Australia and New Zealand have relatively high rates of asthma by international measures, with a population rate of about one in nine. For years the management model has been empirical. The more serious the disease, the more the dose of controller therapy is increased. But this doesn't work for everyone. In at least 10 per cent of patients, there is an excessive symptom burden despite maximum controller therapy. 

Severe asthma is marked by frequent exacerbations that may require hospitalisation, and the chronic narrowing of the airways that can often present like COPD. A rational approach to treatment requires identifying one of three endotypes with distinct pathophysiology. Eosinophilic asthma, allergic asthma, and non-eosinophilic asthma can be differentiated by markers in blood and sputum. And targeted therapies have emerged, such as monoclonal antibodies to stages in the cytokine pathway that underlies eosinophil recruitment. It's also important to consider the co-morbidities and risk factors that contribute to the disease, and to coordinate therapy in a multi-disciplinary way. The guests for this episode published a 'Clinical Perspectives'; review in June's edition of RACP's Internal Medicine Journal.

Guests
Professor Peter Gibson FRACP (Hunter Medical Research Institute, Co-Director of the University of Newcastle's Priority Research Centre for Asthma and Respiratory Diseases)
Professor Vanessa McDonald FRCNA (Co-Director of NHMRC CRE in Severe Asthma at HMRI, University of Newcastle).

Production
This episode was produced by Mic Cavazzini. Music from Jason Shaw ('Namaste', 'Timen Passing By'), Kai Engel ('Wake Up'), Mark Neill ('Shakey'). Photo courtesy iStock. The production manager was Anne Fredrickson.

Editorial feedback was provided by RACP Fellows Dr Michael Herd, Dr Joseph Lee and Dr Tessa Davis, and Dr Steven Maltby, HMRI, University of Newcastle. 

Please visit the RACP website for a transcript embedded with citations. Fellows of the College can claim CPD credits for listening and additional reading.