101
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Reibman J, Tan L, Ambrose C, Chung Y, Desai P, Llanos JP, Moynihan M, Tkacz J. Clinical and economic burden of severe asthma among US patients treated with biologic therapies. Ann Allergy Asthma Immunol 2021; 127:318-325.e2. [PMID: 33775904 DOI: 10.1016/j.anai.2021.03.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 02/23/2021] [Accepted: 03/16/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Patients with severe asthma may remain uncontrolled despite biologic therapy in addition to standard therapy, but this disease burden has not been quantified. OBJECTIVE To estimate the clinical and economic burden in a US national sample. METHODS Patients who have severe asthma with indicated biologic treatment (earliest use = index date) were selected from the MarketScan database between January 1, 2013, and June 30, 2018. Inclusion criteria were continuous enrollment for 12 months postindex with a minimum of 2 biologic fills, greater than or equal to 12 years of age, evidence of medium- to high-dose inhaled corticosteroids and long-acting β-agonist combination before the index, and absence of other respiratory diagnoses and malignancies. Disease exacerbations (used to classify asthma control), health care costs, and treatment characteristics were reported during the 12-month postindex period. RESULTS The sample included 3262 biologic patients; 88% with anti-immunoglobulin E therapy (omalizumab) and 12% non-anti-immunoglobulin E (reslizumab, mepolizumab, benralizumab). The mean age was 49 (±15) years; 64% were women. Prescriptions included inhaled corticosteroids and long-acting β-agonist (82%), systemic corticosteroids (76%), and leukotriene receptor antagonists (68%). Notably, 63% of patients presented greater than or equal to 1 asthma exacerbation (mean 1.3 per patient/year). Furthermore, 35% of patients were categorized as having controlled asthma, whereas 28% were suboptimally controlled and 29% were uncontrolled. Patients with uncontrolled disease had higher all-cause and asthma-related costs ($69,206 and $45,693, respectively) than patients with suboptimally controlled ($59,407 and $40,793, respectively) or controlled disease ($53,083 and $38,393, respectively). Furthermore, 62% of newly treated patients were persistent with their index biologic. CONCLUSION Biologic therapies are effective in reducing exacerbations, but a substantial proportion of patients with severe asthma treated with current biologics continue to experience uncontrolled disease, highlighting a remaining unmet need for patients with severe uncontrolled asthma.
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Affiliation(s)
- Joan Reibman
- Department of Medicine, NYU Langone Health, New York, New York.
| | - Laren Tan
- Department of Medicine, Loma Linda University Health, Loma Linda, California
| | - Chris Ambrose
- Respiratory and Immunology, BioPharmaceuticals Medical, AstraZeneca, Gaithersburg, Maryland
| | - Yen Chung
- Payer Evidence, AstraZeneca, Gaithersburg, Maryland
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Matucci A, Bormioli S, Nencini F, Chiccoli F, Vivarelli E, Maggi E, Vultaggio A. Asthma and Chronic Rhinosinusitis: How Similar Are They in Pathogenesis and Treatment Responses? Int J Mol Sci 2021; 22:3340. [PMID: 33805199 PMCID: PMC8037977 DOI: 10.3390/ijms22073340] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 03/18/2021] [Accepted: 03/23/2021] [Indexed: 12/12/2022] Open
Abstract
Severe asthma and rhinosinusitis represent frequent comorbidities, complicating the overall management of the disease. Both asthma and chronic rhinosinusitis (CRS) can be differentiated into endotypes: those with type 2 eosinophilic inflammation and those with a non-type 2 inflammation. A correct definition of phenotype/endotype for these diseases is crucial, taking into account the availability of novel biological therapies. Even though patients suffering from type 2 severe asthma-with or without CRS with nasal polyps-significantly benefit from treatment with biologics, the existence of different levels of patient response has been clearly demonstrated. In fact, in clinical practice, it is a common experience that patients reach a good clinical response for asthma symptoms, but not for CRS. At first glance, a reason for this could be that although asthma and CRS can coexist in the same patient, they can manifest with different degrees of severity; therefore, efficacy may not be equally achieved. Many questions regarding responders and nonresponders, predictors of response, and residual disease after blocking type 2 pathways are still unanswered. In this review, we discuss whether treatment with biological agents is equally effective in controlling both asthma and sinonasal symptoms in patients in which asthma and chronic rhinosinusitis with nasal polyps coexist.
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Affiliation(s)
- Andrea Matucci
- Immunoallergology Unit, University Hospital Careggi, 50134 Florence, Italy; (S.B.); (F.N.); (E.V.); (A.V.)
| | - Susanna Bormioli
- Immunoallergology Unit, University Hospital Careggi, 50134 Florence, Italy; (S.B.); (F.N.); (E.V.); (A.V.)
| | - Francesca Nencini
- Immunoallergology Unit, University Hospital Careggi, 50134 Florence, Italy; (S.B.); (F.N.); (E.V.); (A.V.)
| | - Fabio Chiccoli
- Immunology and Cellular Therapy Unit, University Hospital Careggi, 50134 Florence, Italy;
| | - Emanuele Vivarelli
- Immunoallergology Unit, University Hospital Careggi, 50134 Florence, Italy; (S.B.); (F.N.); (E.V.); (A.V.)
| | - Enrico Maggi
- Immunology Department, Children Hospital Bambino Gesù, IRCCS, 00165 Rome, Italy
| | - Alessandra Vultaggio
- Immunoallergology Unit, University Hospital Careggi, 50134 Florence, Italy; (S.B.); (F.N.); (E.V.); (A.V.)
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103
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The basic immunology of asthma. Cell 2021; 184:1469-1485. [PMID: 33711259 DOI: 10.1016/j.cell.2021.02.016] [Citation(s) in RCA: 344] [Impact Index Per Article: 114.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Revised: 01/21/2021] [Accepted: 02/04/2021] [Indexed: 12/21/2022]
Abstract
In many asthmatics, chronic airway inflammation is driven by IL-4-, IL-5-, and IL-13-producing Th2 cells or ILC2s. Type 2 cytokines promote hallmark features of the disease such as eosinophilia, mucus hypersecretion, bronchial hyperresponsiveness (BHR), IgE production, and susceptibility to exacerbations. However, only half the asthmatics have this "type 2-high" signature, and "type 2-low" asthma is more associated with obesity, presence of neutrophils, and unresponsiveness to corticosteroids, the mainstay asthma therapy. Here, we review the underlying immunological basis of various asthma endotypes by discussing results obtained from animal studies as well as results generated in clinical studies targeting specific immune pathways.
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CD3E as a new predictive biomarker of response to omalizumab treatment in asthma patients: Evidence from bioinformatic analysis. Int Immunopharmacol 2021; 93:107423. [PMID: 33578181 DOI: 10.1016/j.intimp.2021.107423] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 12/27/2020] [Accepted: 01/19/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND AND OBJECTIVE Omalizumab is a bio-targeted agent approved as add-on therapy for the treatment of severe asthma. Most patients with severe asthma show no response to omalizumab. American Thoracic Society (ATS) and European Respiratory Society (ERS) recommend blood eosinophil count and fractional exhaled nitric oxide (FeNO) as biomarkers with high value for increased response to omalizumab and periostin as a biomarker with a low value. In this study, we aimed to identify the biomarkers for predicting treatment response to omalizumab by performing whole blood transcriptional expression profiling using array and clinical data from GSE134544. METHODS We analyzed GSE134544 whole blood transcriptional and clinical data of omalizumab treatment using xCell, weighted gene co-expression network analysis (WGCNA), gene ontology enrichment analysis, KEGG pathway analysis, protein-protein interaction (PPI) network, and logistic regression analysis. RESULTS We calculated the immune enrichment score using xCell and found that CD4+ T cells, CD4+ Tem, CD4+ memory T cells, CD8+ Tcm, and dendritic cells (DC) were relatively higher in responders than in non-responders. Analysis of omalizumab response using WGCNA revealed that the above-mentioned significant immune cells in the red module was relevant to the sample traits; there were 547 genes in the red module. We identified 20 hub genes for the PPI network using cytoHubba, a Cytoscape plugin. Using logistic regression analysis, CD3E was found to be the only significant biomarker, and the area under the curve of ROC curves was 0.763. CONCLUSION CD3E maybe a new predictive biomarker of response to omalizumab treatment in asthma patients and be used to select more suitable asthma patients for omalizumab treatment.
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Abstract
PURPOSE OF REVIEW The aim of this study was to highlight the phenotypes and endotypes of asthma as a tool for selection of the Food and Drug Administration approved biologic therapies. RECENT FINDINGS An evolving concept of asthma has led to the identification of distinct phenotypes and endotypes in this disease. Asthma endotypes are defined as the biological mechanism and are often categorized as T2-high and T2-low based on the influence of T helper type 2 (T2) cells and type 2 cytokines, including interleukin (IL)-4, IL-5, IL-9 and IL-13. Biomarkers such as peripheral blood absolute eosinophil count, total IgE, specific IgE and fractional exhaled nitric oxide may be used as indicators of asthma endotypes and help predict response to biologic therapies. There are currently five biologic therapies approved as a treatment option for T2-high asthma: omalizumab, benralizumab, mepolizumab, reslizumab and dupilumab. SUMMARY Here, we explore the current understandings of asthma endotypes and review their associated phenotypes. We provide practical and evidence-based guidance for clinicians considering a biologic for asthma add-on maintenance therapy.
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Affiliation(s)
- Hannah Wangberg
- Division of Allergy, Asthma, and Immunology, Scripps Clinic, San Diego, California, USA
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106
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Bousquet J, Humbert M, Gibson PG, Kostikas K, Jaumont X, Pfister P, Nissen F. Real-World Effectiveness of Omalizumab in Severe Allergic Asthma: A Meta-Analysis of Observational Studies. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:2702-2714. [PMID: 33486142 DOI: 10.1016/j.jaip.2021.01.011] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 12/22/2020] [Accepted: 01/06/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Assessment of clinical outcomes in the real-world corroborates findings from randomized controlled trials (RCTs). OBJECTIVE This meta-analysis evaluated real-world data of omalizumab on treatment response, lung function, exacerbations, oral corticosteroid (OCS) use, patient-reported outcomes (PROs), health care resource utilization (HCRU), and school/work absenteeism at 4, 6, and 12 months after treatment. METHODS Observational studies in patients with severe allergic asthma (≥6 years) treated with omalizumab for ≥16 weeks, published from January 2005 to October 2018, were retrieved from PubMed, Embase, and Cochrane. A random-effects model was used to assess heterogeneity. RESULTS In total, 86 publications were included. Global evaluation of treatment effectiveness (GETE) was good/excellent in 77% patients at 16 weeks (risk difference: 0.77; 95% confidence interval [CI]: 0.70-0.84; I2 = 96%) and in 82% patients at 12 months (0.82, 0.73-0.91; 97%). The mean improvement in forced expiratory volume in 1 second was 160, 220, and 250 mL at 16 weeks, 6 months, and 12 months, respectively. There was a decrease in Asthma Control Questionnaire score at 16 weeks (-1.14), 6 months (-1.56), and 12 months (-1.13) after omalizumab therapy. Omalizumab significantly reduced annualized rate of severe exacerbations (risk ratio [RR]: 0.41, 95% CI: 0.30-0.56; I2 = 96%), proportion of patients receiving OCS (RR: 0.59, 95% CI: 0.47-0.75; I2 = 96%), and number of unscheduled physician visits (mean difference: -2.34, 95% CI: -3.54 to -1.13; I2 = 98%) at 12 months versus baseline. CONCLUSION The consistent improvements in GETE, lung function, and PROs, and reductions in asthma exacerbations, OCS use, and HCRU with add-on omalizumab in real-life confirm and complement the efficacy data of RCTs.
