"Real-life" Effectiveness Studies of Omalizumab in Adult Patients with Severe Allergic Asthma: Meta-analysis

Self-reported satisfaction of patients receiving omalizumab for severe allergic asthma in Malta

Treatment satisfaction is of utmost importance for ensuring adherence. Omalizumab is administered long-term if effective and well-tolerated in a hospital setting. The aim was to evaluate treatment satisfaction with omalizumab in Malta and to identify factors that may influence patients' satisfaction. A questionnaire was distributed to all asthmatic adult patients receiving omalizumab for at least one year. The questionnaire included demographic data, dosing regimen, asthma control test and the 14-item English version of the Treatment Satisfaction Questionnaire for Medication (TSQM) Version 1.4. The TSQM 1.4 domain scores range from 0 to 100. Higher scores represent higher satisfaction. Our cohort included 33 patients (52% males), mean age 53.7 ± 11 years, mean baseline IgE level 510.6IU/ml, mean duration of treatment 3.8 ± 1.98 years and mean number of injections per month 4.6 ± 2.6. Median TSQM scores were as follows: graded effectiveness 78%, graded side effects 100%, graded convenience 74.2% and overall satisfaction 76%. Regression analysis showed that convenience score, effectiveness score and ACT score were significantly associated with global satisfaction. Global satisfaction scored high among the Maltese cohort of patients despite the inconvenience and side effects associated with receiving omalizumab. This is an add-on beneficial effect to the efficacy and effectiveness already been achieved with this medication.

Proportion of Severe Asthma Patients Eligible for Mepolizumab Therapy by Age and Age of Onset of Asthma

BACKGROUND

Mepolizumab is an anti-IL-5 antibody approved for the treatment of severe eosinophilic asthma. However, the prevalence of patients with severe asthma eligible for mepolizumab remains unknown, especially among children.

OBJECTIVE

To determine, in a population of patients with severe asthma from a tertiary referral center, the proportion of patients with an eosinophilic phenotype who would be eligible for mepolizumab, when stratified for the age of onset of asthma, and the prevalence of phenotypic features that favor mepolizumab therapy.

METHODS

An extensive database of 245 adults and children referred for severe asthma was used. The prevalence of severe asthma was estimated by using the European Respiratory Society/American Thoracic Society criteria. Patients with an eosinophilic uncontrolled phenotype qualified for mepolizumab.

RESULTS

In our cohort, 216 (88%) had severe asthma. Based on blood eosinophils of either greater than or equal to 150 cells/μL or greater than or equal to 300 cells/μL, 61%/41% had an eosinophilic phenotype, while 49%/34% were eligible for mepolizumab therapy. A greater percentage of adults (60%/47% of adults with asthma onset in adulthood [AoA] and 48%/26% adults with childhood-onset asthma [<18 years, CoA]) were eligible compared with children (33%/24%), for eosinophil counts of ≥150 and ≥300 cells/μL, respectively; P < .05. Compared with adults, children had a similar number of exacerbations while having better lung function (P < .05). Among adults, those with AoA were older, were more likely to have nasal polyps (28% vs 5%; P < .05), and had higher blood eosinophil counts (272 vs 150 cells/μL; P < .05) compared with those with CoA, with no difference in lung function noted between the 2 groups. Subjects showing greater than or equal to 500 eosinophils/μL, a strong indicator for mepolizumab therapy, had more nasal polyps, higher inhaled steroid dose, lower lung function, and AoA predominance than did those with less than 500 eosinophils/μL (P < .05).

CONCLUSIONS

A smaller percentage of children with severe asthma were eligible for mepolizumab compared with their adult peers. Severe AoA has distinct phenotypic features that favor treatment with mepolizumab, including greater eosinophilia and nasal polyposis, in contrast to CoA, which appears to have fewer features of type 2 mucosal inflammation.

