An Eight-Century Evolution of Asthma Therapeutics in Western Countries: From Medieval Regimens to Anti-inflammatory Reliever Therapy and Precision Biologics

The changes in our understanding of asthma etiopathogenesis has led to new therapies and a significant reduction in asthma exacerbations as well as mortality. The management of asthma has evolved over several centuries from constitutional/environmental palliation, to the recognition of recurrent reversible airway obstruction and to the recognition of inflammatory changes in the lung compartment. The therapeutic armamentarium has also shifted from using alternative therapies at first, to bronchodilator rescue alone and then to inflammation-directed controller therapy with corticosteroids. In the 2000s, biomarker- and endotype-guided therapy with biologics started a major shift in our understanding of asthma which has generated new treatments and outcomes. This review summarizes how clinicians approached patients with the therapeutic armamentarium available in each era, and how those changes translated into success or failure in reducing exacerbations, hospitalizations, relapses, and mortality. The emphasis is on Western countries, where clinicians described, implemented, and quantified the principal modern therapeutic shifts.