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Affiliation(s)
- Jean Bousquet
- Contre les Maladies Chroniques pour un VIeillissement Actif (MACVIA) en France European Innovation Partnership on Active and Healthy Ageing Reference Site, Montpellier, France; Centre Hospitalier Universitaire de Montpellier, Montpellier, France; Charité, Universitätsmedizin Berlin, Humboldt-Universität zu Berlin, Berlin, Germany; Department of Dermatology and Allergy, Comprehensive Allergy Center, Berlin Institute of Health, Berlin, Germany.
| | - Marc Humbert
- School of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France; INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, France; AP-HP, Department of Respiratory and Intensive Care Medicine, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Peter G Gibson
- Department of Respiratory and Sleep Medicine, John Hunter Hospital, Hunter Medical Research Institute, Newcastle, NSW, Australia; Priority Research Centre for Asthma and Respiratory Disease, the University of Newcastle, Newcastle, NSW, Australia
| | - Konstantinos Kostikas
- Respiratory Medicine Department, University of Ioannina Medical School, Ioannina, Greece
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Chen M, Choo E, Yoo B, Raut P, Haselkorn T, Pazwash H, Holweg CTJ, Hudes G. No difference in omalizumab efficacy in patients with asthma by number of asthma-related and allergic comorbidities. Ann Allergy Asthma Immunol 2021; 126:666-673. [PMID: 33465457 DOI: 10.1016/j.anai.2021.01.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 12/23/2020] [Accepted: 01/10/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Comorbidities are common in asthma and may complicate treatment response. OBJECTIVE To examine response to omalizumab in patients with moderate-to-severe allergic asthma by asthma-related and allergic comorbidities. METHODS Patients aged 12 years or more from placebo-controlled 008/009 (n = 1071), EXTRA (n = 848), and INNOVATE (n = 419), and single-armed PROSPERO (n = 801) omalizumab studies were included. Poisson regression/analysis of covariance models were used to estimate adjusted exacerbation rates and forced expiratory volume in 1 second (FEV1) change from baseline after omalizumab initiation for subgroups by number of comorbidities (0, 1 [008/009]; 0, 1, ≥2 [EXTRA and INNOVATE]; 0, 1, 2, ≥3 [PROSPERO]). Self-reported comorbidities included allergic rhinoconjunctivitis, chronic rhinosinusitis, recurrent acute sinusitis, nasal polyps, atopic and contact dermatitis, urticaria, food allergy, anaphylaxis, other allergies, gastroesophageal reflux disease, eosinophilic esophagitis, and eosinophilic granulomatosis with polyangiitis. RESULTS In the EXTRA and INNOVATE studies, no consistent pattern was observed for placebo-corrected relative rate reduction in normalized asthma exacerbations among omalizumab-treated comorbidity subgroups. In PROSPERO, on-study exacerbation rates in the comorbidity subgroups were similar (0, 0.68; 1, 0.70; 2, 0.77; ≥3, 0.80). FEV1 improvements were observed throughout the study for omalizumab vs placebo for all comorbidity subgroups. There were no consistent differences in FEV1 improvements among comorbidity subgroups in 008/009, EXTRA, or INNOVATE. Similarly, no among-group differences were observed for FEV1 change from baseline at month 12 in PROSPERO (0, 0.05 L; 1, 0.08 L; 2, 0.00 L; ≥3, 0.04 L). The 95% confidence intervals overlapped substantially in all instances. CONCLUSION In these analyses of placebo-controlled/single-armed studies, on-study exacerbation rates and FEV1 improvements with omalizumab treatment were similar irrespective of comorbidity burden. TRIAL REGISTRATION ClinicalTrials.gov identifiers are as follows: EXTRA, NCT00314574 (https://clinicaltrials.gov/ct2/show/NCT00314574); INNOVATE, NCT00046748 (https://clinicaltrials.gov/ct2/show/NCT00046748); and PROSPERO, NCT01922037 (https://clinicaltrials.gov/ct2/show/NCT01922037).
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Affiliation(s)
- Meng Chen
- Southwest Asthma and Allergy Associates, Houston, Texas
| | - Eugene Choo
- University of California San Francisco, San Francisco, California
| | - Bongin Yoo
- Genentech, Inc., South San Francisco, California
| | - Pranil Raut
- Genentech, Inc., South San Francisco, California
| | | | | | | | - Golda Hudes
- Albert Einstein College of Medicine, Bronx, New York
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108
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Eldaboussi S, Qabil A, Lotfi A, Awad A, Abdel Salam E, Alkhamis A, Abuelhassan UE. Saudi Arabian real-life experience with biologic therapy in severe asthma. Multidiscip Respir Med 2021; 16:807. [PMID: 35070293 PMCID: PMC8743612 DOI: 10.4081/mrm.2021.807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 11/15/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Severe asthma (SA) is a common health problem associated with increased morbidity and mortality and high medical costs. Biological therapies have emerged in recent decades as promising treatment options for patients with high type 2 (T2) SA. This retrospective observational study from Saudi Arabia aimed to investigate the effects of additional biologics therapy on reducing oral corticosteroid (OCS) consumption, frequency of asthma exacerbations, improvement in lung function, and asthma control. METHODS This multicenter observational study enrolled a cohort of 97 patients from March 2019 to February 2021. Outcomes of anti-IgE, anti-IL5/IL5R, and anti-IL4R therapies in severe type 2 asthma were recorded and analyzed in terms of number of exacerbations (emergency visits or hospitalizations required), asthma symptoms, and use of oral corticosteroids, blood eosinophil count, asthma control according to GINA classification, and FEV1 before and during biologic therapy. RESULTS Ninety-seven patients were included in the analysis The mean age was 46.7±14.1 years, and 69.1% of them were female. The average duration of biological treatment was 16.4±6.8 months. At the time of data collection, the four biologic therapies reduced the exacerbation rate per year from 82/97 (84.5%) to 14/97 (14.4%) with a percent improvement of 83% from 2.9 per year in the year before biologic treatment to 1.6 per year (p<0.001). OCS was reduced from 75/97 (77.3%) to 10/97 (10.3%) for a percent improvement of 86.7%, and the average OCS dose decreased from 7.12 mg to 6.8 mg. Mean blood eosinophil count also decreased after biologic therapy from 750.5±498.5 to 188.0±122.4 cells/μl, most significant result achieved with benralizumab, and mean FEV1 improved from 59.0±12.9% to 76.0±10.2%, most significant result achieved with omalizumab. ll patients had uncontrolled asthma before biologics therapy, but asthma control improved by 91.8% after treatment. CONCLUSIONS Biologic as add-on therapy for high T2 SA was found to reduce asthma exacerbations, systemic glucocorticoid doses, and SA symptoms.
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Affiliation(s)
- Safwat Eldaboussi
- Almoosa Specialist Hospital, Alhasa, Saudi Arabia
- Department of Chest Diseases, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Ahmed Qabil
- Department of Chest Diseases, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
- Al Hayat National Hospital, Riyadh, Saudi Arabia
| | - Ahmed Lotfi
- Al Hayat National Hospital, Riyadh, Saudi Arabia
- Al Hayat National Hospital, Jizan, Saudi Arabia
| | - Amgad Awad
- Almoosa Specialist Hospital, Alhasa, Saudi Arabia
- Department of Internal Medicine, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Eman Abdel Salam
- Department of Internal Medicine, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
- King Khaled Hospital, Hail, Saudi Arabia
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Chen M, Shepard K, Yang M, Raut P, Pazwash H, Holweg CTJ, Choo E. Overlap of allergic, eosinophilic and type 2 inflammatory subtypes in moderate-to-severe asthma. Clin Exp Allergy 2021; 51:546-555. [PMID: 33217063 PMCID: PMC8048421 DOI: 10.1111/cea.13790] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 10/08/2020] [Accepted: 11/04/2020] [Indexed: 12/18/2022]
Abstract
Background Current biologic therapies target allergic, eosinophilic or type 2 inflammation phenotypic asthma. However, frequency and degree of overlap among these subtypes is unclear. Objective To characterize overlap among allergic, eosinophilic and type 2 asthma phenotypes. Methods Post hoc analyses of baseline data were performed in two adult populations: (a) not selected for any asthma subtype (N = 935) and (b) selected for allergic asthma (N = 1049). Degree of overlap was examined using commonly accepted phenotypic definitions to guide treatment for allergic asthma (skin prick–positive and/or positive serum–specific immunoglobulin E > 0.35 kU/L) and eosinophilic asthma (blood eosinophil high count ≥ 300 cells/µL; low cut‐off ≥ 150 cells/µL). Consistent with previous studies, fractional exhaled nitric oxide high level of ≥ 35 ppb and low cut‐off of ≥ 25 ppb were selected as local markers of type 2 inflammation and to prevent overlap with the systemic eosinophilic asthma definition. Results In the non‐subtype–selected population, 78.0% had allergic asthma; of these, 39.5% had eosinophilic asthma and 29.5% had type 2 asthma. Within patients with eosinophilic asthma (40.6% of total), 75.8% had allergic asthma and 41.3% had type 2 asthma. Within patients with type 2 asthma (28.3% of total), 81.1% had allergic asthma and 59.2% had eosinophilic asthma. In the allergic asthma–selected population, 38.3% had eosinophilic asthma and 29.2% had type 2 asthma. Within patients with eosinophilic asthma, 46.3% had type 2 asthma. Within patients with type 2 asthma, 60.8% had eosinophilic asthma. Overlaps among subtypes increased at low cut‐off values. Conclusions and clinical relevance In this post hoc analysis in adults with moderate‐to‐severe asthma, allergic asthma was the most prevalent phenotype, followed by eosinophilic and type 2 asthma. Despite observed overlaps, a considerable proportion of patients had only a predominantly allergic subtype. Understanding the degree of overlap across phenotypes will help patient management and guide treatment options.
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Affiliation(s)
- Meng Chen
- Southwest Asthma and Allergy Associates, Houston, TX, USA
| | | | - Ming Yang
- Genentech, Inc., South San Francisco, CA, USA
| | - Pranil Raut
- Genentech, Inc., South San Francisco, CA, USA
| | | | | | - Eugene Choo
- University of California, San Francisco, CA, USA
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Agache I, Akdis CA, Akdis M, Canonica GW, Casale T, Chivato T, Corren J, Chu DK, Del Giacco S, Eiwegger T, Flood B, Firinu D, Gern JE, Hamelmann E, Hanania N, Hernández‐Martín I, Knibb R, Mäkelä M, Nair P, O’Mahony L, Papadopoulos NG, Papi A, Park H, Pérez de Llano L, Pfaar O, Quirce S, Sastre J, Shamji M, Schwarze J, Palomares O, Jutel M. EAACI Biologicals Guidelines-Recommendations for severe asthma. Allergy 2021; 76:14-44. [PMID: 32484954 DOI: 10.1111/all.14425] [Citation(s) in RCA: 123] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 05/19/2020] [Indexed: 12/20/2022]
Abstract
Severe asthma imposes a significant burden on patients, families and healthcare systems. Management is difficult, due to disease heterogeneity, co-morbidities, complexity in care pathways and differences between national or regional healthcare systems. Better understanding of the mechanisms has enabled a stratified approach to the management of severe asthma, supporting the use of targeted treatments with biologicals. However, there are still many issues that require further clarification. These include selection of a certain biological (as they all target overlapping disease phenotypes), the definition of response, strategies to enhance the responder rate, the duration of treatment and its regimen (in the clinic or home-based) and its cost-effectiveness. The EAACI Guidelines on the use of biologicals in severe asthma follow the GRADE approach in formulating recommendations for each biological and each outcome. In addition, a management algorithm for the use of biologicals in the clinic is proposed, together with future approaches and research priorities.