[Severe asthma revisited by biologic therapies emergences]

Severe asthma defined as uncontrolled or refractory asthma despite adequate use of high dose of inhaled steroid and additional long acting bronchodilators is associated with a high risk of comorbidities, exacerbations and persistent asthma-related symptoms. It remains a significant health care problem and represents the majority of health costs due to asthma. A better understanding of the basic mechanisms of the disease has allowed identification of new phenotypes and endotypes and of some predictive biomarkers. In the meantime an increasing number of promising biologicals are commercialized or on development providing new hopes to achieve asthma control and decrease exacerbation rate without the use of systemic corticosteroid. The increasing number of highly expensive available molecules poses physicians a new challenge: the identification of "the good treatment for the good patient". This article discuss the different biological available or in development in the field of severe asthma based on their mechanism of action and target. One of the aims is to help clarify the clinical decision-making process taking in account both the phenotype/endotype of the patient and the characteristics of these new drugs.

Short- and long-term real-world effectiveness of omalizumab in severe allergic asthma: systematic review of 42 studies published 2008-2018

INTRODUCTION

Omalizumab is a recombinant monoclonal anti-IgE antibody approved in the US as add-on treatment in moderate-to-severe allergic asthma (in severe allergic asthma [SAA] in Europe). A 2016 review of 24 real-world effectiveness studies in SAA published between 2008-2015 concluded that omalizumab was associated with significant improvements in objective and subjective outcomes with benefits extending beyond 2 years. Several new real-world studies have been published since, bringing the total to 42 studies. Areas covered: This systematic review of 42 studies published since 2008 updates and extends the 2016 review on the real-word evidence on omalizumab in SAA. It offers greater granularity as to time windows within which outcomes are reported and includes studies extending well beyond 4 years post omalizumab initiation. Expert commentary: This review firmly establishes the short-term effectiveness of omalizumab in adolescent and adult patients with SAA at 1 year, and provides strong evidence of long-term effectiveness up to 4 years and emergent evidence of effectiveness beyond 4 years. In the aggregate, these 42 studies underscore the long-term effectiveness of omalizumab in terms of: reducing exacerbations and symptoms, achieving asthma control, improving lung function, enhancing quality of life, decreasing emergency department visits and hospitalizations, and promoting concomitant medication-sparing.

Omalizumab lowers asthma exacerbations, oral corticosteroid intake and blood eosinophils: Results of a 5-YEAR single-centre observational study

Omalizumab is a humanized monoclonal antibody which binds to human immunoglobulins E (IgE), thus preventing their interactions with both high affinity and low affinity IgE receptors. Therefore, omalizumab is currently recommended for add-on biological therapy of uncontrolled allergic asthma, mainly characterized by type 2 airway eosinophilic inflammation. Because omalizumab has been the first, and for a long time the only available monoclonal antibody for add-on treatment of type 2 asthma, some long-term studies have been published which provide a clear evidence of the therapeutic effectiveness of the anti-IgE pharmacological strategy. Within this context, the present single-centre observational study refers to 15 patients with severe allergic asthma, treated with omalizumab for at least 5 years at the Respiratory Unit of "Magna Græcia" University Hospital located in Catanzaro, Italy. In these asthmatic subjects we observed significant increases in asthma control test (ACT) score, with respect to baseline (14.60 ± 2.97), after 1 year (19.20 ± 2.98; p < 0.0001) and 5 years (21.67 ± 2.38; p < 0.0001) of add-on treatment with omalizumab. More importantly, omalizumab significantly lowered the number of annual asthma exacerbations (baseline: 3.66 ± 2.01) after 1 year (0.83 ± 1.14; p < 0.0001) and 5 years (0.63 ± 0.99; p < 0.0001), respectively. This excellent therapeutic outcome made it possible to drastically decrease the daily oral intake of prednisone (baseline: 22.50 ± 5.17 mg) after 1 year (1.83 ± 4.06 mg; p < 0.0001), as well as after 5 years (1.66 ± 3.61 mg; p < 0.0001). With regard to lung function, omalizumab significantly and persistently enhanced FEV₁ (baseline: 1636 ± 628.4 mL) after 1 year (2000 ± 679.7 mL; p < 0.05) and 5 years (1929 ± 564.8 mL; p < 0.05), respectively. Such relevant clinical and functional improvements were associated with reductions of blood eosinophil counts (baseline: 646.0 ± 458.9 cells/μl), already detectable after 1 year (512.7 ± 327.8 cells/μl; not significant), which reached the threshold of statistical significance after 5 years (326.0 ± 171.8 cells/μl; p < 0.05). Therefore, these real-life data referring to our single-centre observational investigation further corroborate the long-term therapeutic ability of omalizumab to improve several clinical, functional and haematological signatures of severe type 2 asthma.

