Approach to Patients with Severe Asthma: a Consensus Statement from the Respiratory Care Experts’ Input Forum (RC-EIF), Iran

Document Type : Review Article


1 Tuberculosis and Lung Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran,

2 Lung Disease Research Center, Mashhad University of Medical Science, Mashhad, Iran,

3 Chronic Respiratory Diseases Research Center, National Research Institute of Tuberculosis and Lung Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran,

4 Advanced Thoracic Research Center, Pulmonary and Critical Care Department, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran,

5 Department of Pulmonology, Razi Hospital, Guilan University of Medical Sciences, Rasht, Iran,

6 Department of Internal Medicine, Pulmonary and Critical Care Division, Mazandaran University of Medical Sciences, Sari, Iran,

7 Allergy Research Center, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran,

8 Department of Internal Medicine, Division of Pulmonology, Nemazee Hospital, Shiraz University of Medical Sciences, Shiraz, Iran,

9 Department of Internal Medicine, Pulmonary Division, School of Medicine, Ardabil University of Medical Sciences, Ardabil, Iran,

10 Behphar Scientific Committee, Behphar Group, Tehran, Iran,

11 Respiratory-Care Experts’ Input Forum, Mortaz Hospital, Yazd, Iran,

12 Department of Pulmonology, Artesh University of Medical Sciences, Tehran, Iran,

13 Department of Internal medicine, Division of Pulmonary and Critical Care Medicine , Shahid Sadoughi University of Medical Sciences, Yazd, Iran

14 Department of Pulmonary Diseases, Qazvin University of Medical Sciences, Qazvin, Iran,

15 Department of Pulmonary Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran,

16 Clinical Research & Development Center, Shahid Modarres Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran,

17 Department of Neuroscience, School of Advanced Medical Sciences and Technologies, Shiraz University of Medical Sciences, Shiraz, Iran,

18 Division of Pulmonology, Department of Internal Medicine, Imam Reza Hospital, Mashhad University of Medical Sciences, Mashhad, Iran


Challenges in the assessment, diagnosis and management of severe, difficult-to-control asthma are increasingly regarded as clinical needs yet unmet. The assessments required to determine asthma severity, comorbidities and confounding factors, disease phenotypes and optimal treatment are among the controversial issues in the field. The respiratory care experts’ input forum (RC-EIF), comprised of an Iranian panel of experts, reviewed the definition, appraised the available guidelines and provided a consensus for evaluation and treatment of severe asthma in adults. A systematic literature review followed by discussions during and after the forum, yielded the present consensus. The expert panel used the appraisal of guidelines for research and evaluation-II (AGREE-II) protocol to define an initial locally-adapted strategy for the management of severe asthma. Severe asthma is considered a heterogeneous condition with various phenotypes. Issues such as assessment of difficult-tocontrol asthma, phenotyping, the use of blood and sputum eosinophil count, exhaled nitric oxide to guide therapy, the position of anti-IgE antibody, methotrexate, macrolide antibiotics, antifungal agents and bronchial thermoplasty as well as the use of established, recently-developed and evolving treatment approaches were discussed and unanimously agreed upon in the panel. A systematic approach is required to ensure proper diagnosis, evaluate compliance, and to identify comorbidities and triggering factors in severe asthma. Phenotyping helps select optimized treatment. The treatment approach laid down by the Global Initiative for Asthma (GINA) needs to be followed, while the benefit of using biological therapies should be weighed against the cost and safety concerns.