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Affiliation(s)
- Ioana Agache
- Faculty of Medicine Transylvania University Brasov Romania
| | - Cezmi A. Akdis
- Swiss Institute of Allergy and Asthma Research (SIAF) University of Zurich Davos Switzerland
- Christine‐Kühne‐Center for Allergy Research and Education (CK‐CARE) Davos Switzerland
| | - Mubeccel Akdis
- Swiss Institute of Allergy and Asthma Research (SIAF) University of Zurich Davos Switzerland
| | - Giorgio Walter Canonica
- Personalized Medicine, Asthma and Allergy Humanitas Clinical and Research Center IRCCS Rozzano Italy
| | - Thomas Casale
- Division of Allergy and Immunology University of South Florida Morsani College of Medicine Tampa FL USA
| | - Tomas Chivato
- School of Medicine University CEU San Pablo Madrid Spain
| | | | - Derek K. Chu
- Department of Health Research Methods, Evidence and Impact Division of Immunology and Allergy, and Department of Medicine McMaster University Hamilton ON Canada
| | - Stefano Del Giacco
- Department of Medical Sciences and Public Health University of Cagliari Cagliari Italy
| | - Thomas Eiwegger
- Translational Medicine Program, Research Institute Hospital for Sick Children Toronto ON Canada
- Department of Immunology University of Toronto Toronto ON Canada
- Division of Immunology and Allergy Food Allergy and Anaphylaxis Program The Hospital for Sick Children Departments of Paediatrics and Immunology University of Toronto Toronto ON Canada
| | - Breda Flood
- European Federation of Allergy and Airway Diseases Brussels Belgium
| | - Davide Firinu
- Department of Medical Sciences and Public Health University of Cagliari Cagliari Italy
| | - James E. Gern
- Department of Pediatrics School of Medicine and Public Health University of Wisconsin Madison WI USA
| | - Eckard Hamelmann
- Children’s Center Bethel Evangelical Hospital Bethel University of Bielefeld Bielefeld Germany
| | - Nicola Hanania
- Section of Pulmonary, Critical Care and Sleep Medicine Baylor College of Medicine Houston TX USA
| | | | - Rebeca Knibb
- Department of Psychology School of Life and Health Sciences Aston University Birmingham UK
| | - Mika Mäkelä
- Skin and Allergy Hospital Helsinki University Hospital and University of Helsinki Helsinki Finland
| | - Parameswaran Nair
- Division of Respirology Department of Medicine McMaster University Hamilton ON Canada
- Firestone Institute for Respiratory Health St Joseph's Healthcare Hamilton ON Canada
| | - Liam O’Mahony
- Departments of Medicine and Microbiology APC Microbiome Ireland University College Cork Cork Ireland
| | - Nikolaos G. Papadopoulos
- Division of Infection, Immunity and Respiratory Medicine University of Manchester Manchester UK
- Allergy Department 2nd Pediatric Clinic National Kapodistrian University of Athens Athens Greece
| | - Alberto Papi
- Research Center on Asthma and COPD Department of Medical Sciences University of Ferrara Ferrara Italy
| | - Hae‐Sim Park
- Department of Allergy and Clinical Immunology Ajou University Ajou Korea
| | | | - Oliver Pfaar
- Department of Otorhinolaryngology, Head and Neck Surgery Section of Rhinology and Allergy University Hospital Marburg Philipps‐Universität Marburg Marburg Germany
| | - Santiago Quirce
- Department of Allergy La Paz University Hospital IdiPAZ CIBER of Respiratory Diseases (CIBERES) Universidad Autónoma de Madrid Madrid Spain
| | - Joaquin Sastre
- Facultad de Medicina Universidad Autónoma de Madrid Madrid Spain
| | - Mohamed Shamji
- Immunomodulation and Tolerance Group, Allergy and Clinical Immunology, Inflammation, Repair, Development National Heart and Lung Institute London UK
- Imperial College NIHR Biomedical Research Centre Asthma UK Centre in Allergic Mechanisms of Asthma London UK
| | - Jurgen Schwarze
- Centre for Inflammation Research, Child Life and Health The University of Edinburgh Edinburgh UK
| | - Oscar Palomares
- Department of Biochemistry and Molecular Biology Chemistry School Complutense University of Madrid Madrid Spain
| | - Marek Jutel
- Department of Clinical Immunology Wroclaw Medical University Wroclaw Poland
- All‐MED Medical Research Institute Wroclaw Poland
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Papaioannou AI, Fouka E, Papakosta D, Papiris S, Loukides S. Switching between biologics in severe asthma patients. When the first choice is not proven to be the best. Clin Exp Allergy 2020; 51:221-227. [PMID: 33305478 DOI: 10.1111/cea.13809] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 11/28/2020] [Accepted: 12/06/2020] [Indexed: 12/14/2022]
Abstract
During the last decades, new treatments targeting disease mechanisms referred as biologics have been introduced in the therapy of asthma and currently, five monoclonal antibodies have been approved. Although these therapeutic agents have been formulated to target specific asthma endotypes, it is often difficult for the treating physician to identify which patient is the best candidate for each one of these specific treatments especially in the clinical scenario of a patient in whom clinical characteristics overlap between different endotypes, allowing the selection of more than one biologic agent. As no head-to-head comparisons between these biologics have been attempted, there is no evidence on the superiority of one biologic agent over the other. Furthermore, a physician's first therapeutic decision, no matter how carefully has been made, may often result in suboptimal clinical response and drug discontinuation, indicating the need for switching to a different biologic. In this short review, we discuss the available evidence regarding the switching between biologics in patients with severe asthma and we propose a simple algorithm on switching possibilities in case that the physicians' initial choice is proven not to be the best.
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Affiliation(s)
- Andriana I Papaioannou
- National and Kapodistrian University of Athens, Medical School, 2nd Respiratory medicine Dept Attikon' University Hospital, Athens, Greece
| | - Evangelia Fouka
- Respiratory Medicine Department, G Papanikolaou Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Despina Papakosta
- Respiratory Medicine Department, G Papanikolaou Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Spyridon Papiris
- National and Kapodistrian University of Athens, Medical School, 2nd Respiratory medicine Dept Attikon' University Hospital, Athens, Greece
| | - Stelios Loukides
- National and Kapodistrian University of Athens, Medical School, 2nd Respiratory medicine Dept Attikon' University Hospital, Athens, Greece
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Menzies-Gow A, Szefler SJ, Busse WW. The Relationship of Asthma Biologics to Remission for Asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 9:1090-1098. [PMID: 33130146 DOI: 10.1016/j.jaip.2020.10.035] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 10/21/2020] [Accepted: 10/22/2020] [Indexed: 12/20/2022]
Abstract
Asthma treatments have evolved from bronchodilators to interventions directed toward the regulation of airway inflammation. From these advances has come greater disease control and reduced morbidity. The addition of biologics directed toward specific pathways of inflammation has advanced the efficacy of asthma control. With these treatment advances, a renewed interest in achieving a remission in asthma has arisen. Although asthma remission has been considered to reflect a "cure," new evaluations of this concept have proposed criteria for remission while on treatment. These criteria reflect a high level of disease control including absence of symptoms, optimization and stabilization of lung function, and absence of the use of systemic corticosteroids and have been proposed to indicate a remission of disease activity. Given the added efficacy found with biologics in asthma treatment for patients with moderate to severe disease, the question has arisen as to whether the use of biologics meets criteria for remission and may this change a component of underlying disease and risks. Biologics are highly effective in reducing exacerbations, diminishing symptoms, and improving lung function in well-defined asthma populations. At present, however, biologics achieve some, but in most cases not all criteria for a remission on treatment. However, the concept of promoting treatment efforts to achieve disease remission in asthma is important, potentially achievable, and merits consideration for future guideline-directed care approaches.
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Affiliation(s)
| | - Stanley J Szefler
- The Breathing Institute, Children's Hospital Colorado, Aurora, Colo; Department of Pediatrics, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colo
| | - William W Busse
- Department of Medicine, Allergy, Pulmonary and Critical Care Medicine, University of Wisconsin-Madison, Madison, Wis.
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113
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Navanandan N, Szefler SJ. Personalized asthma management in pediatric patients based on treatment response. EXPERT REVIEW OF PRECISION MEDICINE AND DRUG DEVELOPMENT 2020. [DOI: 10.1080/23808993.2020.1834843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Nidhya Navanandan
- Pediatric Emergency Medicine, Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA
| | - Stanley J. Szefler
- Pediatric Pulmonary and Sleep Medicine, Children’s Hospital Colorado, Breathing Institute, University of Colorado School of Medicine, Aurora, CO, USA
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Vaník P, Novosad J, Kirchnerová O, Krčmová I, Teřl M. Effect of individual allergen sensitization on omalizumab treatment outcomes in patients with severe allergic asthma determined using data from the Czech Anti-IgE Registry. Allergy Asthma Clin Immunol 2020; 16:81. [PMID: 32944035 PMCID: PMC7493349 DOI: 10.1186/s13223-020-00479-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 08/31/2020] [Indexed: 02/05/2023] Open
Abstract
Background Omalizumab is an efficient drug for patients with uncontrolled severe allergic asthma (SAA). However, little is known about the differences in omalizumab treatment outcomes among patients with different types of atopic sensitization. Here, we assessed the effect of sensitization to individual allergens or their combinations on the outcomes of anti-IgE therapy in patients with SAA. Methods We performed a post hoc analysis of data of subgroups of patients enrolled in the Czech Anti-IgE Registry (CAR). The patients were evaluated at baseline and 16 weeks and 12 months after omalizumab treatment initiation. We analyzed the dependence of primary treatment outcomes [global evaluation of treatment effectiveness (GETE) after 16 weeks of treatment, a reduction in severe exacerbation rate (ER), and an improvement in the asthma control test (ACT) result during 12 months of treatment] and secondary outcomes [a reduction in systemic corticosteroid (SCS) use, an improvement in lung functions, and a fraction of exhaled nitric oxide] of patients with SAA treated with omalizumab for 12 months on sensitization to different perennial aeroallergens. We assessed sensitization to house dust mites, molds, and pets at baseline using skin prick tests and/or specific IgE measurement (semiquantitative evaluation). We compared polysensitized patients (sensitized to all tested allergens) with monosensitized (single positivity) or partially polysensitized patients (combined positivity but not to all allergens). Results We enrolled 279 patients (58.3% women, mean age 52.9 years). Omalizumab treatment presented an 82.8% response rate (according to GETE). It significantly reduced severe asthma exacerbations and SCS use, and improved the ACT result in 161 responders. We identified a subgroup of responders with distinct sensitization patterns (polysensitization to all tested perennial allergens) with higher odds of being responders (OR = 2.217, p = 0.02) and lower tendency to improve ACT result (OR 0.398, p = 0.023) and reduce ER (OR 0.431, p = 0.034) than non-polysensitized patients. Conclusions The clinical benefit of sensitization for patients with SAA receiving omalizumab may be particularly dependent on sensitization pattern. Polysensitized patients showed a higher tendency to be responders (GETE), but a lower tendency to improve the ACT result and reduce ER than non-polysensitized patients.
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Affiliation(s)
- Petr Vaník
- Department of Respiratory Diseases, B. Němcové 54, Hospital České Budějovice, a.s., Faculty of Medicine in Pilsen, Charles University, 37001 Prague, Czech Republic
| | - Jakub Novosad
- Institute of Clinical Immunology and Allergy, University Hospital and Faculty of Medicine, Hradec Kralove, Czech Republic
| | - Olga Kirchnerová
- Department of Pneumology and Phthisiology, University Hospital and Faculty of Medicine in Pilsen, Charles University, Prague, Czech Republic
| | - Irena Krčmová
- Institute of Clinical Immunology and Allergy, University Hospital and Faculty of Medicine, Hradec Kralove, Czech Republic
| | - Milan Teřl
- Department of Pneumology and Phthisiology, University Hospital and Faculty of Medicine in Pilsen, Charles University, Prague, Czech Republic
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Bakakos A, Loukides S, Usmani OS, Bakakos P. Biologics in severe asthma: the overlap endotype - opportunities and challenges. Expert Opin Biol Ther 2020; 20:1427-1434. [PMID: 32779950 DOI: 10.1080/14712598.2020.1809651] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Patients with severe asthma experience a significant burden of symptoms, disease exacerbations and medication side-effects. Severe asthma interferes with the patients' quality of life and has high health-care costs. New targeted biologic therapies have improved the management of severe asthma by significantly reducing exacerbations and maintenance corticosteroid use, and also improving lung function and patient quality of life. AREAS COVERED Not all severe asthmatics are eligible for such therapies. Those with allergic and eosinophilic asthma, usually referred to as 'T2-high' asthma benefit from anti-IgE and anti-IL-5/5 R antibodies respectively, whereas some asthmatics are eligible for both: 'overlap' endotype. In this review, we present briefly the monoclonal antibodies that have been approved in the management of severe asthma and we focus on the 'overlap' endotype. EXPERT OPINION Since these therapies are costly, it is extremely important to choose the right treatment for the right patient especially in the 'overlapping' one. The decision is mainly based on the judgment of the clinician and is often driven by the most easily obtainable biomarker, thus the blood eosinophil count. Comorbidities, patient's input and administration frequency may aid the decision of choosing one over another biologic.