Chronic rhinosinusitis with nasal polyps: insights into mechanisms of disease from emerging biological therapies

Introduction: Chronic rhinosinusitis with nasal polyps (CRSwNP) is a complex disease of the upper airway, with long-term morbidity. With detailed mechanistic studies currently lacking, understanding of the immunopathogenesis is still limited. However, outcomes from CRSwNP clinical studies using biologics that block key mediators or cells may provide some insights into how immune signaling pathways potentially integrate and modulate each other and contribute to disease. Current treatments are often ineffective and there is an urgent unmet clinical need for effective therapeutic strategies. Emerging biologics hold promise. Areas covered: This review covers the biology of CRSwNP in terms of the clinical outcomes reported from blocking immune cascades with available biologics. Immune amplification mechanisms and how biologics can potentially modulate such 'master' cytokines and signaling proteins that drive inflammation and contribute to tissue remodeling in CRSwNP are discussed. Expert commentary: Biologics have the potential to transform CRSwNP treatment. The ability to predict clinical response in a complex disease as CRSwNP to a biologic cannot necessarily be predicted by measuring a single protein or cell as a biomarker of disease. Further studies with biologics must be carefully undertaken to fully evaluate wider biomarker associated pheno-endotype responses along with any associated asthma outcome measures.

Two decades with omalizumab: what we still have to learn

From its availability for clinical use nearly two decades ago for severe asthma, omalizumab has gained strong evidence of efficacy and safety in the treatment of severe asthma not controlled by standard-of-care therapy. It has been acknowledged by Global Initiative on Asthma guidelines as add-on therapy against severe uncontrolled asthma. Thanks to controlled trials supporting its efficacy, omalizumab has also been licensed for the treatment of chronic spontaneous urticaria. The optimal duration of treatment in either disease has not been established. Despite its high price, omalizumab appears to be cost-effective in severe uncontrolled asthma as well as in chronic urticaria. The literature suggests a wide range of applications for omalizumab in various disorders regardless of allergic or non-allergic pathophysiology.

Omalizumab Treatment for Atopic Severe Persistant Asthma: A Single-Center, Long-Term, Real-Life Experience with 38 Patients

OBJECTIVES

Omalizumab is a monoclonal antibody that is used as add-on therapy for treating moderate-to-severe persistant atopic asthma in patients with persistant symptoms and frequent exacerbations, despite step 4 treatment according to GINA guidelines. Real-life studies on omalizumab treatment are limited in Turkey. Thus, the present study aims to assess the clinical efficacy and treatment outcomes of omalizumab in patients with atopic severe persistant asthma.

MATERIALS AND METHODS

Patients with atopic severe persistant asthma who were treated with omalizumab between 2009 and 2017 were retrospectively evaluated. Baseline and last results of the following variables were compared: symptom scores (GINA categorical), controller medications, blood eosinophil counts, forced expiratory volume in 1 second (FEV₁) values, and the number of exacerbations that were treated with systemic corticosteroids for at least 3 days within the last 1 year. The effect of coexisting aspirin-exacerbated respiratory disease (AERD) on these parameters was also analyzed. Step-down of other asthma medications was attempted in patients with symptom control and in those without an exacerbation history within the last 6 months.

