a Age 6–12 years Age >12 years Beclomethasone dipropionate ≥800 (CFC MDI) ≥2000 (CFC MDI) ≥320 (HFA MDI) ≥1000 (HFA MDI) Budesonide ≥800 (MDI or DPI) ≥1600 (MDI or DPI) Ciclesonide ≥160 (HFA MDI) ≥320 (HFA MDI) Fluticasone propionate ≥500 (HFA MDI or DPI) ≥1000 (HFA MDI or DPI) Mometasone furoate ≥500 (DPI) ≥800 (DPI) Triamcinolone acetonide ≥1200 ≥2000 a e thresholds provided in this table were defined by the ATS/ERS Severe Asthma guidelines. Notes: 1) Designation of high doses is provided from manufacturers' recommendations where possible. 2) As chlorofluorocarbon (CFC) preparations are being taken from the market, medication inserts for hydrofluoroalkane (HFA) preparations should be carefully reviewed by the clinician for the equivalent correct dosage.

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