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Affiliation(s)
- A Bakakos
- 1st University Department of Respiratory Medicine, National and Kapodistrian University of Athens , Athens Greece
| | - S Loukides
- 2 University Department of Respiratory Medicine, National and Kapodistrian University of Athens , Athens Greece
| | - O S Usmani
- Airways Disease Section, National Heart and Lung Institute, Imperial College London, & Royal Brompton Hospital , UK
| | - P Bakakos
- 1st University Department of Respiratory Medicine, National and Kapodistrian University of Athens , Athens Greece
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Martin MJ, Beasley R, Harrison TW. Towards a personalised treatment approach for asthma attacks. Thorax 2020; 75:1119-1129. [PMID: 32839286 DOI: 10.1136/thoraxjnl-2020-214692] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 07/02/2020] [Accepted: 07/05/2020] [Indexed: 12/16/2022]
Abstract
Asthma attacks (exacerbations) are common, accounting for over 90 000 UK hospital admissions per annum. They kill nearly 1500 people per year in the UK, have significant associated direct and indirect costs and lead to accelerated and permanent loss of lung function. The recognition of asthma as a heterogeneous condition with multiple phenotypes has revolutionised the approach to the long-term management of the condition, with greater emphasis on personalised treatment and the introduction of the treatable traits concept. In contrast asthma attacks are poorly defined and understood and our treatment approach consists of bronchodilators and systemic corticosteroids. This review aims to explore the current limitations in the description, assessment and management of asthma attacks. We will outline the risk factors for attacks, strategies to modify this risk and describe the recognised characteristics of attacks as a first step towards the development of an approach for phenotyping and personalising the treatment of these critically important events. By doing this, we hope to gradually improve asthma attack treatment and reduce the adverse effects associated with recurrent courses of corticosteroids.
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Affiliation(s)
- Matthew J Martin
- Nottingham Respiratory Research Unit, University of Nottingham, Nottingham, UK
| | - Richard Beasley
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Tim W Harrison
- Nottingham Respiratory Research Unit, University of Nottingham, Nottingham, UK
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117
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Biologics for Severe Asthma: Treatment-Specific Effects Are Important in Choosing a Specific Agent. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 7:1379-1392. [PMID: 31076056 DOI: 10.1016/j.jaip.2019.03.008] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Revised: 02/25/2019] [Accepted: 03/03/2019] [Indexed: 12/19/2022]
Abstract
Patients with uncontrolled severe persistent asthma have greater morbidity, greater use of health care resources, and more impairment in health-related quality of life when compared with their peers with well-controlled disease. Fortunately, since the introduction of biological therapeutics, patients with severe eosinophilic asthma now have beneficial treatment options that they did not have just a few years ago. In addition to anti-IgE therapy for allergic asthma, 3 new biological therapeutics targeting IL-5 and 1 targeting IL-4 and IL-13 signaling have recently been approved by the Food and Drug Administration for the treatment of severe eosinophilic asthma, and approval of more biological therapeutics is on the horizon. These medications decrease the frequency of asthma exacerbations, improve lung function, reduce corticosteroid usage, and improve health-related quality of life. This article reviews the mechanisms of action, specific indications, benefits, and side effects of each of the approved biological therapies for asthma. Furthermore, this article reviews how a clinician could use specific patient characteristics to decide which biologic treatment may be optimal for a given patient.
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118
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Caminati M, Senna G. Biologic Therapy in a Patient with Asthma and Nasal Polyps. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 7:1700-1701. [PMID: 31076065 DOI: 10.1016/j.jaip.2018.11.036] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 11/05/2018] [Accepted: 11/05/2018] [Indexed: 11/19/2022]
Affiliation(s)
- Marco Caminati
- Asthma Center and Allergy Unit, Verona University Hospital, Piazzale Scuro, Verona, Italy.
| | - Gianenrico Senna
- Asthma Center and Allergy Unit, Verona University Hospital, Piazzale Scuro, Verona, Italy
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119
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Álvarez-Gutiérrez FJ, Blanco-Aparicio M, Plaza V, Cisneros C, García-Rivero JL, Padilla A, Pérez-de Llano L, Perpiñá M, Soto-Campos G. Documento de consenso de asma grave en adultos. Actualización 2020. OPEN RESPIRATORY ARCHIVES 2020. [DOI: 10.1016/j.opresp.2020.03.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Tanaka A, Sato H, Akimoto K, Matsunaga T, Sagara H. Spontaneous sputum discriminates inflammatory phenotypes in patients with asthma. Ann Allergy Asthma Immunol 2020; 126:54-60.e1. [PMID: 32553777 DOI: 10.1016/j.anai.2020.06.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 05/05/2020] [Accepted: 06/06/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Eosinophils in induced sputum are not only a useful biomarker for diagnosing asthma but are also associated with severe asthma. However, little is known about the association between eosinophils in spontaneous sputum and asthma severity. OBJECTIVE To investigate whether spontaneous sputum eosinophils are related to severe asthma in adult patients with asthma. METHODS We conducted a retrospective cross-sectional study on 86 people with asthma whose spontaneous sputa were successfully collected. Patients were classified into 4 phenotypes according to the eosinophil and neutrophil levels in spontaneous sputum. We determined the association between inflammatory phenotypes and severe asthma. Moreover, we also compared asthma severity among the phenotypes classified according to blood eosinophils and spontaneous sputum eosinophils. RESULTS Asthma phenotypes were as follows: paucigranulocytic, 30.2%; neutrophilic, 18.6%; eosinophilic, 32.6%; and mixed, 18.6%. People with eosinophilic asthma had the highest blood eosinophils, total immunoglobulin E (IgE), and fractional exhaled nitric oxide among the 4 phenotypes. Significant differences were observed in asthma severity between the phenotypes (P = .019). In particular, 57.2% and 56.2% of patients had severe eosinophilic asthma and mixed asthma, respectively. The logistic regression analysis revealed that spontaneous sputum eosinophilia represented the strongest association with severe asthma among the inflammatory variables. Finally, more patients with severe asthma were included in the phenotype with spontaneous sputum eosinophils greater than 3% and blood eosinophils less than or equal to 300/μL and in the phenotype with spontaneous sputum eosinophils greater than 3% and blood eosinophils greater than 300/μL. CONCLUSION Spontaneous sputum can provide helpful information on airway inflammatory phenotyping in patients with asthma.
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Affiliation(s)
- Akihiko Tanaka
- Division of Respiratory Medicine and Allergology, Department of Medicine, School of Medicine, Showa University, Tokyo, Japan.
| | - Hiroki Sato
- Division of Respiratory Medicine and Allergology, Department of Medicine, School of Medicine, Showa University, Tokyo, Japan
| | - Kaho Akimoto
- Division of Respiratory Medicine and Allergology, Department of Medicine, School of Medicine, Showa University, Tokyo, Japan
| | - Tomohiro Matsunaga
- Division of Respiratory Medicine and Allergology, Department of Medicine, School of Medicine, Showa University, Tokyo, Japan
| | - Hironori Sagara
- Division of Respiratory Medicine and Allergology, Department of Medicine, School of Medicine, Showa University, Tokyo, Japan
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121
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Promises and challenges of biologics for severe asthma. Biochem Pharmacol 2020; 179:114012. [PMID: 32389637 DOI: 10.1016/j.bcp.2020.114012] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 05/01/2020] [Indexed: 12/23/2022]
Abstract
Patients with severe asthma that remain uncontrolled incur significant medical burden and healthcare costs. Severe asthma is a heterogeneous airway disorder with complex pathophysiological mechanisms which can be broadly divided into type 2 (T2)-high and T2-low inflammatory pathways. Recent advances in asthma therapeutics with the advent of biologics have heralded an era of promising targeted therapy in this group of patients. The current available biologics, including anti-IgE mAb, anti-IL-5/IL-5R mAb and anti-IL-4Rα mAb, mainly target patients with an asthma endotype characterised by T2-high inflammation. While they have delivered positive outcomes in terms of reduction in exacerbations, improving lung function and quality of life, as well as reducing the dependence on oral corticosteroids, they have not functioned as the "panacea" as a significant proportion of patients do not respond completely to these targeted therapies. In addition, there is a lack of markers that can predict treatment response and clinicians are guided only by subjective asthma symptom scores. Suboptimal treatment response is common for individual patients. There has also been a dearth of effective targeted therapy for patients with T2-low asthma and treatment options remain limited for these patients. There is a pipeline of newer biologics targeting cytokines that operate at the interface between innate and adaptive immunity (e.g. IL-17A, thymic stromal lymphopoietin (TSLP), IL-25, IL-33, IL-32 and IL-36γ) with potential of modifying and reducing the severity of asthma. This commentary provides an overview of treatment with the current biologics and highlights the limitations, challenges and unmet needs in clinical management. We also summarise up-and-coming potential targets and therapeutic biologics for severe asthma.
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122
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Cabrejos S, Moreira A, Ramirez A, Quirce S, Soto Campos G, Dávila I, Campo P. FENOMA Study: Achieving Full Control in Patients with Severe Allergic Asthma. J Asthma Allergy 2020; 13:159-166. [PMID: 32440161 PMCID: PMC7221411 DOI: 10.2147/jaa.s246902] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 04/10/2020] [Indexed: 11/23/2022] Open
Abstract
Introduction A Spanish real-world study in patients with severe persistent asthma who achieved asthma control after a one-year treatment with omalizumab highlighted the phenotypic heterogeneity of these patients (FENOMA study). In this subanalysis, we describe the clinical improvement in patients with severe allergic asthma in this study (positive skin test and IgE level 30-1500 IU/mL); n=240. Patients and Methods FENOMA was an observational, multicentre, retrospective study in 345 patients achieving asthma control according to Spanish guidelines (GEMA). Baseline demographic and asthma-related characteristics were collected. Outcomes analyzed were those included in asthma control definition plus changes in background treatments and in blood eosinophil count (%) and exhaled nitric oxide fraction [FeNO]. Results At baseline, patients were aged 45.4±15.0 years; 67% were women. Median (Q1;Q3) IgE levels were 302.5 (154.0; 553.5) IU/mL. After one-year treatment with omalizumab: 43.3% of patients had daytime symptoms vs 97.7% before treatment and 49.6% stopped taking oral corticosteroids. FEV1 increased a median of 12.0 (4.0; 23.0)%; P <0.0001. The number of non-severe asthma exacerbations decreased a median of -4.0 (-7.0; 2.0); P <0.0001. Median unplanned visits to primary care or specialists and days of school/workplace absenteeism decreased from 4.9 (2.0; 6.0), 1.0 (0.0; 3.0) and 0.0 (0.0; 14.0) to 0.0 (0.0; 1.0), 0.0 (0.0; 0.0) and 0.0 (0.0; 0.0), respectively. Median eosinophil blood count and FeNO decreased from 5.0 (3:0; 8.0)% to 3.0 (2.0; 5.5)% and from 36.0 (23:0; 53.0) ppb to 20.0 (13.0; 34.0) ppb, respectively. Conclusion This study highlights the asthma control achieved by patients with severe allergic asthma treated with omalizumab, with relevant benefits on the burden of the disease both on patients and the healthcare system.
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Affiliation(s)
- Sheila Cabrejos
- Allergy Service, Hospital Rafael Mendez de Lorca, Murcia, Spain
| | | | | | - Santiago Quirce
- Department of Allergy, Hospital La Paz Institute for Health Research (IdiPAZ), Madrid, Spain, CIBER de Enfermedades Respiratorias, CIBERES, Madrid, Spain
| | | | - Ignacio Dávila
- Allergy Service, University Hospital of Salamanca and Institute for Biomedical Research of Salamanca (IBSAL), Salamanca, Spain, Biomedical and Diagnosis Science Department, Salamanca University School of Medicine, Salamanca, Spain
| | - Paloma Campo
- Allergy Unit, IBIMA-Regional University Hospital of Málaga, ARADyAL, Málaga, Spain
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123
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How to compare the efficacy of biologic agents in asthma. Ann Allergy Asthma Immunol 2020; 125:137-149. [PMID: 32387169 DOI: 10.1016/j.anai.2020.04.031] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 04/22/2020] [Accepted: 04/28/2020] [Indexed: 02/08/2023]
Abstract
OBJECTIVE The use of biologics in severe asthma has made substantial strides in disease management and fostered a personalized medicine approach; however, how, when, and which biologic to choose are unresolved issues, which form the focus of this review. DATA SOURCES The data sources were published literature, including current guidelines, available through PubMed searches and online resources. STUDY SELECTIONS Studies and randomized controlled trials pertaining to the use of biologics in various phenotypes and/or endotypes of asthma and comparative analyses between biologics in asthma were included. RESULTS Inflammatory constructs in asthma are complex and translate differentially into clinical practice for both disease severity and treatment responsiveness. The utilization of biologics, which target selected components of inflammation, has begun to dramatically improve the course of management for many patients with severe asthma. A retuning of our approach into selecting appropriate patient cohorts or phenotypes for studies and selection of clinically relevant outcomes, which are reflected by existing and novel emerging biomarkers, is enabling a paradigm shift in asthma management. Comparing the efficacy of the available biologics for asthma is challenging as no direct head-to-head studies are available, and indirect comparisons to this query provide varying results. CONCLUSION Significant progress has been achieved in the management of severe asthma with treatment of target-specific biologics. Sophisticated algorithms and trial designs, using a combination of available biomarker profiles and clinical characteristics to stratify patient populations into more precise subphenotypes and endotypes to guide our choice of a biologic or therapy, are critically needed but currently not formulated.