RESULTS

Thirty-eight patients (mean age, 50 years; females, 30) were included in this study, of whom four showed AERD. After treating with a mean time of 30±22.1 (min: 6, max: 92) months, 26 (68%) patients showed complete controlled disease and 12 (32%) showed partly controlled disease, of whom all had uncontrolled disease before. Mean exacerbation rates within the last 1 year decreased by approximately 76% (9.4±8.4 vs. 1.8±1.5; p<0.001) and FEV₁ values increased by approximately 14% (2075±729 vs. 2321±800 cc; p=0.001) compared with baseline levels. Although the reduction in eosinophil count was not significant in all patients (503.8±524.8 vs. 370.8±314.5; p=0.134), repeated measures analysis of variance revealed a more prominent reduction in eosinophil count in the AERD group than in the non-AERD group, independent from the treatment period (F: 4.23, p=0.049). The mean inhaled corticosteroid dose (budesonide eq., 1063±397 vs. 958±439 mcg; p=0.084), the number of other controller medications, and the number of patients with long-term systemic steroid use decreased after omalizumab treatment. No serious adverse events were recorded during the follow-up period.

CONCLUSION

Our results confirm that omalizumab significantly improves disease control and is a safe add-on therapy. In addition, in suitable patients with controlled disease over time, the step-down of other asthma medications will be appropriate.

Controversies and opportunities in severe asthma

PURPOSE OF REVIEW

Despite currently available treatments, many asthma patients remain inadequately controlled, but identifying distinct patient populations (phenotypes/endotypes) may optimize their management. This review discusses some of the controversies and opportunities for improved disease control in severe asthma.

RECENT FINDINGS

Currently approved anti-immunoglobulin E and anti-interleukin 5 biologics, which target specific pathways instead of using a 'one size fits all' strategy, are efficacious and well tolerated therapies for severe asthma. The appropriate use of these biologics, and of those in development (e.g., benralizumab and dupilumab), should be aided by further understanding of asthma phenotypes and endotypes, utilizing appropriate biomarkers.Oral corticosteroids are often added as maintenance therapy for patients with severe uncontrolled asthma, but their use is associated with significant adverse effects and should be considered a last option. The true cost of this therapy, including the cost of morbidities associated with its use, remains to be determined.Severe asthma in pediatrics poses a unique opportunity for possible prevention strategies and the potential for primary prevention. Although several avenues for primary prevention are being explored and are out of the scope of this review, we focus our discussion on the use of omalizumab, which has been recently explored in clinical trials.

SUMMARY

Appropriate use of biologics in severe asthma should be supported by further understanding of biomarkers predicting response to targeted therapy. Because of their association with significant adverse effects, add-on oral corticosteroids should be considered a last treatment option for patients with uncontrolled severe asthma. Finally, severe asthma in pediatrics poses a unique opportunity for potential prevention strategies.

The use of intravenous versus subcutaneous monoclonal antibodies in the treatment of severe asthma: a review

BACKGROUND

Monoclonal antibodies (mAbs) approved for use as add-on therapy in patients with severe asthma target the underlying pathogenesis of asthma.

MAIN BODY

Omalizumab binds immunoglobulin E (IgE), thereby inhibiting its interaction with the high-affinity IgE receptor and reducing the quantity of free IgE available to trigger the allergic cascade. Anti-interleukin (IL)-5 mAbs mepolizumab, benralizumab and reslizumab block the interaction between IL-5 and its receptor on eosinophils, thus targeting the eosinophilic pathway in asthma. Most mAbs are available as intravenous (IV) or subcutaneous (SC) formulations, as their high molecular weight and gastric degradation preclude oral administration. This review compares the pharmacology, efficacy, immunogenicity, injection- and infusion-related adverse drug reactions of subcutaneously administered omalizumab and mepolizumab with the intravenously administered reslizumab. In terms of pharmacokinetics, IV route of administration appears to be superior to the SC route due to quicker absorption, greater bioavailability, shorter time to maximum serum concentration and similar elimination half-life. Route of administration does not appear to translate into striking differences in efficacy and safety of mAbs used for the treatment of severe asthma, as all are generally considered to be effective and well tolerated. Hypersensitivity and administration-related reactions have been described with both IV and SC mAbs.

