ATS GUIDELINES Bundle

Key Points ➤ Following the recent appearance of new anti-interleukin biologic agents and standardization of sputum eosinophil counts and exhaled nitric oxide fraction (F ENO ), ATS/ERS have added recommendations for these agents for adults with severe uncontrolled asthma and modified certain other recommendations from the 2014 guideline. Treatment Table 1. Recommendations for the Management of Severe Asthma Recommendation Strength of Recommendation Quality of evidence We suggest an anti-IL-5 strateg y as add-on therapy for adult patients with severe uncontrolled asthma with an eosinophilic phenotype and for those with severe corticosteroid-dependent asthma. Conditional Low We 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 exacerbations. Conditional Low We 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 treatment. Conditional Low We suggest using a F ENO cut-off ≥19.5 ppb to identify adolescents (>12 years) and adults with severe allergic asthma more likely to benefit from anti-IgE treatment. Conditional Low For children, adolescents and adults with severe asthma uncontrolled despite GINA step 4–5 or NAEPP step 5 therapies, we recommend the addition of tiotropium. Strong Moderate We 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 uncontrolled. Conditional Low We suggest against the use of chronic macrolide treatment in children and adolescents with severe uncontrolled asthma. Conditional Low We suggest dupilumab as add-on therapy for adult patients with severe eosinophilic asthma and for those with severe corticosteroid-dependent asthma regardless of eosinophil levels. Conditional Low

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