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124
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Menzies-Gow A, Mansur AH, Brightling CE. Clinical utility of fractional exhaled nitric oxide in severe asthma management. Eur Respir J 2020; 55:13993003.01633-2019. [PMID: 31949116 DOI: 10.1183/13993003.01633-2019] [Citation(s) in RCA: 79] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 12/25/2019] [Indexed: 02/06/2023]
Abstract
Asthma is a chronic inflammatory disease of the airways, affecting over 350 million people worldwide and placing a significant burden on healthcare providers and wider society. Approximately 5-10% of asthma patients are diagnosed with severe asthma and typically are associated with increased risk of hospitalisation from exacerbations, increased morbidity, mortality and higher asthma-associated healthcare costs. Nitric oxide (NO) is an important regulator of immune responses and is a product of inflammation in the airways that is over-produced in asthma. Fractional exhaled NO (F eNO) is predominantly used as a predictor of response to inhaled corticosteroids (ICSs), to monitor adherence and as a diagnostic tool in ICS-naïve patients. In the UK, the National Institute for Health and Care Excellence (NICE) guidelines recommend the use of F eNO for the initial diagnosis of patients with suspected asthma. In the USA, American Thoracic Society (ATS) guidelines recommend F eNO as part of the initial diagnosis of asthma and for monitoring of airway inflammation. F eNO has also been shown to be a predictive factor for asthma exacerbations, with higher levels being associated with a greater number of exacerbations. In addition, higher levels of F eNO have been shown to be associated with a decline in lung function. F eNO testing is a cost-effective procedure and has been shown to improve patient management when combined with standard assessment methods. Recent evidence suggests that F eNO may also be useful as a surrogate biomarker for the assessment and management of severe asthma and to predict responsiveness to some biological therapies.
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Affiliation(s)
| | - Adel H Mansur
- Dept of Respiratory Medicine, Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Christopher E Brightling
- Institute for Lung Health, NIHR Leicester Biomedical Research Centre, Dept of Respiratory Sciences, University of Leicester, Leicester, UK
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McGregor MC, Krings J, Nair P, Castro M. Reply to Yilmaz: Selection of Biologics for Type 2-High Asthma. Am J Respir Crit Care Med 2020; 200:791-792. [PMID: 31106571 PMCID: PMC6775882 DOI: 10.1164/rccm.201904-0898le] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
| | - James Krings
- Washington University School of MedicineSt. Louis, Missouriand
| | | | - Mario Castro
- Washington University School of MedicineSt. Louis, Missouriand
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126
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Yilmaz I. Selection of Biologics for Type 2-High Asthma. Am J Respir Crit Care Med 2020; 200:790-791. [PMID: 31106563 PMCID: PMC6775871 DOI: 10.1164/rccm.201904-0763le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- Insu Yilmaz
- Erciyes University School of MedicineKayseri, Turkey
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127
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Adherence to omalizumab: A multicenter "real-world" study. World Allergy Organ J 2020; 13:100103. [PMID: 32082464 PMCID: PMC7016448 DOI: 10.1016/j.waojou.2020.100103] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 12/13/2019] [Accepted: 12/23/2019] [Indexed: 01/23/2023] Open
Abstract
Background Adherence to medications is crucial in patients with severe asthma in light of the negative clinical impact and costs of non-adherence. Adherence to omalizumab has not been well studied in real-world settings. The aim of this study was to assess adherence to omalizumab and evaluate treatment effectiveness in relation to adherence. Methods This was a retrospective, observational, and multicenter real-world study. Omalizumab dose, timing of administration, and duration of treatment (<2 years; 2–4 years; > 4 years) were analyzed. Adherence was evaluated by examining rates of expected and missing doses. Good adherence (<10% of doses missed) and poor adherence (>10% doses missed) were determined. For effectiveness in relation to adherence of omalizumab we considered asthma exacerbations, hospitalizations, asthma control test (ACT), and Forced Expiratory Volume in 1 s (FEV1). Results A total of 196 patients were evaluated, and 161 were suitable for data analyses. Good adherence was shown in 90.7% of patients and poor adherence in 9.3%. Considering adherence in relation to treatment duration: <2 years, 87.8% of patients were adherent (expected doses, 1186; missed doses, 53); 2–4 years, 85.9% were adherent (expected doses, 2985; missed doses, 127); >4 years, 100% were adherent (expected doses, 6120; missed doses, none). Indices of efficacy between pre- and post-treatment showed significant improvement (p < 0.001). The effectiveness indices between pre- and post-treatment, among adherent and non-adherent patients, ACT, and asthma exacerbations both showed significant differences (p = 0.043 and p = 0.049, respectively). Binomial logistic regression analysis showed that increasing age, better ACT score, and 14-day timing were significantly associated with increased adherence to therapy. Conclusions High adherence to omalizumab was demonstrated in a real-world setting, which was associated with better outcomes and control of asthma.
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128
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McDowell PJ, Heaney LG. Different endotypes and phenotypes drive the heterogeneity in severe asthma. Allergy 2020; 75:302-310. [PMID: 31267562 DOI: 10.1111/all.13966] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 06/05/2019] [Accepted: 06/21/2019] [Indexed: 12/12/2022]
Abstract
The identification of sputum eosinophilia indicating corticosteroid responsiveness in subjects with severe asthma heralded the beginning of phenotyping asthmatic subjects based on airways inflammation. Since then, the heterogeneity of severe asthma has been explored and the importance of immunobiology has come sharply into focus with the identification of the key type-2 cytokine pathways driving eosinophilic inflammation. The development of molecules targeting these type-2 pathways has transformed severe asthma treatment, but necessitates robust clinical evaluation, biomarker profiling and assessment of comorbid factors to identify subjects most likely to benefit from these therapies. It has also become clear that targeting these pathways does not eradicate asthma symptoms and exacerbation risk; further work is needed to clarify underlying non-type-2 mechanisms in severe asthma pathways and possible therapeutic targets. This review addresses progress to date in clinical assessment and management of severe asthma and some of the challenges and unmet needs in severe asthma to achieve the goal of delivering individualized patient care.
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Affiliation(s)
- P. Jane McDowell
- Centre for Experimental Medicine Queen's University Belfast Belfast UK
| | - Liam G. Heaney
- Centre for Experimental Medicine Queen's University Belfast Belfast UK
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129
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Hanania NA, Djukanovic R, Heaney LG, Yang M, Yoo B, Iqbal A, Griffin NM, Chipps BE. Determinants of lung function improvement with omalizumab in adults with allergic asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:2068-2070. [PMID: 31981731 DOI: 10.1016/j.jaip.2020.01.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 12/19/2019] [Accepted: 01/08/2020] [Indexed: 01/28/2023]
Affiliation(s)
- Nicola A Hanania
- Section of Pulmonary and Critical Care Medicine, Airways Clinical Research Center, Baylor College of Medicine, Houston, Tex
| | - Ratko Djukanovic
- University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Liam G Heaney
- Centre for Experimental Medicine, Queen's University Belfast, Belfast, United Kingdom
| | - Ming Yang
- Genentech, Inc., San Francisco, Calif
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130
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Schatz M, Sicherer SH, Khan DA, Zeiger RS. The Journal of Allergy and Clinical Immunology: In Practice 2019 Highlights. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:912-936. [PMID: 31980411 DOI: 10.1016/j.jaip.2020.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 01/03/2020] [Indexed: 10/25/2022]
Abstract
This article provides highlights of the clinically impactful original studies and reviews published in The Journal of Allergy and Clinical Immunology: In Practice in 2019 on the subjects of anaphylaxis, asthma, dermatitis, drug allergy, food allergy, immunodeficiency, immunotherapy, rhinitis/sinusitis, and urticaria/angioedema/mast cell disorders. Within each topic, practical aspects of diagnosis and management are emphasized. Treatments discussed include lifestyle modifications, allergen avoidance therapy, positive and negative effects of pharmacologic therapy, and various forms of immunologic and desensitization management. We designed this review to help readers consolidate and use this extensive and practical knowledge for the benefit of their patients.
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Affiliation(s)
- Michael Schatz
- Department of Allergy, Kaiser Permanente Southern California, San Diego, Calif.
| | - Scott H Sicherer
- Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - David A Khan
- Department of Internal Medicine, Division of Allergy & Immunology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Robert S Zeiger
- Department of Allergy, Kaiser Permanente Southern California, San Diego, Calif; Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, Calif
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131
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McGregor MC, Krings JG, Nair P, Castro M. Role of Biologics in Asthma. Am J Respir Crit Care Med 2020; 199:433-445. [PMID: 30525902 DOI: 10.1164/rccm.201810-1944ci] [Citation(s) in RCA: 259] [Impact Index Per Article: 64.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Patients with severe uncontrolled asthma have disproportionally high morbidity and healthcare utilization as compared with their peers with well-controlled disease. Although treatment options for these patients were previously limited, with unacceptable side effects, the emergence of biologic therapies for the treatment of asthma has provided promising targeted therapy for these patients. Biologic therapies target specific inflammatory pathways involved in the pathogenesis of asthma, particularly in patients with an endotype driven by type 2 (T2) inflammation. In addition to anti-IgE therapy that has improved outcomes in allergic asthma for more than a decade, three anti-IL-5 biologics and one anti-IL-4R biologic have recently emerged as promising treatments for T2 asthma. These targeted therapies have been shown to reduce asthma exacerbations, improve lung function, reduce oral corticosteroid use, and improve quality of life in appropriately selected patients. In addition to the currently approved biologic agents, several biologics targeting upstream inflammatory mediators are in clinical trials, with possible approval on the horizon. This article reviews the mechanism of action, indications, expected benefits, and side effects of each of the currently approved biologics for severe uncontrolled asthma and discusses promising therapeutic targets for the future.
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Affiliation(s)
- Mary Clare McGregor
- 1 Division of Pulmonary and Critical Care, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri; and
| | - James G Krings
- 1 Division of Pulmonary and Critical Care, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri; and
| | - Parameswaran Nair
- 2 Division of Respirology, Department of Medicine, St. Joseph's Healthcare Hamilton, McMaster University, Hamilton, Ontario, Canada
| | - Mario Castro
- 1 Division of Pulmonary and Critical Care, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri; and
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132
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Sullivan PW, Li Q, Bilir SP, Dang J, Kavati A, Yang M, Rajput Y. Cost-effectiveness of omalizumab for the treatment of moderate-to-severe uncontrolled allergic asthma in the United States. Curr Med Res Opin 2020; 36:23-32. [PMID: 31491337 DOI: 10.1080/03007995.2019.1660539] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Objective: Uncontrolled asthma is associated with considerable clinical burden and costs to payers and patients. US economic models evaluating biologics using data from clinical trials demonstrate high incremental cost-effectiveness ratios (ICERs), but the cost-effectiveness based on real-world treatment patterns is unknown. This analysis used real-world evidence to assess the cost-effectiveness of adding omalizumab to standard of care (SOC).Methods: A Markov model was applied to track patients' health states in 2-week cycles, comparing costs and treatment effects of SOC alone versus SOC + omalizumab over a lifetime (US payer perspective). Outcomes included exacerbation events, life years, quality-adjusted life years (QALYs), total costs, and an ICER. Patient characteristics, exacerbations, patient-reported outcomes, and work productivity were derived from the real-world PROSPERO (Prospective Study to Evaluate Predictors of Clinical Effectiveness in Response to Omalizumab) study. Published literature informed mortality, exacerbation-related disutility, and unit costs. Sensitivity analyses assessed model robustness.Results: Over a lifetime horizon, omalizumab was associated with an increase of 2.0 QALYs at a cost of $US 148,319 in patients with uncontrolled asthma (ICER of $75,319/QALY gained) and a reduction in exacerbations of 6.0 events/patient. Accounting for responder status improved the ICER ($70,505/QALY); incorporating indirect costs further reduced the ICER. One-way and multivariate sensitivity analyses confirmed that the base case outcome was robust to variation in inputs.Conclusions: Based on real-world outcomes, omalizumab may be cost-effective for uncontrolled asthma from the US payer perspective. Including broader evidence on treatment discontinuation, caregiver burden, and oral corticosteroid reduction from real-world studies may better reflect the effects and value of omalizumab for all healthcare stakeholders.
