17711 Biologic Therapy For Severe Asthma

Overview

Severe asthma is asthma that stays hard to control even when someone uses strong preventer inhalers every day and follows their treatment plan carefully. It is different from mild or moderate asthma, which usually settles with standard inhalers. Biologic therapy is a group of add-on treatments for people with severe asthma. Biologics are medicines given as an injection, usually every few weeks, that are made from proteins designed to block one specific step in the immune system. Asthma causes inflammation (swelling and irritation) inside the breathing tubes. In some people, one particular immune 'switch' is stuck on and keeps the inflammation going. A biologic targets that switch, so the airways calm down, flare-ups happen less often, and people often need fewer steroid tablets.

Severe asthma is uncommon. Most people with asthma — the large majority — keep their symptoms well controlled with inhalers and a written action plan. Only a small fraction of people with asthma have true severe asthma, and only some of those are suitable for biologic therapy. So if you are being assessed for it, you are in a relatively small group, and that is exactly why specialist assessment is needed.

Biologic therapy is used in adults and in some children and teenagers with severe asthma. Different biologics are approved for different age groups — some can be used from around 6 years old, others only in older children or adults — so your specialist team will advise what is suitable. It is also used in people whose asthma is linked to allergies or to certain patterns of inflammation, and in people who have repeated flare-ups despite good inhaler treatment.

Symptoms

Common symptoms

• Wheezing (a whistling sound when breathing out)
• Shortness of breath, especially with exercise, cold air, or at night
• Chest tightness or a feeling of pressure
• A dry or chesty cough that is worse at night or early morning
• Waking at night because of cough or breathlessness
• Needing your reliever inhaler more than a few times a week
• Flare-ups (asthma attacks) that need steroid tablets, urgent appointments, or hospital care
• Symptoms that keep coming back even though you use your preventer inhaler every day

Symptoms in children

• Coughing or wheezing that keeps your child awake at night
• Breathing that looks like hard work — the ribs or the base of the neck sucking in
• Being less active or avoiding running and playing
• Missing school or needing time off because of breathing problems
• Frequent flare-ups triggered by colds or chest infections
• Coughing or wheezing that lasts longer than usual after a virus

Symptoms in older adults

• Breathlessness that is put down to 'getting older' or being unfit
• Reduced ability to walk or do daily tasks without stopping
• Cough or wheeze on and off for months
• More chest infections than usual
• Symptoms that overlap with other conditions, such as heart or lung problems, which can make asthma harder to recognise
• Side effects from long-term steroid tablets, such as thin bones, easy bruising, or high blood sugar

Causes

Main causes

• Ongoing inflammation in the breathing tubes that does not fully settle even with strong preventer treatment
• An overactive immune response in the airways, often driven by allergy-type cells or a specific immune signal
• A genetic tendency towards asthma and allergies, which runs in families
• Frequent triggers such as colds, pollens, dust mites, pets, air pollution, smoke, or cold air
• Problems that make asthma harder to control — for example poor inhaler technique, not taking preventers regularly, or other conditions such as nasal polyps or reflux
• Some people have a pattern of asthma that does not fit the usual allergy or inflammatory type, in which case biologics may be less likely to help

Risk factors

• A personal or family history of asthma, eczema, or hay fever
• Exposure to tobacco smoke, including second-hand smoke
• Occupational exposure to dusts, fumes, or chemicals
• Obesity, which can worsen asthma control
• Repeated viral chest infections, especially in childhood
• Nasal polyps or sensitivity to aspirin-type painkillers
• Living in areas with high air pollution
• Having had asthma flare-ups needing hospital care in the past year

When to see a doctor

See a doctor urgently if:

• Your usual reliever inhaler is not lasting as long, or you are needing it more often than before
• You are waking at night with breathing symptoms several times a week
• You have had a flare-up needing steroid tablets or an urgent care visit in the last few months
• You are getting side effects from long-term steroid tablets, such as bruising easily, mood changes, or indigestion
• You notice your peak flow readings are gradually falling

