Bronchial asthma (asthma) is a common chronic inflammatory respiratory disease that affects hundreds of millions of people worldwide. According to the World Health Organization (WHO), the global prevalence of asthma is increasing and has become a major public health problem worldwide. Asthma not only brings physical pain to patients, but also brings a huge economic burden to patients’ families and society. Because the pathogenesis of asthma is complex and involves multiple factors such as genetics, environment, and lifestyle, its treatment and management also face many dilemmas, such as poor patient compliance, insufficient treatment, and difficulties in the management of severe asthma.
In order to better control asthma and improve patients’ quality of life, the total management strategy is particularly important. The total management strategy emphasizes all-round management from early diagnosis of the disease, standardized treatment to long-term follow-up in order to achieve long-term control of asthma. In this process, the combined regimen of inhaled glucocorticosteroids (ICS) and biologics has attracted much attention.
ICS, the cornerstone of anti-inflammatory therapy for asthma, is effective in suppressing the onset and progression of airway inflammation. Biologics, on the other hand, provide more precise treatment for specific inflammatory phenotypes of asthma, and the Global Initiative to Address Asthma 2024 (GINA 2024) also emphasizes the importance of asthma management, noting that existing treatment options still fall short in some areas.
- The evolution of asthma management: from symptom control to risk reduction
Since its inception, GINA has been committed to driving continuous progress in asthma management strategies. Through many iterations, the philosophy and practice of asthma management has changed significantly. Initially, asthma management focused primarily on symptom control, aiming to alleviate symptoms such as wheezing, coughing and dyspnea in order to improve patients’ quality of life. However, with a deeper understanding of the nature of asthma disease, it has been gradually realized that focusing on symptom control alone is not enough.
Asthma is a chronic inflammatory airway disease whose core pathological feature is chronic inflammation of the airways, and this inflammation leads to airway hyperresponsiveness and airway remodeling, which in turn triggers acute exacerbations and poses a serious health risk to patients. Therefore, minimizing future risks (e.g., reducing the risk of asthma-related deaths, acute exacerbations, persistent airflow limitation/irreversible impairment of lung function, and medication-related adverse effects) has become another important goal of asthma management.
Against this background, the GINA guidelines, in their 2021 and 2022 updates, specifically emphasize the key role of inhaled glucocorticoids (ICS) in the anti-inflammatory treatment of asthma.ICS, as a glucocorticoid with a strong local effect and few systemic side effects, can effectively inhibit the activity of inflammatory cells in the airways and reduce the release of inflammatory mediators, thereby reducing airway inflammation and airway hyperresponsiveness. Glucocorticoids can effectively inhibit the activity of airway inflammatory cells and reduce the release of inflammatory mediators, thus reducing airway inflammation and airway hyperresponsiveness. A large number of clinical studies have shown that the standardized use of ICS can significantly reduce the risk of acute asthma exacerbation, reduce the number of emergency room visits and hospitalizations, and improve the quality of life of patients. Therefore, ICS has been established as the cornerstone drug in the anti-inflammatory treatment of asthma, and plays an indispensable role in the treatment of both mild, moderate and severe asthma.
At the same time, asthma treatment has evolved. Traditional asthma treatment relies heavily on reliever medications, such as short-acting β2 agonists (SABAs), which are used to alleviate symptoms during acute exacerbations. However, this mode of treatment has limitations as it is only symptomatic and does not control airway inflammation at its root.
In recent years, anti-inflammatory relievers have emerged as a new direction in asthma treatment. GINA 2023 recommends ICS-formoterol as the first choice for asthma control and relief, based on a large body of clinical evidence that it has significant efficacy in controlling asthma symptoms, reducing the risk of acute exacerbations, and improving patients’ lung function. This recommendation is based on extensive clinical evidence that ICS formoterol is effective in controlling asthma symptoms, reducing the risk of acute exacerbations and improving lung function in patients.
The unique advantage of ICS-Formoterol as an anti-inflammatory reliever is that it combines the anti-inflammatory effect of ICS with the rapid bronchodilator effect of formoterol. In daily use, ICS-Formoterol can be inhaled regularly to control airway inflammation and prevent the onset of asthma symptoms, while ICS-Formoterol can rapidly dilate the bronchial tubes to relieve symptoms such as dyspnea when an acute attack occurs. This “two for one” treatment model not only improves patient compliance, but also more effectively controls asthma and reduces the occurrence of acute attacks.