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Affiliation(s)
| | | | | | - Joseph Dang
- Genentech, Inc., South San Francisco, CA, USA
| | | | - Ming Yang
- Genentech, Inc., South San Francisco, CA, USA
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133
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Rogliani P, Calzetta L, Matera MG, Laitano R, Ritondo BL, Hanania NA, Cazzola M. Severe Asthma and Biological Therapy: When, Which, and for Whom. Pulm Ther 2019; 6:47-66. [PMID: 32048241 PMCID: PMC7229123 DOI: 10.1007/s41030-019-00109-1] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Indexed: 02/01/2023] Open
Abstract
Asthma is a heterogeneous chronic inflammatory disease of the airways that affects approximately 300 million people worldwide. About 5-10% of all asthmatics suffer from severe or uncontrolled asthma, associated with increased mortality and hospitalization, reduced quality of life, and increased health care costs. In recent years, new treatments have become available, and different asthma phenotypes characterized by specific biomarkers have been identified. Biological drugs are currently indicated for patients with severe asthma that is not controlled with recommended treatments. They are mostly directed against inflammatory molecules of the type 2 inflammatory pathway and are effective at reducing exacerbations, maintaining control over asthma symptoms, and reducing systemic steroid use, which is associated with well-known adverse events. Although biological drugs for severe asthma have had a major impact on the management of the disease, there is still a need for head-to-head comparison studies of biologics and to identify new biomarkers for asthma diagnosis, prognosis, and response to treatment. Identifying novel biomarkers could facilitate the development of therapeutic strategies that are precisely tailored to each patient's requirements.
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Affiliation(s)
- Paola Rogliani
- Respiratory Unit, Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Luigino Calzetta
- Respiratory Unit, Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy.
| | - Maria Gabriella Matera
- Department of Experimental Medicine, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Rossella Laitano
- Respiratory Unit, Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Beatrice Ludovica Ritondo
- Respiratory Unit, Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Nicola A Hanania
- Section of Pulmonary, Critical Care and Sleep Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Mario Cazzola
- Respiratory Unit, Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
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134
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Busse WW, Humbert M, Haselkorn T, Ortiz B, Trzaskoma BL, Stephenson P, Garcia Conde L, Kianifard F, Holgate ST. Effect of omalizumab on lung function and eosinophil levels in adolescents with moderate-to-severe allergic asthma. Ann Allergy Asthma Immunol 2019; 124:190-196. [PMID: 31760132 DOI: 10.1016/j.anai.2019.11.016] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 11/12/2019] [Accepted: 11/14/2019] [Indexed: 01/14/2023]
Abstract
BACKGROUND Omalizumab improves clinical outcomes in patients with asthma. Several studies have shown lung function improvements with omalizumab; however, this has not been examined exclusively in adolescents. OBJECTIVE To assess the effect of omalizumab on lung function and eosinophil counts in adolescents with uncontrolled moderate-to-severe allergic asthma. METHODS In this post hoc analysis, data from adolescents aged 12 to 17 years from 8 randomized trials of omalizumab were pooled (studies 008, 009, and 011, and SOLAR, INNOVATE, ALTO, ETOPA, and EXTRA). Changes from baseline to end of study in forced expiratory volume in 1 second (FEV1), percent predicted FEV1 (ppFEV1), forced vital capacity (FVC), and blood eosinophil counts were assessed by fitting an analysis of covariance model and calculating least squares mean (LSM) difference for omalizumab vs placebo. RESULTS A total of 340 adolescents were identified (omalizumab, n = 203 [59.7%]; placebo, n = 137 [40.3%]). Omalizumab increased all baseline lung function variables more than placebo by end of study: LSM treatment differences (95% confidence interval) were 3.0% (0.2%-5.7%; P = .035), 120.9 mL (30.6-211.2 mL; P = .009), and 101.5 mL (8.3-194.6 mL; P = .033) for ppFEV1, absolute FEV1, and FVC, respectively. The LSM difference demonstrated a greater reduction in eosinophil counts for omalizumab vs placebo: -85.9 cells/μL (-137.1 to -34.6 cells/μL; P = .001). CONCLUSION Omalizumab was associated with lung function improvements and circulating eosinophil counts reductions in adolescents with moderate-to-severe uncontrolled asthma. Findings emphasize the effect of omalizumab in young patients and the need to optimize treatment early in the disease course. https://clinicaltrials.gov/: NCT00314574, NCT00046748, NCT00401596.
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Affiliation(s)
- William W Busse
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.
| | | | | | - Benjamin Ortiz
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey
| | | | | | | | - Farid Kianifard
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey
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135
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Denlinger LC, Heymann P, Lutter R, Gern JE. Exacerbation-Prone Asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 8:474-482. [PMID: 31765853 DOI: 10.1016/j.jaip.2019.11.009] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Revised: 10/28/2019] [Accepted: 11/12/2019] [Indexed: 02/07/2023]
Abstract
Patients who are prone to exacerbations of asthma experience significant costs in terms of missed work and school, acute care visits, and hospitalizations. Exacerbations are largely driven by environmental exposures including pollutants, stress, and viral and bacterial pathogens. These exposures are most likely to induce acute severe "asthma attacks" in high-risk patients. These personal risk factors for exacerbations can vary with the phenotype of asthma and age of the patient. In children, allergic sensitization is a strong risk factor, especially for those children who develop sensitization early in life. Airway inflammation is an important risk factor, and biomarkers are under evaluation for utility in detecting eosinophilic and type 2 inflammation and neutrophilic inflammation as indicators of risk for recurrent exacerbations. Insights into inflammatory mechanisms have led to new approaches to prevent exacerbations using mAb-based biologics that target specific type 2 pathways. Challenges remain in developing an evidence base to support precision interventions with these effective yet expensive therapies, and in determining whether these treatments will be safe and effective in young children. Unfortunately, there has been less progress in developing treatments for acute exacerbations. Hopefully, greater understanding of mechanisms relating airway viruses, bacteria, mucin production, and neutrophilic inflammatory responses will lead to additional treatment options for patients experiencing acute exacerbations.
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Affiliation(s)
- Loren C Denlinger
- Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wis.
| | - Peter Heymann
- Department of Pediatrics, University of Virginia, Charlottesville, Va
| | - Rene Lutter
- Departments of Respiratory Medicine and Experimental Immunology, Amsterdam University Centers, University of Amsterdam, Amsterdam Infection and Immunity Institute, Amsterdam, The Netherlands
| | - James E Gern
- Department of Pediatrics, University of Wisconsin-Madison, School of Medicine and Public Health, Madison, Wis
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136
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Ledford DK, Casale TB. Can Xolair Be Used in Nonallergic Asthmatic? THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 6:2170. [PMID: 30390909 DOI: 10.1016/j.jaip.2018.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Accepted: 08/11/2018] [Indexed: 11/18/2022]
Affiliation(s)
- Dennis K Ledford
- Division of Allergy/Immunology, Department of Internal Medicine, Morsani College of Medicine, University of South Florida, Tampa, Fla; James A. Haley Veterans' Hospital, Tampa, Fla.
| | - Thomas B Casale
- Division of Allergy/Immunology, Department of Internal Medicine, Morsani College of Medicine, University of South Florida, Tampa, Fla; James A. Haley Veterans' Hospital, Tampa, Fla
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137
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Resolution of allergic asthma. Semin Immunopathol 2019; 41:665-674. [PMID: 31705318 DOI: 10.1007/s00281-019-00770-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 10/15/2019] [Indexed: 02/07/2023]
Abstract
Allergic asthma is an inflammatory disease of the airways characterized by recurrent episodes of wheezing and bronchoconstriction. Chronic inflammation may finally lead to structural damage followed by airway remodeling. Various studies in recent years contributed to unravel important aspects of the immunopathogenesis of asthma and adapted new pharmaceutical developments. Here, I consider some novel insights into the immunopathogenesis of asthma and the protective and pathogenic roles of some innate and adaptive immune cells as well as the function of soluble mediators such as cytokines. Particular attention will be given to new concepts on resolution of chronic airway inflammation for prevention of airway structural damage.
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138
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Aberumand B, Ellis AK. Asthma and the Biologics Revolution, Part 1: Here and Now. CURRENT TREATMENT OPTIONS IN ALLERGY 2019. [DOI: 10.1007/s40521-019-00232-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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139
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Schoettler N, Strek ME. Recent Advances in Severe Asthma: From Phenotypes to Personalized Medicine. Chest 2019; 157:516-528. [PMID: 31678077 DOI: 10.1016/j.chest.2019.10.009] [Citation(s) in RCA: 90] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 09/15/2019] [Accepted: 10/18/2019] [Indexed: 12/31/2022] Open
Abstract
This review focuses on recent clinical and translational discoveries in severe and uncontrolled asthma that now enable phenotyping and personalized therapies in these patients. Although asthma is common in both children and adults and typically responds to standard therapies, a subset of individuals with asthma experience severe and/or persistent symptoms despite appropriate therapies. Airflow obstruction leading to frequent symptoms requiring higher levels of controller therapy is the cardinal feature of severe asthma, but the underlying molecular mechanisms, or endotypes, are diverse and variable between individuals. Two major risk factors that contribute to severe asthma are genetics and environmental exposures that modulate immune responses, and although these often interact in complex manners that are not fully understood, certain endotypes converge in severe asthma. A number of studies have evaluated various features of patients with severe asthma and classified patients into phenotypes with clinical relevance. This phenotyping is now incorporated into clinical practice and can be used to guide advanced biological therapies that target specific molecules and inflammatory pathways that contribute to asthma pathogenesis.
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Affiliation(s)
- Nathan Schoettler
- Department of Medicine, Section of Pulmonary and Critical Care, University of Chicago, Chicago, IL.
| | - Mary E Strek
- Department of Medicine, Section of Pulmonary and Critical Care, University of Chicago, Chicago, IL
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140
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Doroudchi A, Pathria M, Modena BD. Asthma biologics: Comparing trial designs, patient cohorts and study results. Ann Allergy Asthma Immunol 2019; 124:44-56. [PMID: 31655122 DOI: 10.1016/j.anai.2019.10.016] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 09/25/2019] [Accepted: 10/15/2019] [Indexed: 12/17/2022]
Abstract
OBJECTIVE Five biologic therapies have FDA-approved indications for difficult-to-control asthma. The clinical trials that proved the efficacy and safety of these biologics were often similar in their inclusion criteria, study designs, and endpoints. Many of these trials have been reanalyzed post hoc to identify subsets of subjects considered to be enhanced responders. As a result, keeping up with the literature and deciding on the most appropriate biologic for our patients has become increasingly difficult. This review summarizes and compares trial designs, patient cohorts, and study results of the major trials involving these therapies. DATA SOURCES Included are basic science articles, online Food and Drug Administration (FDA) applications, and all the published reports of phase II and phase III clinical trials for FDA-approved asthma biologics. STUDY SELECTIONS Included are the major phase II and phase III clinical trials of 5 asthma biologics. RESULTS Because of variations in inclusion criteria and natural variations in enrolled cohorts, the baseline clinical traits and severity of study populations in asthma biologic trials differed significantly, which is important because baseline annualized exacerbation rates and blood eosinophilia are both strong predictors of a biologic's success. Notwithstanding, the trial results, when considered together, can help guide care providers in choosing the most appropriate biologic for our patients. CONCLUSION Understanding the details and differences in asthma biologic trial designs, patient cohorts, and in study results will help care providers make more informed decisions when choosing a biologic. We are hopeful this review will serve as a reference to care providers for this purpose.
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Affiliation(s)
- Ali Doroudchi
- Department of Pediatrics, University of California Los Angeles, Los Angeles, California
| | - Mohini Pathria
- Division of Allergy, National Jewish Health, Denver, Colorado
| | - Brian D Modena
- Division of Allergy, National Jewish Health, Denver, Colorado.
