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Antagonism of tumour necrosis factor α in refractory asthma

Asthma that is refractory to treatment with inhaled corticosteroids affects 5–10% of patients with asthma; it is an important health and economic problem in the UK and most industrialised nations. It is estimated that €17.7 billion is spent on asthma healthcare per annum in Europe,1 of which a disproportionately large amount is attributed to patients with refractory asthma, on average six times more per patient compared with mild to moderate disease.2 Patients with this condition suffer considerable morbidity and mortality and they therefore represent an important unmet clinical need. The European Respiratory Society2 and the American Thoracic Society3 have identified research into the mechanisms and treatment of refractory asthma as a research priority.

Asthma can be apparently refractory to treatment because of poor treatment adherence or because symptoms are caused by comorbid conditions such as rhinitis, hyperventilation and bronchiectasis.4 However, a significant number of patients have genuinely severe disease. The patterns of refractory disease are heterogeneous, both between and within patients: some have recurrent exacerbations with satisfactory day-to-day control of symptoms and lung function; in others the predominant feature is symptoms due to persistent airway dysfunction. There is also heterogeneity in the response to treatment, with some patients not achieving control despite maximum corticosteroid therapy and others achieving control, but requiring an unacceptably high dose systemic corticosteroid treatment to do so. We are only beginning to understand how these different clinical patterns of disease relate to airway dysfunction and the pattern of airway inflammation. The ultimate hope is …