Updated Canadian severe asthma guidelines expand guidance on biologics and triple therapy

The Canadian Thoracic Society (CTS) has released updated, evidence-based recommendations for the pharmacologic management of severe asthma in children (6–11 years), adolescents (12–17 years) and adults (≥ 18 years).1 The guidelines provide updates to the 2017 CTS position statement on recognition and management of severe asthma.2Severe asthma affects 5%–8% of adults and 2.5% of children living with asthma. It accounts for a disproportionate burden of morbidity, mortality and healthcare utilization among Canadians with asthma.1The therapeutic management of severe asthma has been altered by advances in the understanding of asthma endotypes, the increasing recognition of corticosteroid-associated harms and the rapid expansion of targeted therapies.1The updated guidelines include new and updated recommendations that address biologic therapies targeting IgE, interleukin (IL)-5/IL-5R, IL-4/IL-13 and thymic stromal lymphopoietin (TSLP) pathways. It also includes updated information on long-acting muscarinic antagonists (LAMAs), beyond tiotropium, including single-inhaler versus multiple-inhaler triple therapy.1 In children and adolescents, recommendations encompass both severe controlled and severe, exacerbating asthma. The CTS notes that some recommendations extend beyond Health Canada-approved indications.1Highlights of the contents of the updated guidelines on management of severe asthma:A description of type 2 and non-type 2 asthma;Identification of severe asthma and initial assessment—a concise reminder of the essential steps in the initial assessment of suspected severe asthma;A table summarizing Health Canada-approved biologic medications for severe asthma (as of January 2026): benralizumab, dupilumab, mepolizumab, omalizumab, reslizumab and tezepelumab;A figure reviewing the approach to suspected uncontrolled severe asthma (to confirm the diagnosis of severe asthma);Key definitions used to describe individuals with severe asthma: severe asthma, severe uncontrolled asthma, poor symptom control, frequent severe exacerbations, serious exacerbations, airflow limitation, severe exacerbating asthma;Management of severe exacerbating asthma in adults, including a figure summarizing guideline-based biologic selection in adults;Management of severe asthma that is controlled, uncontrolled and/or exacerbating in children and adolescents, including a figure outlining guideline-based biologic selection in children (6–11 years) and adolescents (12–17 years).1Key changes from the previous 2017 CTS severe asthma position statement:Updated recommendations for anti-IgE therapy (i.e., omalizumab); Updated recommendations for IL-5 inhibitors (i.e., benralizumab, mepolizumab, reslizumab, depemokimab [currently under consideration for approval by Health Canada]);New recommendations for IL-4/IL-13 inhibitors (i.e., dupilumab, lebrikizumab, tralokinumab);New recommendations for TSLP inhibitors (i.e., tezepelumab);A discussion on the cost-effectiveness of severe asthma biologics in the Canadian context;Updated recommendations for LAMAs including single-inhaler triple therapy versus multi-inhaler triple therapy;New guidance for home administration of biologics, including patient/caregiver training, informed consent and a systematic assessment of adherence.1The authors noted that due to a lack of direct comparative trials, the guideline panel was unable to provide guidance related to assessing biologic treatment failure, when to switch to a different biologic, the optimal duration of biologic therapy, and how and when to consider de-escalating background therapies such as inhaled corticosteroids in patients who achieve sustained disease control.1The panel recognized that while the number of biologics available for the treatment of severe and severe uncontrolled asthma has grown, many patients eligible for biologics remain suboptimally treated. A significant proportion continue to experience asthma symptoms and exacerbations and rely on high-dose inhaled corticosteroids as well as oral corticosteroids.1 The panel believes that appropriate implementation of the recommendations on the use of biologic and other therapies presented in these guidelines are crucial to advancing the quality of care and clinical outcomes of adults and children with severe asthma in Canada.1Overall, the 51-page guidelines are intended to summarize the evidence supporting available treatment options for severe asthma and to facilitate individualized, shared decision-making that integrates patient preferences, target outcomes and cost considerations.1ReferencesCôté A, Godbout K, Ramsey C, et al. Canadian Thoracic Society guideline for the management of severe asthma in children, adolescents and adults. Can J Resp Crit Care Sleep Med 2026; Published online September 14, 2026 (accessed October 1, 2026). FitzGerald JM, Lemiere C, Lougheed MD, et al. Recognition and management of severe asthma: a Canadian Thoracic Society position statement. Can J Resp Crit Care Sleep Med 2017;1(4):199-221 (accessed October 1, 2026).

Updated Canadian severe asthma guidelines expand guidance on biologics and triple therapy

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