In addition, GINA 2023 also proposes for the first time a glossary of asthma medications, which clarifies the concept of anti-inflammatory relief (AIR) medications, specific medications and their dosages. The proposal of this glossary helps to unify the classification and naming of asthma therapeutic drugs, enabling doctors and patients to understand and use asthma medications more clearly. And the important position of ICS-Formoterol in the whole management of asthma has been further consolidated.
- Guarding respiratory health: asthma follow-up and acute exacerbation management
Despite the significant clinical value of ICS-Formoterol in asthma treatment, some patients may still fail to achieve the desired therapeutic effect in practical application. Therefore, standardized follow-up management is a key component to ensure the effectiveness of treatment and timely adjustment of the treatment plan.
-Frequency of follow-up and content of monitoring
Usually, follow-up is required every 2-4 weeks after the initial treatment and every 1-3 months thereafter, and the main monitoring contents of the follow-up include the following aspects:
Symptom assessment: The level of asthma control is assessed by asking the patient about the frequency and severity of symptoms and their impact on daily life. Commonly used assessment tools include the Asthma Control Test (ACT) and the Asthma Control Questionnaire (ACQ).
Acute exacerbations: To record whether the patient had an acute exacerbation during the follow-up period, the frequency and severity of acute exacerbations, and whether emergency medications were required.
Inhaled medication adherence: to find out whether the patients used medications such as ICS-LABA in a standardized manner according to medical advice, and whether there was inappropriate use or poor adherence.
Inflammatory markers test: To detect inflammatory markers in serum, such as eosinophil count (EOS), serum IgE level, and exhaled nitric oxide (FeNO), in order to assess the status of airway inflammation and guide subsequent treatment. Testing of blood EOS count every 3 months is recommended for patients with severe asthma.
Pulmonary function tests: Pulmonary function tests, such as first second force expiratory volume (FEV1) and forceful lung capacity (FVC), are performed regularly to monitor the degree of airway obstruction and changes in lung function.
-Therapeutic adjustments after follow-up
During follow-up, if it is found that patients do not achieve good asthma control (e.g., poor symptom control, high number of acute exacerbations, persistent airflow limitation, etc.) despite treatment with medium- to high-dose ICS-LABAs, consideration should be given to adjusting the treatment regimen and introducing biologics as a combination therapy.
- Breaking through limitations and combining treatments: Biologics offer new hope for patients with severe asthma
In patients with uncontrolled asthma despite standardized treatment with medium- to high-dose ICS-LABA, the addition of biologics may achieve additional benefit if factors such as improper inhalation technique and poor compliance have been ruled out. Patients with severe asthma of different phenotypes, such as eosinophilic, neutrophilic, and mixed cellular, require individualized selection of biologics. For example, patients with eosinophilic asthma may choose anti-IL-5 monoclonal antibody, IL-5R monoclonal antibody, and IL-4Rα monoclonal antibody, while patients with neutrophilic asthma need to explore other targeted therapies.
Different biologics have shown significant benefits in the full management of severe asthma, for example, several Asia-Pacific/China phase III studies have shown that biologics significantly improve patients’ symptom scores. Several global phase III studies have also shown that biologics can significantly reduce the risk of acute exacerbations, improve lung function, and reduce the use of oral glucocorticoids (OCS) in patients.
Clinical cure is a higher therapeutic goal for severe asthma and includes a symptom-free duration of 1 year or more, no acute exacerbations, normal or essentially normal pulmonary function test results, and no need for treatment with OCS. Biologic therapies can greatly increase the proportion of patients who achieve clinical cure.
Biologics play a key role in the entire management of severe asthma, effectively improving patient symptoms, reducing acute exacerbations, improving lung function, reducing hormone use, and helping to achieve clinical cure through precisely targeted therapy. Individualized phenotype-based combination therapy regimen further enhances the therapeutic efficacy and provides a more precise and effective treatment option for patients with severe asthma, which is expected to achieve long-term stable control and improve the prognosis.
