The information in this section will help you to understand the fundamentals of recognising, referring and supporting a patient with severe asthma in primary care.
This is not a substitute for completing an appropriate respiratory assessment module. For advice and support on choosing the right course for you, please see our training and development page.
What is severe asthma?
Severe asthma is a condition that can be life-threatening and needs management by specialist services. People with severe asthma often have frequent exacerbations, hospital admissions, and many suffer complications from long term or frequent oral steroid use.
It is defined as asthma that stays uncontrolled even when the patient:
• is on the highest appropriate dose of asthma medicines,
• is taking their medicines correctly and regularly, and
• has had any other health conditions (like allergies or reflux) treated or managed correctly.
Uncontrolled asthma means the patient is experiencing one or all of the following:
- any asthma exacerbation that requires treatment with oral steroids
- frequent symptoms, such as needing their reliever inhaler on 3 or more days a week or waking up one or more nights a week because of asthma symptoms
- using 6 or more SABAs in a 12-month period
Approximately 200,000 adults and children in the UK - around 4% of people with asthma - have severe asthma .
Severe asthma is recognised as a disability under the Equality Act 2010 in the UK.
Biologic therapies can be life-changing for people with severe asthma. However, current estimates suggest that over 80% of those who could benefit from biologics are missing out because they are not being identified or referred from primary care for specialist assessment.
‘Severe asthma is so much more than dealing with individual asthma attacks and hospital admissions. It can have devastating consequences on general wellbeing with patients feeling isolated, lonely and scared’.
What causes severe asthma?
Patients with severe asthma do not respond as well to regular use of inhaled corticosteroids and bronchodilators as patients with regular asthma.
Severe asthma is a complex condition driven by different types of inflammation.
Broadly, there are two types of inflammation that drive severe asthma. The more common of these is type 2 inflammation, which is often seen in patients with:
• high blood eosinophil level (above laboratory reference range)
• high FeNO.
Some, but not all, patients with type 2 inflammation may have allergies and have frequent exacerbations.
Less commonly, patients have non type 2 inflammation. They often:
• have normal eosinophil counts
• do not respond well to steroids
• have raised neutrophils.
Non type 2 inflammation is associated with adult-onset asthma, obesity, smoking and being biologically female.
How is severe asthma treated?
Patients with severe asthma can be treated with biologic therapies which are also known as monoclonal antibodies (mAbs). mAbs are drugs that have been developed to target specific biological markers in order to reduce inflammation in the lungs.
Biologics are prescribed by severe asthma specialists and are given by injection. Patients often self-administer mAbs at home.
What biologic treatments are available for asthma?
There are currently six biologic treatments approved for use in the UK and available on the NHS to treat severe asthma. 5 target type 2 inflammation and 1 targets non type 2 inflammation.
| Name of biologic |
What type of asthma does it treat? | How often do I need to have it? |
|---|---|---|
| Mepolizumab (Nucala) | type 2 inflammation | subcutaneous injection given every four weeks |
| Reslizumab (Cinqaero) | type 2 inflammation | given intravenously every four weeks |
| Benralizumab (Fasenra) | type 2 inflammation | subcutaneous injection given every four weeks for the first three treatments and then every eight weeks |
| Omalizumab (Xolair and Omlyclo) | type 2 inflammation | subcutaneous injection given every two to four weeks |
| Dupilumab (Dupixent) | type 2 inflammation | subcutaneous injection given every two weeks |
Tezepelumab (Tezspire) |
type 2 and non-type 2 inflammation | subcutaneous injection given every four weeks |
How to identify patients with severe asthma in primary care
You may find patients who can be referred directly to an asthma specialist in secondary care. If your patient:
• is on maintenance oral steroids (prednisolone) for asthma
• has had one or more asthma-related emergency department or hospital admissions in the past 12 months
⦁ has had more than 2 exacerbations requiring prednisolone in the past 12 months
• has had a previous admission to intensive care for asthma
then you can refer straight away.
You should check patients whenever you see them for signs of uncontrolled asthma. This could be at their annual asthma review, or following an exacerbation or a change of medication.
Asthma can be also uncontrolled because patients are struggling to use to use their inhalers correctly, or to remember to take them.
It could also be uncontrolled because they have a condition that is making their asthma worse and is untreated, like allergies, reflux, rhinosinusitis, exposure to pollution, breathing pattern disorders or stress.
Make sure that you address all these factors prior to referring your patient with suspected severe asthma, using the guide below. Once you have made any changes to care, make sure that you check in with your patient regularly to see if their control is improving. You can use the Asthma Control Test to measure any improvement or decline.
You can allow up to 6 months for these interventions to work before you refer but if your patient deteriorates during this time then you should refer them sooner.
| Actions to take before referring your patient to an asthma specialist |
|---|
| Review patient notes to confirm their diagnosis is evidenced and correct. |
| Check biomarkers: blood eosinophils and FeNO (if available) |
| Step up treatment to ICS/LABA +/- LTRA + LAMA |
| Review and optimise inhaler technique. Check that their inhaler device is right for them. |
| Check for and treat seasonal or environmental triggers, such as hayfever, pets, mould, or air pollution. |
| Check for smoking, exposure to smoke or vaping and offer smoking cessation |
| Identify occupational exposures that are triggering their symptoms. |
| Check your patient's ability to breathe through their nose, and treat rhinitis or post nasal drip. |
| Review your patient notes for medications such as NSAIDs or beta-blockers that might be causing symptoms of asthma. |
| Check for reflux and treat if appropriate. |
| Address any weight concerns and encourage physical activity to avoid deconditioning. |
| Review adherence. Check how regularly the patient is collecting their ICS inhalers by reviewing their prescription collection records. Suggest a reminder on their phone, an app or keeping their inhaler next to their toothbrush. Explore any worries or concerns about their medication. |
| Consider mental health or social issues that might be exacerbating symptoms. Refer to your social prescriber if appropriate. |
| Ensure the patient has a written or digital personalised asthma action plan. |
You can use the HASTE tool below to help decide if a patient should be referred to secondary care.
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You can run searches on your clinical system to identify patients with uncontrolled asthma using identifiers such as two or more courses of oral steroids for exacerbations in the past year, frequent SABA prescriptions (e.g. six or more per year), or hospital admissions.
The SPECTRA tool can be used to do this. It works within existing clinical systems to highlight high-risk patients, support treatment reviews, and prompt timely referral to specialist services.
Watch this webinar to find out more about identifying uncontrolled asthma in primary care and how SPECTRA can help.
Making a referral
Your referral letter should include:
- reason for referral
- current asthma treatment and previously tried treatment
- number of courses of steroids (for asthma) in previous 12 months
- number of emergency department and/or hospital admissions for asthma in previous 12 months
- number of ICS containing inhalers and SABAs prescribed in previous 12 months
- any relevant co-morbidities
- results of relevant investigations –blood eosinophil count, FeNO (and date), spirometry, PEFR monitoring (and any relevant chest imaging)
- smoking history and BMI.
Key resources and further reading
Key resources and further reading
