LIJEČENJE TEŠKE ASTME

Suzana Kukulj, Marina Serdarević, Sanja Popović-Grle

Teška astma javlja se u 5–10% bolesnika s astmom. Točni patofiziološki mehanizmi nisu poznati. Najčešće je karakterizira neutrofilna upala dišnih putova ili odsutnost upalnih promjena uz ubrzano remodeliranje bronha. Klinički se najčešće radi o nealergijskoj astmi kod žena, a prevladavaju fenotip astme kasne pojavnosti i aspirinska astma. Alergijska astma znatno rjeđe pripada skupini teških astma. Iako se većina bolesnika s blagom i srednje teškom astmom može uspješno liječiti kombinacijskom terapijom, bolesnici s teškom astmom trebaju liječenje peroralnim glukokortikoidima. Prije početka liječenja teške astme peroralnim glukokortikoidima treba upotrijebiti najviše doze inhalacijskih glukokortikoida, do 2000 µg beklometazona ili ekvivalenata, uz dodatak beta2-agonista dugog djelovanja, antagonista leukotrijenskih receptora, teofilinskih preparata i antikolinergika dugog djelovanja. Zbog nuspojava oralnih glukokortikoida važna je alternativna terapija teške astme: liječenje omalizumabom, makrolidnim antibioticima, inhibitorima TNF-a, antagonistima citokinskih receptora i bronhalnom termoplastikom. Unatoč znatnom napretku u razumijevanju toga kompleksnog fenotipa liječenje teške astme ostaje vrlo zahtjevno.

Severe asthma affects 5–10% of the asthma population. Exact pathophysiology of severe asthma mechanisams is complex and not fully understood. Cellular inflammation of the airways with neutrophils is a characteristic feature and is considered relevant to the pathogenesis of the disease, but all components of the airway wall have been reported to be thickened in severe asthma with or without cellular inflammation. Clinically it usually involves women with severe non-allergic asthma, late onset of asthma patients and aspirin induced asthma. Severe asthma rarely affects allergic asthma patients. Although majority of adults with mild or moderate asthma can be treated by inhaled glucocorticoids either alone or in combination with beta 2 agonists bronchodilators, patients with severe asthma require high doses of inhaled glucocorticoids or continuous oral use of glucocorticoids. Treatment of severe asthma should be started with high doses of inhaled steroids, 2000 µg of beclomethasone or its equivalents in addition to long acting beta 2 agonists, leukotriene receptor antagonists, theophylline and long acting anticholinergic drugs. Due to significant short-term and longterm oral glucocorticoids side effects it is essential to emphasize the importance of alternative therapies in severe asthma: treatment with omalizumab, macrolide antibiotics, tumor necrosis factor alpha inhibitors, cytokine receptors inhibitors and bronchial thermoplasty. Although there is a significant improvement in the treatment of severe asthma, the challenge remains to determine therapeutic strategy for appropriate phenotype in view of the heterogeneity of severe asthma.