CONCLUSION

mABs are effective and have low immunogenicity due to their nature as humanised antibodies. Evidence on the use of mAbs in indications other than severe asthma suggest that both the SC and the IV routes of administrations have their respective advantages and disadvantages; but their full utility remains to be elucidated.

Type 2 immunity in asthma

Type 2-immunity represents the typical adaptive response to allergen exposure in atopic individuals. It mainly involves Th2 cells and immunoglobulin E, as the main orchestrators of type 2-inflammation. Recently, it has been highlighted that allergens may be responsible for a Th2 response beside specific IgE activation and that a number of other environmental stimuli, such as viruses and pollutants, can trigger the same pattern of inflammation beyond atopy. Emerging data sustain a substantial role of the so-called epithelial dysfunction in asthma pathogenesis, both from anatomic and functional point of view. Furthermore an increasing amount of evidence demonstrates the relevance of innate immunity in polarizing a Th2 impaired response in asthmatic patients. Under this perspective, the complex cross-talking between airway epithelium, innate and adaptive immunity is emerging as a major determinant of type 2-inflammation beyond allergens.

This review will include an update on the relevance of dysregulation of innate and adaptive type 2-immunity in asthma pathogenesis, particularly severe asthma, and on the role of the allergens that are associated with severe asthma. Type 2-immunity also will be reviewed in the light of the current and upcoming targeted treatments for severe asthma.

Factors reducing omalizumab response in severe asthma

BACKGROUND

Despite adding Omalizumab to conventional therapy, several severe asthmatics still show poor disease control. We investigated the factors that may affect a reduced Omalizumab response in a large population of severe asthmatics.

METHODS

340 patients were retrospectively evaluated. FEV₁%, FVC%, Asthma Control Test (ACT), fractional exhaled nitric oxide (FENO), possible step-downs/step-ups of concomitant therapies, exacerbations, disease control levels, ICS doses and SABA use, observed at the end of treatment, were considered as a response to Omalizumab.

RESULTS

Age was an independent risk factor for a reduced response concerning FEV₁%, FVC%, ACT and for a lower asthma control. Obesity (vs normal weight) was a determinant condition for exacerbations (OR:3.114[1.509-6.424], p = 0.002), for a disease partial/no control (OR:2.665[1.064-6.680], p = 0.036), for excessive SABA use (OR:4.448[1.837-10.768], p = 0.002) and for an unchanged/increased level of concomitant asthma medications. Furthermore, obesity also reduced the response in FEV₁ (β = -6.981,p = 0.04), FVC (β = -11.689,p = 0.014) and ACT (β = -2.585, p = 0.027) and was associated with a higher FENO level (β = 49.045,p = 0.040). Having at least one comorbidity was a risk factor for exacerbations (OR:1.383[1.128-1.697], p = 0.008) and for an ACT <20 (OR:2.410[1.071-3.690], p = 0.008). Specifically, chronic heart disease was associated with both a lower ACT and FVC% whereas gastroesophageal reflux with a partial/no asthma control. Nasal polyps were a predisposing factor leading both to exacerbations and to the use of higher inhaled corticosteroids doses. Moreover, smoking habits, pollen or dog/cat dander co-sensitizations may negatively influence Omalizumab response.

CONCLUSION

Age, obesity, comorbidities, smoking habits, nasal polyps, allergic poly-sensitization might reduce Omalizumab effectiveness independently to other asthma-influencing factors.

