## 4 Discussion  
In the present study, we evaluated the treatment with biological drugs in patients with severe asthma during the COVID-19 lockdown. In particular, when comparing the results referring to pre-pandemic and pandemic periods, we found non-significant differences with regard to mean values of ACT score, FEV\({}_{1}\), and exacerbation rate. Such observations are consistent with other studies conducted during the pandemic outbreak [13; 18; 19; 20; 21], which failed to report in patients with severe asthma relevant increases in exacerbation number or SARS-CoV-2 infections. Therefore, the lockdown policy did not affect the overall asthma control. As anecdotal evidence supporting our data, two case studies referring to severe asthma patients treated with biologics reported no changes in asthmacontrol, even during SARS-CoV-2 infection [22, 23]. Furthermore, it is noteworthy that the mean frequency of hospital accesses finalized to receive biologic therapies decreased, whilst the numbers of biologic drug administrations performed as either self-injections or treatments at general practitioner's office increased. According to other studies [13, 24], self-administration could thus be a useful tool to maintain adherence to biological therapies. Consistently with recent reports [15, 25], our survey does not support the hypothesis that severe asthmatic patients could be more susceptible to COVID-19. However, awareness of the possible risk of exacerbations due to viral infections might prompt a self-containment behavior, respectful of the kindly recommended social distancing policy. On the other hand, several studies suggest that asthmatic patients, particularly those under biologic treatment, can be more susceptible to SARS-CoV-2 infection when compared to the general population [26, 27]. Nevertheless, the severity of COVID-19 was similar between these two groups [26, 27]. Anyway, it is still hard to predict whether asthma patients are more likely to be infected by SARS-CoV-2 [28]. Finally, despite the relatively high number (14 out of 28) of overweight/obese patients enrolled in this study, obesity did not appear to have affected our results. In fact, our patients were characterized by type 2 asthma phenotype, whereas obesity is mainly associated with T2-low severe asthma [29]. Several limitations affect the reliability of our results. Due to the monocentric setting of this study, recruiting an extensive number of patients was difficult. In this regard, the small sample size prevents a certain generalization of the results. Moreover, the study design, the subjectivity bias related to ACT, and the unavoidable memory bias dependent on the effort to recall events that occurred several months earlier, represent relevant factors challenging our data. Finally, because in our study population the number of female patients was over two times higher than males, it was not possible to correctly analyze any gender-related variability. Taken together, our findings suggest that the COVID-19 pandemic did not affect the global health status of patients with severe asthma. Indeed, the lack of any significant difference related to asthma control encourages the continuation of biological therapies, even under circumstances that limit the access to health facilities. However, more studies are needed to assess any eventual worsening of severe asthma control during lockdown periods. The following supporting information can be downloaded at: [[https://www.mdpi.com/article/10.3390/app112412089/s1](https://www.mdpi.com/article/10.3390/app112412089/s1)]([https://www.mdpi.com/article/10.3390/app112412089/s1](https://www.mdpi.com/article/10.3390/app112412089/s1)). Conceptualization, C.P. ([PERSON]) and A.C.; methodology, C.P. ([PERSON]) and L.G. ; software, R.C. ; validation, V.R., G.M., L.M., G.P., C.P. ([PERSON]) and R.R. ; formal analysis, C.P. ([PERSON]) and R.C. ; investigation, V.R., C.P. ([PERSON]), G.M. and G.P. ; data curation, C.P. ([PERSON]); writing--original draft preparation, C.P.