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141
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Marone G, Spadaro G, Braile M, Poto R, Criscuolo G, Pahima H, Loffredo S, Levi-Schaffer F, Varricchi G. Tezepelumab: a novel biological therapy for the treatment of severe uncontrolled asthma. Expert Opin Investig Drugs 2019; 28:931-940. [PMID: 31549891 DOI: 10.1080/13543784.2019.1672657] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Introduction: Thymic stromal lymphopoietin (TSLP) is overexpressed in the airways of severe asthmatics and is an upstream cytokine that orchestrates inflammatory responses in asthma. TSLP exerts its effects by binding to a high affinity heteromeric receptor complex composed of TSLPR and IL-7Rα. An association of polymorphisms in TSLP with airway hyperresponsiveness, IgE, eosinophilia and asthma has been documented. TSLP has been implicated in asthma pathophysiology. Tezepelumab is a first-in-class human monoclonal antibody that binds to TSLP, thus inhibiting its interaction with TSLP receptor complex. Tezepelumab given as an add-on-therapy to patients with severe uncontrolled asthma has shown safety, tolerability and efficacy. Several trials are evaluating the long-term safety and the efficacy of tezepelumab in adults and adolescents with severe uncontrolled asthma.Areas covered: We provide an overview of the monoclonal antibody therapeutics market for severe uncontrolled asthma, examine the underlying pathophysiology that drives TSLP and discuss the use of tezepelumab for the treatment of severe uncontrolled asthma,Expert opinion: TSLP is a promising target for T2-high and perhaps some patients with T2-low asthma. The results of preliminary clinical trials are encouraging. Several unanswered questions concerning basic pathophysiological aspects of TSLP variants, the long-term safety and efficacy of tezepelumab with different phenotypes/endotypes of asthma should be addressed.
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Affiliation(s)
- Giancarlo Marone
- Department of Public Health, University of Naples Federico II, Naples, Italy.,Azienda Ospedaliera Ospedali dei Colli - Monaldi Hospital Pharmacy, Naples, Italy
| | - Giuseppe Spadaro
- Department of Translational Medical Sciences and Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, Naples, Italy.,WAO Center of Excellence, Naples, Italy
| | - Mariantonia Braile
- Department of Translational Medical Sciences and Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, Naples, Italy.,WAO Center of Excellence, Naples, Italy
| | - Remo Poto
- Department of Translational Medical Sciences and Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, Naples, Italy.,WAO Center of Excellence, Naples, Italy
| | - Gjada Criscuolo
- Department of Translational Medical Sciences and Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, Naples, Italy.,WAO Center of Excellence, Naples, Italy
| | - Hadas Pahima
- Pharmacology and Experimental Therapeutics Unit, School of Pharmacy, Institute for Drug Research, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Stefania Loffredo
- Department of Translational Medical Sciences and Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, Naples, Italy.,WAO Center of Excellence, Naples, Italy.,Institute of Experimental Endocrinology and Oncology "G. Salvatore" (IEOS), National Research Council (CNR), Naples, Italy
| | - Francesca Levi-Schaffer
- Pharmacology and Experimental Therapeutics Unit, School of Pharmacy, Institute for Drug Research, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Gilda Varricchi
- Department of Translational Medical Sciences and Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, Naples, Italy.,WAO Center of Excellence, Naples, Italy.,Institute of Experimental Endocrinology and Oncology "G. Salvatore" (IEOS), National Research Council (CNR), Naples, Italy
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142
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Diamant Z, Vijverberg S, Alving K, Bakirtas A, Bjermer L, Custovic A, Dahlen S, Gaga M, Gerth van Wijk R, Del Giacco S, Hamelmann E, Heaney LG, Heffler E, Kalayci Ö, Kostikas K, Lutter R, Olin A, Sergejeva S, Simpson A, Sterk PJ, Tufvesson E, Agache I, Seys SF. Toward clinically applicable biomarkers for asthma: An EAACI position paper. Allergy 2019; 74:1835-1851. [PMID: 30953574 DOI: 10.1111/all.13806] [Citation(s) in RCA: 118] [Impact Index Per Article: 23.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 03/17/2019] [Indexed: 12/13/2022]
Abstract
Inflammation, structural, and functional abnormalities within the airways are key features of asthma. Although these processes are well documented, their expression varies across the heterogeneous spectrum of asthma. Type 2 inflammatory responses are characterized by increased levels of eosinophils, FeNO, and type 2 cytokines in blood and/or airways. Presently, type 2 asthma is the best-defined endotype, typically found in patients with allergic asthma, but surprisingly also in nonallergic patients with (severe) asthma. The etiology of asthma with non-type 2 inflammation is less clear. During the past decade, targeted therapies, including biologicals and small molecules, have been increasingly integrated into treatment strategies of severe asthma. These treatments block specific inflammatory pathways or single mediators. Single or composite biomarkers help to identify patients who will benefit from these treatments. So far, only a few inflammatory biomarkers have been validated for clinical application. The European Academy of Allergy & Clinical Immunology Task Force on Biomarkers in Asthma was initiated to review different biomarker sampling methods and to investigate clinical applicability of new and existing inflammatory biomarkers (point-of-care) to support diagnosis, targeted treatment, and monitoring of severe asthma. Subsequently, we discuss existing and novel targeted therapies for asthma as well as applicable biomarkers.
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Affiliation(s)
- Zuzana Diamant
- Department of Respiratory Medicine and Allergology Institute for Clinical Science Skane University Hospital Lund Sweden
- Department of Clinical Pharmacy and Pharmacology UMCG and QPS‐NL Groningen The Netherlands
- Department of Respiratory Medicine First Faculty of Medicine Charles University and Thomayer Hospital Prague Czech Republic
| | - Susanne Vijverberg
- Department of Respiratory Medicine Amsterdam UMC University of Amsterdam Amsterdam The Netherlands
| | - Kjell Alving
- Department of Women's and Children's Health Uppsala University Uppsala Sweden
| | - Arzu Bakirtas
- Department of Pediatrics Division of Pediatric Allergy and Asthma Gazi University School of Medicine Ankara Turkey
| | - Leif Bjermer
- Department of Clinical Pharmacy and Pharmacology UMCG and QPS‐NL Groningen The Netherlands
| | - Adnan Custovic
- Section of Paediatrics Department of Medicine Imperial College London London UK
| | - Sven‐Erik Dahlen
- Experimental Asthma and Allergy Research Institute of Environmental Medicine Karolinska Institutet Stockholm Sweden
| | - Mina Gaga
- 7th Respiratory Medicine Department and Asthma Centre Athens Chest Hospital Athens Greece
| | - Roy Gerth van Wijk
- Section of Allergology Department of Internal Medicine Erasmus Medical Center Rotterdam the Netherlands
| | - Stefano Del Giacco
- Department of Medical Sciences and Public Health University of Cagliari Cagliari Italy
| | - Eckard Hamelmann
- Children's Center Protestant Hospital Bethel Bielefeld Germany
- Allergy Center Ruhr University Bochum Bochum Germany
| | - Liam G. Heaney
- Centre for Experimental Medicine, School of MedicineDentistry and Biomedical Sciences, Queen's University Belfast Belfast UK
| | - Enrico Heffler
- Department of Biomedical Sciences Humanitas University Milan Italy
- Personalized Medicine, Asthma and Allergy Humanitas Research Hospital Milan Italy
| | - Ömer Kalayci
- Division of Pediatric Allergy Faculty of Medicine Hacettepe University Ankara Turkey
| | - Konstantinos Kostikas
- Respiratory Medicine Department University of Ioannina Medical School Ioannina Greece
| | - Rene Lutter
- Department of Respiratory Medicine Amsterdam UMC University of Amsterdam Amsterdam The Netherlands
| | - Anna‐Carin Olin
- Section of Occupational and Environmental Medicine Sahlgrenska Academy University of Gothenburg Gothenburg Sweden
| | | | - Angela Simpson
- Division of Infection, Immunity and Respiratory Medicine Faculty of Biology, Medicine and Health Manchester Academic Health Sciences Centre University of Manchester and University Hospital of South Manchester NHS Foundation Trust Manchester UK
| | - Peter J. Sterk
- Department of Respiratory Medicine Amsterdam UMC University of Amsterdam Amsterdam The Netherlands
| | - Ellen Tufvesson
- Department of Clinical Pharmacy and Pharmacology UMCG and QPS‐NL Groningen The Netherlands
| | - Ioana Agache
- Department of Allergy and Clinical Immunology Faculty of Medicine Transylvania University Brasov Brasov Romania
| | - Sven F. Seys
- Allergy and Clinical Immunology Research Group Department of Microbiology, Immunology and Transplantation KU Leuven Leuven Belgium
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Kavati A, Zhdanava M, Ortiz B, Lecocq J, Schiffman B, Pilon D, Ho H, Lefebvre P, Stone B. Retrospective Study on the Association of Biomarkers With Real-world Outcomes of Omalizumab-treated Patients With Allergic Asthma. Clin Ther 2019; 41:1956-1971. [PMID: 31563391 DOI: 10.1016/j.clinthera.2019.07.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Revised: 06/26/2019] [Accepted: 07/27/2019] [Indexed: 12/19/2022]
Abstract
PURPOSE Biomarkers, including blood eosinophils (EoS) and fractional exhaled nitric oxide (FeNO), may affect omalizumab outcomes in allergic asthma, but evidence in the literature remains mixed. This study assessed omalizumab outcomes in real-world patients with allergic asthma stratified by pretreatment biomarker levels. METHODS Patients with allergic asthma aged ≥12 years initiated on omalizumab with ≥12 months of data after index were identified in the Allergy Partners electronic medical records (2007-2018). Patients with ≥1 diagnosis of chronic obstructive pulmonary disease in combination with ≥10 pack-years of smoking, cystic fibrosis, Alpha-1 antitrypsin deficiency, bronchiectasis, interstitial lung disease, and sarcoidosis in the 12 months before or after index were excluded. Patients were stratified by pretreatment EoS (≥/<300 cells/μL) and FeNO (≥/<25 parts per billion). Outcomes, including Asthma Control Test (ACT) scores, forced expiratory volume in 1 second (FEV1), and FEV1 as a percentage of predicted value (FEV1% predicted), were compared using generalized estimating equations at 6 and 12 months after versus before index date in stratified patients with outcome measures available at both time periods. FINDINGS A total of 77 and 86 patients were stratified into the high and low EoS strata, respectively, and 56 patients into each of the intermediate-high and low FeNO strata. Compared with 6 months before index, mean difference (MD) in ACT scores at 6 months after index reached the minimally important difference of ≥3 points in high (MD = 3.75; 95% CI, 2.05-5.45) and low (MD = 4.56; 95% CI, 2.86-6.26) EoS, as well in the intermediate-high (MD = 3.75; 95% CI, 1.95-5.55) and low (MD = 3.55; 95% CI, 1.53-5.57) FeNO strata. Statistically significant improvements in mean FEV1 were observed in the high EoS (MD = 0.22 L/s; 95% CI, 0.08-0.35 L/s) and intermediate-high FeNO (MD = 0.13 L/s; 95% CI, 0.03-0.24 L/s) strata but not in the lower strata. In terms of mean FEV1% predicted, a statistically significant improvement was observed in high EoS stratum (MD = 4.95%; 95% CI, 0.60%-9.30%). Results that compared 12 months after versus before index date were similar. IMPLICATIONS Omalizumab was associated with statistically significant improvements in ACT scores largely reaching or exceeding minimally important difference across biomarker levels and with a statistically significant improvement in lung function more evident in high biomarker strata. Although response varied by biomarkers for some outcomes, all strata indicated improvements on ≥1 measure. Real-world patients with allergic asthma could benefit from omalizumab regardless of pretreatment biomarker levels, suggesting that pretreatment biomarker levels might not inform response.
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Affiliation(s)
| | | | - Benjamin Ortiz
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | - Jason Lecocq
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | | | | | - Harriet Ho
- Analysis Group, Montreal, Quebec, Canada
| | | | - Brian Stone
- Allergy Partners of San Diego, San Diego, CA, USA
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144
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Severe Eosinophilic Asthma. J Clin Med 2019; 8:jcm8091375. [PMID: 31480806 PMCID: PMC6780074 DOI: 10.3390/jcm8091375] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 08/28/2019] [Accepted: 08/29/2019] [Indexed: 12/18/2022] Open
Abstract
Asthma is a heterogeneous disease with varying severity. Severe asthma is a subject of constant research because it greatly affects patients’ quality of life, and patients with severe asthma experience symptoms, exacerbations, and medication side effects. Eosinophils, although at first considered insignificant, were later specifically associated with features of the ongoing inflammatory process in asthma, particularly in the severe case. In this review, we discuss new insights into the pathogenesis of severe asthma related to eosinophilic inflammation and the pivotal role of cytokines in a spectrum that is usually referred to as “T2-high inflammation” that accounts for almost half of patients with severe asthma. Recent literature is summarized as to the role of eosinophils in asthmatic inflammation, airway remodeling, and airway hypersensitivity. Major advances in the management of severe asthma occurred the past few years due to the new targeted biological therapies. Novel biologics that are already widely used in severe eosinophilic asthma are discussed, focusing on the choice of the right treatment for the right patient. These monoclonal antibodies primarily led to a significant reduction of asthma exacerbations, as well as improvement of lung function and patient quality of life.