A clinical follow-up of omalizumab in routine treatment of allergic asthma monitored by CD-sens

Introduction

Omalizumab has been available for treatment of allergic asthma for more than a decade and thus, its efficacy in routine treatment was of interest to evaluate. Basophil allergen threshold sensitivity (CD‐sens) has been shown to correlate with the bronchial allergen threshold sensitivity and can be used to objectively measure omalizumab treatment efficacy. We aimed to evaluate the effect of omalizumab treatment of allergic asthma by CD‐sens, as an objective marker of the IgE‐mediated inflammation, and related to SPT, spirometry, FeNO, Asthma Control Questionnaire (ACQ), and Global Evaluation of Treatment Effectiveness (GETE).

Methods

Thirty‐two patients were treated with omalizumab for 16 weeks. CD‐sens was used to define the response and related to clinical parameters. If CD‐sens was negative (<0.1) (CD‐sens low Group) the patient continued with the standard dose. If CD‐sens was ≥0.1 (CD‐sens high Group) a second 16 weeks period with 25–50% dosage increase was started and evaluated after a total of 32 weeks.

Results

Nine of 32 patients became CD‐sens negative after treatment (CD‐sens start: 8.0; 16 weeks: <0.01) and regarded as successful. 15/23 were unsuccessful (CD‐sens start: 13; 16 weeks: 1.65) and the omalizumab dose was increased. CD‐sens decreased significantly (p < 0.05) and further 3/15 patients became CD‐sens negative (CD‐sens at 32 weeks: 0.5). There was a significantly smaller IgE‐ab fraction (IgE‐ab/IgE) in the CD‐sens low versus the CD‐sens high Group (p < 0.0001). A significant decrease in ACQ was seen in both groups after 16 weeks treatment (p = 0.05 and 0.01, respectively). No significant changes could be detected for the other clinical parameters.

Conclusion

By the use of the objective laboratory method CD‐sens, which effectively measure the direct effect of omalizumab, that is, the IgE‐mediated part of the allergic asthma, in combination with clinical parameters it might be possible to more effectively monitor and treat IgE‐mediated allergic asthma.

Therapeutic antibodies: A new era in the treatment of respiratory diseases?

Respiratory diseases affect millions of people worldwide, and account for significant levels of disability and mortality. The treatment of lung cancer and asthma with therapeutic antibodies (Abs) is a breakthrough that opens up new paradigms for the management of respiratory diseases. Antibodies are becoming increasingly important in respiratory medicine; dozens of Abs have received marketing approval, and many more are currently in clinical development. Most of these Abs target asthma, lung cancer and respiratory infections, while very few target chronic obstructive pulmonary disease - one of the most common non-communicable causes of death - and idiopathic pulmonary fibrosis. Here, we review Abs approved for or in clinical development for the treatment of respiratory diseases. We notably highlight their molecular mechanisms, strengths, and likely future trends.

Effectiveness of omalizumab in adolescent and adult patients with chronic idiopathic/spontaneous urticaria: a systematic review of 'real-world' evidence

INTRODUCTION

Chronic idiopathic/spontaneous urticaria (CIU/CSU) is a dermatological condition characterized by itchy wheals and/or angioedema of continuous or intermittent duration of ≥6 weeks with a high burden of disease and impact on quality of life. Omalizumab is a recombinant humanized monoclonal antibody that inhibits the binding of IgE to high affinity receptors, and is approved for the CIU/CSU indication. The objective of this systematic review was to evaluate and synthesize the evidence on the real-world effectiveness of omalizumab in CIU/CSU in daily clinical practice.

AREAS COVERED

This review of 84 observational effectiveness studies covers treatments (dosing, medication use), clinical outcomes (treatment response, disease activity, quality of life), and safety.

