Beyond Symptom Control: Remission as a Depth-Stratified Treatment Goal in Severe Asthma

The management of severe asthma has shifted from symptom control to the ambition of remission, a goal borrowed from rheumatology. Biologics targeting immunoglobulin E, interleukin-5 and its receptor, the interleukin-4 receptor alpha subunit, and thymic stromal lymphopoietin have made sustained quiescence realistic for many patients, yet estimates that roughly one-third achieve remission shift by tens of percentage points depending on the definition used. This narrative review advances two linked arguments. First, that the heterogeneity of definitions, not any shortage of effective agents, is the central obstacle to using remission as a treatment target. Second, that remission is best read as a multidimensional construct in which clinical, functional and biological quiescence are distinct axes, reached independently and often discordantly, with complete remission denoting their convergence rather than the last step of a sequence. Where each biologic acts within the type 2 cascade determines which biomarkers move under treatment and, only hypothetically, how deep remission can reach. Structural remodeling and the fact that current agents suppress rather than reset inflammation cap that depth, so remission remains a pharmacologically maintained state on treatment. Concomitant chronic rhinosinusitis with nasal polyps is treated as a modifier of asthma remission rather than a separate endpoint. The framework is conceptual and unvalidated. The priority is a harmonized, depth-resolved definition, explicit about treatment burden and patient-centered outcomes, against which any therapy can be judged.