To Achieve Asthma Remission, or to Achieve Asthma Control, That Is the Question in Asthma Treatment

Asthma has traditionally been managed with the primary goal of achieving control— minimizing symptoms and preventing exacerbations through maintenance treatment. This concept, widely endorsed by evidence-based guidelines like those from the Global Initiative for Asthma (GINA), has served as a practical benchmark for evaluating disease control and guiding treatment decisions [1]. However, recent clinical trials suggest that ‘remission’ may be a viable therapeutic target for a subset of patients with asthma, particularly those with type 2 inflammation [2-4]. This evolving paradigm necessitates a re-examination of our treatment goals.

Asthma control: a practical current goal

Asthma control encompasses two key domains: symptom control and risk reduction. According to the GINA report, well-controlled asthma is characterized by infrequent daytime symptoms, no nighttime awakenings, minimal need for reliever medication, and no activity limitations [1]. Furthermore, the risk of exacerbations, fixed airflow limitation, and treatment side effects should be minimized.

These parameters are straightforward to assess and monitor in clinical practice and can be achieved in most patients through a stepwise approach to therapy. However, control does not imply disease inactivity; rather, it indicates stabilization under pharmacologic intervention.

Asthma remission: a higher future goal

Remission, in contrast, implies the ‘absence’ of disease activity. Borrowed from fields such as rheumatology and inflammatory bowel disease, the concept of remission in asthma has garnered increasing attention in recent years [5] (Table 1). Proposed criteria, although not yet universally defined, often include:

Table 1.

Control strategy vs. remission strategy in asthma treatment

Feature	Control strategy	Remission strategy
Treatment intensity	Lowest effective dose	A higher level (e.g., biologics, high-dose ICS/LABA)
Response to high FeNO/blood eosinophils in control state	No treatment escalation	Escalation to achieve complete remission
Symptom	Minimal symptoms	No symptoms
Exacerbations	Reduced frequency	Absent for ≥12 months
Lung function	Stable or improved	Ideally, normalized (FEV1 ≥80% predicted)
Airway inflammation (e.g., FeNO, eosinophils)	Reduced but permit its elevation	Ideally, normalized
Use of maintenance medication	Lowest dose to control disease	Often higher level of treatment
Long-term benefits	Less side effects of medication	Potential for disease modification (remodeling, lung function preservation)
Cost and resources	Lower	Higher (a higher level of treatment, biomarker monitoring)

ICS: inhaled corticosteroid; LABA: long-acting beta-adrenoceptor agonist; FeNO: fraction of exhaled nitric oxide; FEV₁: forced expiratory volume in 1 second.

• No asthma symptoms

• No exacerbations

• Ideally, normalization of lung function (forced expiratory volume in 1 second [FEV₁] ≥80% predicted)

• No need for systemic corticosteroids

• Ideally, absence of airway inflammation (e.g., fraction of exhaled nitric oxide [FeNO] and blood eosinophils normalized)

• Ideally, without treatment but, in reality, a higher level of treatment

• All above maintained over a minimum of 12 months

c.f., The first four criteria are proposed to define ‘clinical remission.’ In addition, the fifth criterion, the absence of airway inflammation, is suggested to define ‘complete remission.’

However, the current reality is that remission without treatment remains an ‘ideal’ and largely unachievable goal for most patients. In contrast, remission achieved through a higher level of treatment—typically involving biologics or high-dose inhaled corticosteroid (ICS)/long-acting beta-adrenoceptor agonist combinations—is emerging as a more realistic objective in asthma management. This approach enables deeper suppression of airway inflammation, potentially altering the long-term disease trajectory. However, it also raises the challenge that more intensive treatment may lead to more side effects from medication.

Similarity and difference between the two strategies: control strategy vs. remission strategy

The concept of asthma remission, particularly ‘clinical remission,’ aligns with the long-term goal of ‘asthma control’ proposed by GINA to achieve optimal asthma outcomes [1]. This includes controlling symptoms over the long term—not just in recent days or weeks—improving or stabilizing lung function, preventing exacerbations, and avoiding the use of maintenance oral corticosteroids.

However, the two strategies differ in their interpretation of biomarker signals. For example, patients who are clinically controlled but have high blood eosinophils or elevated FeNO would not receive treatment escalation under the GINA control strategy. In contrast, these patients may be candidates for ‘level-up’ treatment under the complete remission strategy to suppress ongoing airway inflammation and prevent long-term damage.

Conclusion

The asthma control strategy, based on evidence, remains the current standard, offering a treatment approach with the lowest effective level of asthma management [1,6]. However, the concept of remission—achieved through a higher level of treatment—presents a compelling alternative, particularly for patients at higher risk of exacerbation, such as those with high blood eosinophil counts and/or elevated FeNO.

Given that both strategies have their pros and cons, clinical trials targeting patients with controlled asthma but elevated biomarkers—specifically high blood eosinophil counts and/or high FeNO—are essential to determine which strategy leads to superior long-term outcomes. Such trials will provide a definitive answer to this critical question in asthma treatment.