EXPERT OPINION

The clinical outcomes observed across studies underscore the real-world effectiveness of omalizumab in the management of CIU/CSU. Continued treatment may assist patients showing an initial response to achieve a complete treatment response. Response rates are aligned with observed changes in disease activity, symptom experience, and quality of life, and this across subtypes of CIU/CSU. The positive therapeutic profile is complemented by a positive safety profile. The real-world evidence summarized here points convincingly at the high degree of effectiveness of omalizumab in the treatment of CIU/CSU in daily clinical practice.

A Randomized, Double-Blind, Placebo-Controlled Trial of Escitalopram in Patients with Asthma and Major Depressive Disorder

BACKGROUND

Depression is common in asthma and is associated with poor outcomes. However, antidepressant therapy in depressed patients with asthma has been the topic of little research.

OBJECTIVE

This study examined the impact of antidepressant treatment with escitalopram versus placebo on the Hamilton Rating Scale for Depression (HRSD), Inventory of Depressive Symptomatology-Self Report (IDS-SR), Asthma Control Questionnaire (ACQ), and oral corticosteroid use in patients with asthma and major depressive disorder (MDD).

METHODS

Single-site 12-week, randomized, double-blind, placebo-controlled, parallel-group trial of escitalopram (10 mg/d) was conducted in 139 outpatients with asthma and MDD. Randomization was stratified by oral corticosteroid use (≥3 bursts in past 12 months, yes or no) and baseline depressive symptom severity (HRSD score ≥ 20) (higher severity, n = 42) versus less than 3 bursts, HRSD score less than 20, or both (lower severity, n = 97). The primary data analysis was conducted using hierarchical linear modeling Version 7.01 on the higher and lower severity samples and post hoc was conducted on the combined sample.

RESULTS

Among the higher severity completers (n = 21), a significant reduction in the ACQ score (P = .04) and oral corticosteroid use (P = .04) was observed with escitalopram. In the combined sample, no significant differences were observed, but a trend toward greater reduction in the IDS-SR score was observed with escitalopram (P = .07). Side effects were comparable across groups.

CONCLUSIONS

The findings suggest that patients with more severe asthma and depression symptomatology may have a positive response, in terms of both asthma and depressive symptom reduction, to antidepressant treatment.

The Journal of Allergy and Clinical Immunology: In Practice 2017 Year in Review

An impressive number of clinically impactful studies and reviews were published in The Journal of Allergy and Clinical Immunology: In Practice in 2017. As a service to our readers, the editors provide this Year in Review article to highlight and contextualize the advances published over the past year. We include information from articles on asthma, allergic rhinitis, rhinosinusitis, immunotherapy, atopic dermatitis, contact dermatitis, food allergy, anaphylaxis, drug hypersensitivity, urticarial/angioedema, eosinophilic disorders, and immunodeficiency. Within each topic, epidemiologic findings are presented, relevant aspects of prevention are described, and diagnostic and therapeutic advances are enumerated. Treatments discussed include behavioral therapy, allergen avoidance therapy, positive and negative effects of pharmacologic therapy, and various forms of immunologic and desensitization management. We hope this review will help readers consolidate and use this extensive and practical knowledge for the benefit of patients.

Omalizumab, the first available antibody for biological treatment of severe asthma: more than a decade of real-life effectiveness

Omalizumab was the first, and for a long time the only available monoclonal antibody for the add-on treatment of severe allergic asthma. In particular, omalizumab selectively targets human immunoglobulin (Ig)E, forming small-size immune complexes that inhibit IgE binding to its high- and low-affinity receptors. Therefore, omalizumab effectively blunts the immune response in atopic asthmatic patients, thus significantly improving the control of asthma symptoms and successfully preventing disease exacerbations. These very positive effects of omalizumab make it possible to drastically decrease both referrals to the emergency room and hospitalizations for asthma exacerbations. Such important therapeutic actions of omalizumab have been documented by several randomized clinical trials, and especially by more than 10 years of real-life experience in daily clinical practice. Omalizumab can also interfere with airway remodelling by inhibiting the activation of IgE receptors located on structural cells such as bronchial epithelial cells and airway smooth muscle cells. Moreover, omalizumab is characterized by a very good safety and tolerability profile. Hence, omalizumab represents a valuable therapeutic option for the add-on biological treatment of severe allergic asthma.