Book a routine appointment if:

• Your asthma is not controlled despite using your preventer inhaler every day
• You want your inhaler technique and action plan checked
• You are curious whether you might be suitable for specialist assessment or biologic therapy
• You have questions about side effects or how long a treatment should be continued
• Your symptoms are affecting work, school, sleep, or exercise

Diagnosis

Before biologic therapy is considered, a specialist team first makes sure the diagnosis of asthma is correct and that everything else has been tried. They will review how often you use your inhalers, check your inhaler technique with you in person, and look for other conditions that can mimic or worsen asthma. If your asthma is still poorly controlled at that point, they will do tests to find out which type of inflammation is driving it. Only then can they tell whether a biologic is likely to help, and which one might suit you best.

Tests that may be done

• Breathing tests (spirometry), where you blow into a machine before and after a reliever inhaler
• Peak flow diary, recorded at home over a couple of weeks
• A breath test that measures inflammation in the airways (often called exhaled nitric oxide or FeNO)
• Blood tests to count certain immune cells and allergy-related proteins linked to asthma type
• Allergy skin prick or blood tests
• A chest scan if your specialist needs a closer look at your lungs
• A review of inhaler technique and a check of how regularly you take your preventer
• Sometimes a phlegm (sputum) sample, or tests to rule out other causes of breathlessness

What to expect at your appointment

The assessment usually takes more than one appointment and can take several weeks. You may be asked to keep a diary of symptoms and peak flow readings at home. Expect honest, detailed questions about your inhalers, triggers, and flare-ups — this is not to test you, it is to make sure the right treatment is chosen. If a biologic is started, your team will usually review you after a few months to see whether flare-ups, symptoms, and steroid use have improved. If it is not helping, they will discuss stopping it and trying another option.

Treatment

Biologic therapy is an add-on treatment for severe asthma that is not controlled by standard inhalers. It is given by injection, usually every 2 to 8 weeks. Some biologics can be given at home once you have been trained; others are given in a clinic. Because these medicines damp down part of the immune system, your team will explain what to look out for and will review you regularly. Biologics are not a cure, and they work alongside — not instead of — your inhalers and action plan.

Self-care at home

• Keep taking your preventer inhaler every day, exactly as prescribed, even when you feel well
• Use a spacer with your inhaler if you have been advised to, and ask for your technique to be checked at each review
• Keep a written asthma action plan and share it with family, work, or school
• Track your peak flow if your team recommends it, and know your personal best number
• Avoid your known triggers where you reasonably can — smoke, strong fumes, cold air, pollen at peak times
• Stop smoking if you smoke, and keep your home smoke-free
• Keep your flu and other recommended vaccinations up to date
• Attend your review appointments and report side effects early rather than stopping treatment on your own
• Tell any healthcare professional that you are on a biologic, including your dentist or pharmacist

Medical treatments

Treatment for severe asthma starts with getting the basics right: the right inhalers used correctly, a long-acting reliever of the airways if appropriate, and treatment of conditions that make asthma worse, such as allergies, reflux, or nasal problems. Steroid tablets may be used in short courses for flare-ups, and some people need a low regular dose, with careful monitoring to limit side effects. Biologic therapy is the next step for people whose asthma matches a particular immune pattern: these are injections that block a specific immune signal or cell involved in airway inflammation. Your specialist will explain which type of biologic might suit you and why. If biologics do not help or are not suitable, there are other specialist options, and your team will discuss these with you.

When is surgery considered?

Surgery is not a standard treatment for asthma. There is a specialist procedure called bronchial thermoplasty, where gentle heat is applied inside the airways to reduce the muscle around them. It is only offered in some centres and to a small number of people with particular patterns of severe asthma. Your specialist team can explain whether it is an option for you.

