Severe and difficult-to-treat asthma

Healthcare professionals may describe your asthma as ‘difficult-to-treat’ if you are using a controller inhaler but you find that:  

• your asthma often interrupts your daily routine; 

• your symptoms keep you up at night; 

• and/or you often need to use your rescue inhaler. 

This page looks at how asthma differs in different people, why some people’s asthma is difficult-to-treat and what treatment may be offered to help people control their asthma.

Asthma affects people in different ways. There may be a number of reasons for this which include: 

• the genes people inherit from their parents; 

• other conditions that affect asthma; 

• daily stress levels; 

• physical inactivity; 

• and many other individual factors that are not yet known about.  

As asthma can look different from one person to another, the treatment must also be adjusted to each person. 

Healthcare professionals follow a step-by-step approach to managing asthma.  

If the medication the doctor prescribed is not helping to control your symptoms, they will try to find out why. They may also try adding on a different medication or increasing the dose of your current medication until your asthma is controlled. 

Despite trying different treatment options, sometimes asthma can remain uncontrolled, and is therefore called difficult-to-treat.

There are a number of factors that can affect asthma, and these should be considered if you are experiencing symptoms that are hard to control.

“My asthma was uncontrolled for over a year and a half. During this time, I focused on monitoring the factors that could affect my control: being around people who were smoking, exposure to smoke from wood fires and how much I exercised. One factor I found that helped to improve my asthma was regularly swimming. It was important for me to find my own limit; everyone will be able to achieve a different level. However, doing some exercise can be a big benefit in helping to control your symptoms.” – Betty Frankemölle, the Netherlands, who has severe asthma. 

Following your personalised treatment plan is crucial to improve asthma control.  

Once you and your doctor or nurse have found a treatment plan that works for you, you should continue following it to achieve and maintain good control of your symptoms.  

It can be tempting to stop preventer medication once symptoms have eased, but if you do this, symptoms are likely to get worse again. 

There are three types of medication that are commonly used to treat asthma: 

• Preventer medication, which should be used every day to treat the swelling (inflammation) in your lungs, to reduce symptoms, and lower the risk of an attack. 

• Reliever medication, which can provide quick but short-term relief for symptoms of wheeze or breathlessness. 

• Biologics, which are given as injections. They work by blocking the process in the body that causes swelling (inflammation).   

It is really important that you learn the correct way of using your inhaler. This can be difficult to begin with and you may need to spend some time with your healthcare professional learning the right way to use your inhaler. In some countries, your local pharmacist may also be able to show you how to use the device properly.  

If you are not using your inhaler properly, you may not be getting the correct dose of your medication. This is a very common reason for  asthma not being under control. 

The UK-based patient organisation, Asthma and Lung UK, have a number of videos which show the best ways to use your inhaler.

Even when you follow all the steps of your asthma treatment plan, there are other conditions that can affect the control of your symptoms and may also need to be managed alongside your asthma.  

These conditions could include:  

• Acid reflux 

• Nasal polyps 

• Intolerance to aspirin (approximately 5 in 100 people with asthma have an adverse reaction to aspirin) 

• Obesity 

• Chronic cough 

• Obstructive sleep apnoea 

• Chronic Obstructive Pulmonary Disease (COPD) 

• Allergic bronchopulmonary aspergillosis (ABPA) 

• Vocal Cord Disorder (VCD) 

• Breathing pattern disorder  

• Bronchiectasis  

• Hay fever or rhinitis (often described as a persistent head cold with a runny or blocked nose, itching in the nose and/or sneezing) 

Knowledge and understanding 

After you first receive a diagnosis of asthma, it may be a bit overwhelming. It can be difficult to understand what triggers a worsening of your symptoms and what factors could be preventing you from gaining control. 

One way to try to uncover what is triggering your symptoms is to take some time to monitor your lifestyle by; 

• keeping a diary of your peak flow scores and symptoms,  

• making a mental note about when and where you are when your symptoms are worse;  

• working with your healthcare professional to find a lifestyle and  treatment regime that works for you. 

Support

If your asthma remains uncontrolled, regular meetings with your healthcare professional can help you find ways to improve your symptoms. This could be through changes to your treatment plan or through making some lifestyle changes.  

You should continue to see your healthcare professional regularly until you are confident that your symptoms are under control and you are happy with your plan. If you and your regular healthcare professional cannot reach this goal, you may be referred to a specialist clinic, which can provide a more in-depth check of your symptoms and other factors. 

Receiving a self-management plan from your doctor is another good form of support. This should detail how you might recognise when your asthma is becoming less controlled and what steps you should then take. 

“It is sometimes easy to identify the factors that affect control of your asthma symptoms. Documenting complaints in a diary in order to see a pattern can help to identify these factors. In my case, I noticed a big difference when I move to a better climate, for example from the city to the country, where the air is cleaner. I also saw a big improvement in my asthma symptoms when I changed my job and began working in an indoor environment with cleaner air. Other times, it is not so straightforward. Regular meetings with my healthcare professional are very important to me at times when I do not have control of my asthma. They offer me the psychological support that is often required and they may look at a factor I had not considered and help me adjust my lifestyle to regain control.” – Juliëtte Kamphuis, the Netherlands, who has had difficult-to-treat asthma since 2006 and has gained control over her asthma for over a year now. 

When all the above factors have been addressed, the majority of people gain control of their asthma. However, in a small number of people (less than 10 in 100 people with asthma), asthma symptoms remain uncontrolled. 

If this is your experience, you may have a condition described as ‘severe asthma’. The European Respiratory Society (ERS) defines this form of asthma as: “asthma that requires a high level of treatment with two types of preventer medication to prevent it from becoming uncontrolled, or asthma that remains uncontrolled despite this high level of medication”. 

Healthcare professionals are still in the process of trying to understand why some people experience this type of severe asthma, and to find out the best methods to treat them. 

Experts think that asthma is not just one condition as each individual is affected differently. Current research efforts are looking at different genetic patterns seen in people with severe asthma to try and understand how people respond to different treatments to find patterns in the disease.  

If your healthcare professional confirms that you have severe asthma, then there are a number of treatment options that can be considered. The ERS has published guidelines on severe asthma and asthma in adults and children, giving recommendations to healthcare professionals on how to treat the condition.  

• Read a lay summary of the guideline on Management of Severe Asthma: A European Respiratory Society/American Thoracic Society Guideline. 

• Read a lay summary of the guideline on European Respiratory Society clinical practice guidelines for the diagnosis of asthma in children aged 5-16 years.

• Read a lay summary of the guideline on European Respiratory Society guidelines for the diagnosis of asthma in adults.

This page was produced with the support of members of the Severe Heterogeneous Asthma Research collaboration – Patient centred (SHARP) project: A European Respiratory Society (ERS) Clinical Research Collaboration along with Hilary Hodge, Rikki Müller and members of the ELF asthma Patient Advisory Group.  

Find out more about SHARP.  

This page was last updated in 2025.