Guiding principles for use of newer biologics and bronchial thermoplasty for patients with severe asthma

BACKGROUND

Severe asthma poses significant disease-related and economic burdens in the United States. Challenges in practice include how to define "severe asthma" for a given patient, knowing which are the right tests to perform and when, and having a better understanding of a patient's asthma phenotype. Furthermore, current guidelines do not address a clear, practical approach to treatment that is based on a patient's asthma phenotype.

OBJECTIVE

To develop a consensus on the definition of severe asthma, the role of biomarkers and phenotyping severe asthma, and the use of newer biologic therapies and bronchial thermoplasty to help guide practicing clinicians.

METHODS

A roundtable meeting was convened with a panel of severe asthma experts to discuss areas in practice that are not adequately addressed by current guidelines, specifically phenotype-guided treatment.

RESULTS

We describe a consensus on the definition of severe asthma, asthma phenotyping with the use of available biomarkers, and guiding principles for newer biologic therapies and bronchial thermoplasty.

CONCLUSION

To optimize therapy and improve outcomes such as daily symptoms, quality of life, exacerbations, and hospitalizations, a clear picture of a patient's asthma phenotype is needed to guide therapy. Determining asthma phenotypes is the foundation of precision medicine for this persistent, often difficult-to-treat disease.

The real world effect of omalizumab add on therapy for patients with moderate to severe allergic asthma: The ASTERIX Observational study

Background

Omalizumab is a non-steroidal medication indicated for the treatment of poorly controlled moderate-to-severe allergic asthmatics. This observational study examines the “real world” effectiveness of omalizumab in this population.

Methods

This is a one year open-label observational study that compared clinical outcomes including total oral corticosteroid use, exacerbation history, measures of quality of life and inflammation in patients with moderate-to-severe allergic asthma, who were prescribed omalizumab as part of their treatment with the year prior to therapy.

Results

A total of 99 patients were enrolled at 25 sites in Canada. During the study period, the mean total annual OCS dose was reduced from 2301.5 mg (prednisone equivalents) in the year prior to omalizumab to 1130.0 mg (p<0.0001). There was a 71% reduction in asthma exacerbations and 56% of patients on omalizumab remained exacerbation free when compared to the year prior to study entry. Associated with this was reduced health care utilization. There were significant improvements in the Asthma Control Questionnaire (ACQ) and Asthma Quality of Life questionnaire (AQLQ) Patients with an elevated FeNO at baseline showed a better response to treatment. No new safety issues were identified during the study period.

Conclusion

Our study demonstrates that in “real world” clinical practice, after initiating omalizumab, there is a reduction in total OCS use and exacerbation frequency in patients with moderate-to-severe allergic asthma. Patients on treatment reported improved asthma control and quality of life. FeNO may be a useful biomarker to identify patients who may benefit with omalizumab treatment.

Severe asthma and quality of life

Severe asthma has a great impact on the quality of life (QOL) of patients and their families. The magnitude of this morbidity is affected by several personal factors including age. Appropriate asthma control and modifications of social roles and activities are expected to improve QOL. Biologics, primarily monoclonal antibodies, have been developed to target specific pathways and molecules important in the pathogenesis of asthma. The use of biologics has shown some promising effects on the QOL of patients with severe recalcitrant asthma. Other potential measures involve targeting risk factors and comorbidities and improving the levels of adherence to therapy. This article briefly reviews the impact of severe asthma on QOL and the potential methods to combat this morbidity including the available therapeutic biologics.