Living with this condition

Living with severe asthma means planning ahead a little more than other people might need to. Keep your reliever inhaler with you at all times, know your early warning signs, and act on them quickly rather than waiting to see if things settle. It helps to build routines: a set time each day for your preventer inhaler, a spare reliever kept at work or school, and a plan for what to do if you feel unwell. Many people on biologic therapy find their flare-ups become less frequent over time, which makes daily life feel more predictable.

Lifestyle tips

• Keep your home well ventilated and free from damp and mould
• Reduce dust and pet dander in the bedroom if these trigger your symptoms
• Check air pollution and pollen forecasts, and plan outdoor activity around them
• Avoid smoking and vaping, and ask others not to smoke near you
• Keep a small emergency kit with your reliever inhaler and your action plan
• Get into a regular sleep routine — poor sleep makes asthma symptoms feel worse
• Pace yourself on days when symptoms are troublesome, and don't push through a flare-up

Diet and exercise

Exercise is good for asthma and is encouraged. Many people find that warming up first, choosing gentler activities in cold weather, and using their reliever inhaler before exercise if advised helps them stay comfortable. Swimming is often well tolerated because of the warm, humid air. If exercise reliably triggers your symptoms, tell your team — it may mean your asthma needs better control, not that you should stop moving. There is no special asthma diet, but a balanced way of eating with plenty of fruit and vegetables, and aiming for a healthy weight if you are above it, can support better asthma control. If you have food allergies, keep avoiding those foods and carry any emergency treatment your team has prescribed.

Mental health and emotional wellbeing

Severe asthma can be genuinely stressful. Fear of flare-ups, disrupted sleep, time off work, and the side effects of long-term steroids can all affect mood, and anxiety and low mood are common in people with severe asthma. Steroid tablets in particular can affect emotions and sleep. This is not weakness, and it is worth talking about. If you ever feel you cannot cope, or you have thoughts of harming yourself, please reach out to your local crisis support service or emergency services straight away — help is available and you deserve it. Tell your asthma team how you are feeling too; they can adjust treatment and connect you with support.

Prevention

Severe asthma itself cannot usually be prevented, but the flare-ups and hospital visits that come with it often can be reduced. The biggest gains come from taking preventer inhalers consistently, using good inhaler technique, avoiding triggers, treating allergies and nasal problems, staying up to date with vaccinations, and being seen regularly by a team that knows severe asthma. If you are offered biologic therapy, sticking to the injection schedule is important — missed doses mean less protection.

Vaccines

Vaccination is an important part of asthma care. Flu vaccination is recommended each year for most people with asthma, and COVID-19 vaccination is advised according to your local health guidance. Some people are also offered vaccination against pneumococcal infection. Ask your GP, nurse, or pharmacist which vaccines are recommended for you, and check whether any live vaccines need to be avoided while you are on biologic therapy — this depends on the specific treatment.

Screening programmes

There is no national screening programme for asthma or for biologic therapy. Instead, you will have regular reviews of your asthma control, inhaler technique, and how well treatment is working. If you have taken steroid tablets for a long time, your team may also check your bone strength, blood sugar, blood pressure, and eyes, because long-term steroids can affect these. Keep up with routine dental and eye checks, and mention any new symptoms at your reviews.

Complications

If left untreated

• More frequent and more severe asthma attacks
• Hospital admissions, sometimes needing intensive care
• Ongoing damage to the airways over time, which can make breathing problems more fixed
• Side effects from repeated or long-term steroid tablets, such as thin bones, bruising, weight gain, high blood sugar, and mood changes
• Poor sleep, tiredness, and reduced ability to work, study, or exercise
• Anxiety and low mood related to unpredictable symptoms
• In rare cases, life-threatening attacks

Long-term outlook

The outlook for people with severe asthma has improved a great deal. For people whose asthma fits the right pattern, biologic therapy can mean noticeably fewer flare-ups, less need for steroid tablets, and a more settled daily life. Not everyone responds, and finding the right treatment can take time and a few adjustments. Most people with severe asthma are seen regularly by a specialist team and live full, active lives. The most important things you can do are keep taking your inhalers, keep your review appointments, and act early when symptoms start to change.

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