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145
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Porcaro F, Cutrera R, Pajno GB. Options of immunotherapeutic treatments for children with asthma. Expert Rev Respir Med 2019; 13:937-949. [PMID: 31414917 DOI: 10.1080/17476348.2019.1656533] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Introduction: Asthma is the most common chronic disease in children. Avoiding triggers, and pharmacologic treatment with short acting beta-agonist, inhaler corticosteroids and anti-leukotriene are often enough to obtain symptoms control. Nevertheless, there is a subset of children with severe asthma and poor symptom control despite maximal therapy. In these patients, anti-IgE and anti-IL5 monoclonal antibodies are suggested as the fifth step of Global Initiative for Asthma guidelines. Area covered: Immunotherapeutic treatments are now suggested for asthma management. This article will discuss the available evidence on allergen immunotherapy and biologic drugs in pediatric asthma treatment. Expert opinion: Previously published studies demonstrated a good efficacy and safety profile of Allergen Immunotherapy in patients with mild-moderate asthma and sensitization to one main allergen. New understanding of mechanisms underlying severe asthma inflammation has allowed the identifications of specific biomarkers guiding the clinician in the choice of patient specific drug. Among the suggested immunotherapeutic options, omalizumab (blocking IgE) remains the first choice for atopic 'early onset' asthma in patients aged over 6 years. Instead, mepolizumab (blocking the IL5 ligand) should be considered for 'eosinophilic' asthma. Other biologic drugs are under consideration but data on the pediatric population are still lacking.
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Affiliation(s)
- Federica Porcaro
- Pediatric Pulmonology & Respiratory Intermediate Care Unit, Sleep and Long-Term Ventilation Unit, Department of Pediatrics, Bambino Gesù Children's Hospital , Rome , Italy
| | - Renato Cutrera
- Pediatric Pulmonology & Respiratory Intermediate Care Unit, Sleep and Long-Term Ventilation Unit, Department of Pediatrics, Bambino Gesù Children's Hospital , Rome , Italy
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146
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Koutsokera A, Corriveau S, Sykes J, Coriati A, Cortes D, Vadas P, Chaparro C, McIntyre K, Tullis E, Stephenson AL. Omalizumab for asthma and allergic bronchopulmonary aspergillosis in adults with cystic fibrosis. J Cyst Fibros 2019; 19:119-124. [PMID: 31405730 DOI: 10.1016/j.jcf.2019.07.011] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 07/15/2019] [Accepted: 07/31/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND In cystic fibrosis (CF), omalizumab has been used for difficult-to-treat asthma and allergic bronchopulmonary aspergillosis (ABPA) but safety and efficacy data are limited for this population. METHODS We assessed patients receiving omalizumab for asthma or ABPA in the Toronto adult CF center between 2005 and 2017. We evaluated treatment safety and efficacy by analyzing changes in FEV1% predicted (FEV1pp) max value, slope and variability captured by the area under the curve (AUC), the cumulative dose of systemic corticosteroids (SCS), use of intravenous (IV) antibiotics and hospitalization days before omalizumab and up to 1 year after treatment initiation. Linear mixed effects model was used for FEV1pp slope and the trapezoidal rule for FEV1pp AUC. RESULTS Twenty-seven CF patients received omalizumab, 16 (59.3%) for asthma and 11 (40.7%) for ABPA. No significant omalizumab-related adverse effects were observed. In the asthmatic group, the max value of FEV1pp improved on omalizumab and the cumulative dose of SCS decreased. In the ABPA group, the rate of FEV1pp decline (slope) and the variability of FEV1pp (AUC) improved on omalizumab. In ABPA patients, the cumulative SCS dose was not significantly different but 4 (36%) patients decreased their SCS dose by >50% compared to baseline. Days on IV antibiotics and hospital days did not differ significantly before and while on omalizumab therapy. CONCLUSIONS In adult CF patients with difficult-to-treat asthma or ABPA, omalizumab should be considered. Larger studies are needed to identify patient characteristics that may predict response to omalizumab.
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Affiliation(s)
- Angela Koutsokera
- Division of Respirology, Adult Cystic Fibrosis Centre, St. Michael's Hospital, Toronto, ON, Canada; Division of Pulmonology, Lausanne University Hospital, Lausanne, VD, Switzerland.
| | - Sophie Corriveau
- Division of Respirology, Adult Cystic Fibrosis Centre, St. Michael's Hospital, Toronto, ON, Canada; Division of Respirology, McMaster University, Hamilton, ON, Canada
| | - Jenna Sykes
- Division of Respirology, Adult Cystic Fibrosis Centre, St. Michael's Hospital, Toronto, ON, Canada
| | - Adele Coriati
- Division of Respirology, Adult Cystic Fibrosis Centre, St. Michael's Hospital, Toronto, ON, Canada
| | - Daniel Cortes
- Division of Respirology, Adult Cystic Fibrosis Centre, St. Michael's Hospital, Toronto, ON, Canada
| | - Peter Vadas
- Division of Allergy and Clinical Immunology, St. Michael's Hospital, ON, Canada
| | - Cecilia Chaparro
- Division of Respirology, Adult Cystic Fibrosis Centre, St. Michael's Hospital, Toronto, ON, Canada
| | - Kieran McIntyre
- Division of Respirology, Adult Cystic Fibrosis Centre, St. Michael's Hospital, Toronto, ON, Canada
| | - Elizabeth Tullis
- Division of Respirology, Adult Cystic Fibrosis Centre, St. Michael's Hospital, Toronto, ON, Canada
| | - Anne L Stephenson
- Division of Respirology, Adult Cystic Fibrosis Centre, St. Michael's Hospital, Toronto, ON, Canada
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147
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Maselli DJ, Hanania NA. Management of asthma COPD overlap. Ann Allergy Asthma Immunol 2019; 123:335-344. [PMID: 31376487 DOI: 10.1016/j.anai.2019.07.021] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Revised: 07/21/2019] [Accepted: 07/21/2019] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To review the latest literature on management approaches to patients with asthma chronic obstructive pulmonary disease (COPD) overlap (ACO). DATA SOURCES Studies and reports were identified from the databases of PubMed/Medline and ClinicalTrials.gov from the US National Institutes of Health and the Cochrane Register of Controlled Trials. STUDY SELECTIONS Studies on the management of asthma, COPD, and ACO were included in this review. RESULTS Patients with asthma COPD overlap tend to have greater morbidity than those with asthma or COPD alone, but the information on the best therapeutic approach to this group of patients is still limited. Current treatment recommendations rely on expert opinions, roundtable discussions, and strategy documents, because most clinical studies in asthma and COPD have excluded patients with ACO. Because of the potential risk described in patients with asthma with the use of long-acting 2 agonist monotherapy, initial therapy for patients with ACO is recommended to include a long-acting bronchodilator in conjunction with inhaled corticosteroids. Long-acting muscarinic antagonists are effective in both asthma and COPD and should be considered in ACO as an add-on treatment. If inhaler therapy is not effective, advanced therapies based on phenotyping and identification of treatable traits may be considered. CONCLUSION Few studies have evaluated prospectively therapies in the ACO population, and future studies need to determine best strategies for the treatment of these patients, focusing on targeting its different phenotypes and its treatable traits.
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Affiliation(s)
- Diego Jose Maselli
- Division of Pulmonary Diseases & Critical Care Medicine, Department of Medicine, University of Texas Health at San Antonio, San Antonio, Texas
| | - Nicola Alexander Hanania
- Section of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Baylor College of Medicine, Houston, Texas.
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148
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Just J, Deschildre A, Lejeune S, Amat F. New perspectives of childhood asthma treatment with biologics. Pediatr Allergy Immunol 2019; 30:159-171. [PMID: 30444939 DOI: 10.1111/pai.13007] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 10/30/2018] [Accepted: 11/01/2018] [Indexed: 01/01/2023]
Abstract
Asthma is no longer considered as a single disease but rather as a syndrome corresponding to different entities and pathophysiologic pathways. A targeted strategy is part of personalized medicine which aims to better define each patient's phenotype and endotype so as to prescribe the most suitable treatment at an individual level. Omalizumab and, more recently, mepolizumab are the first biologics approved for children (6-18 years). Omalizumab is now widely used to treat severe allergic asthma in children and is highly effective for asthma exacerbations and asthma control with a good safety profile. Moreover, several other drugs-lebrikizumab, dupilumab, tezepelumab, mepolizumab, reslizumab, benralizumab-are used or are being studied in both teenagers and adults and could benefit younger children in the near future. We hypothesize that defining the asthma phenotype/endotype regarding the type and intensity of inflammation, association with allergic or non-allergic comorbidities, and airway remodeling should contribute to the choice of a specific biologic. Pediatric specificities have to be addressed and validated by studies in children. Long-term effectiveness and particularly the impact on the natural history of asthma should also be investigated. Severe asthma in children is a complex disease, and patients have to be referred to a specialized pediatric asthma center to confirm diagnosis and initiate the best treatment strategy which could include biologics while taking into account their high cost.
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Affiliation(s)
- Jocelyne Just
- Department of Allergology-Centre de l'Asthme et des Allergies, Hôpital d'Enfants Armand Trousseau, Assistance Publique-Hôpitaux de Paris, Paris, France.,UMR-S 1136, Equipe EPAR, INSERM Sorbonne Université, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Paris, France
| | - Antoine Deschildre
- CHU Lille, Pediatric Pulmonology and Allergy Department, Hôpital Jeanne de Flandre, Université Nord de France, Lille, France
| | - Stéphanie Lejeune
- CHU Lille, Pediatric Pulmonology and Allergy Department, Hôpital Jeanne de Flandre, Université Nord de France, Lille, France
| | - Flore Amat
- Department of Allergology-Centre de l'Asthme et des Allergies, Hôpital d'Enfants Armand Trousseau, Assistance Publique-Hôpitaux de Paris, Paris, France.,UMR-S 1136, Equipe EPAR, INSERM Sorbonne Université, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Paris, France
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MacDonald KM, Kavati A, Ortiz B, Alhossan A, Lee CS, Abraham I. Short- and long-term real-world effectiveness of omalizumab in severe allergic asthma: systematic review of 42 studies published 2008-2018. Expert Rev Clin Immunol 2019; 15:553-569. [PMID: 30763137 DOI: 10.1080/1744666x.2019.1574571] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
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.
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Affiliation(s)
| | - Abhishek Kavati
- b Health Economics & Outcomes Research , Novartis , East Hanover , NJ , USA
| | - Benjamin Ortiz
- c Clinical Development & Medical Affairs , Novartis , East Hanover , NJ , USA
| | | | - Christopher S Lee
- a Division of Research , Matrix45 , Tucson , AZ , USA.,e Boston College , Connell School of Nursing , Boston , MA , USA
| | - Ivo Abraham
- a Division of Research , Matrix45 , Tucson , AZ , USA.,f Center for Health Outcomes and Pharmacoeconomic Research , University of Arizona , Tucson , AZ , USA.,g Department of Pharmacy Practice and Science, College of Pharmacy , University of Arizona , Tucson , AZ , USA.,h Department of Family and Community Medicine , College of Medicine - Tucson, University of Arizona , Tucson , AZ , USA
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150
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Cardet JC, Casale TB. New insights into the utility of omalizumab. J Allergy Clin Immunol 2019; 143:923-926.e1. [PMID: 30690050 DOI: 10.1016/j.jaci.2019.01.016] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 12/27/2018] [Accepted: 01/17/2019] [Indexed: 12/13/2022]
Affiliation(s)
- Juan Carlos Cardet
- Department of Internal Medicine, Division of Allergy and Immunology, Morsani College of Medicine, University of South Florida, Tampa, Fla
| | - Thomas B Casale
- Department of Internal Medicine, Division of Allergy and Immunology, Morsani College of Medicine, University of South Florida, Tampa, Fla.
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