Pharmacological and Non-Pharmacological Strategies in the Management of Severe Asthma: A Narrative Review

Abstract

Severe asthma represents a complex and heterogeneous form of the disease that imposes a substantial clinical, social, and economic burden, particularly in low- and middle-income countries. Despite advances in pharmacologic management, morbidity and mortality remain high due to poor adherence, comorbidities, and limited access to specialized care. This narrative review summarizes current pharmacologic and non-pharmacologic strategies for managing severe asthma, emphasizing evidence-based interventions and future perspectives. A comprehensive literature review was conducted using international and Brazilian guidelines, as well as recent studies addressing mechanisms, treatment, and clinical outcomes in severe asthma. Non-pharmacologic approaches—including smoking cessation, patient education, environmental control, pulmonary rehabilitation, and weight management—play an essential role in optimizing disease control. Pharmacologic treatment should be individualized, starting with high-dose inhaled corticosteroids (ICS) combined with long-acting β₂-agonists (LABA), and, when necessary, adding long-acting muscarinic antagonists (LAMA) or triple therapy (ICS/LABA/LAMA). For patients with persistent type 2 inflammation, biologic agents targeting IgE, IL-5, IL-5R, IL-4R, or TSLP pathways have revolutionized disease control and reduced corticosteroid dependence. The optimal management of severe asthma requires an integrated, multidisciplinary, and personalized approach. Combining pharmacologic and non-pharmacologic interventions, guided by biomarkers and patient-centered care, can significantly improve outcomes and quality of life while reducing health system burdens. Future research should focus on predictive biomarkers, equitable access to biologics, and digital tools for disease monitoring.