The use of biologic therapies for the management of pediatric asthma

The Evolution of Scientific Knowledge in Childhood Asthma over Time: A Surprising History

Asthma is a disease that has been described since the times of Hammurabi. However, it is only since the 1960s that effective therapeutic strategies have been available. Pathogenic mechanisms underlying the disease have been deeply studied, contributing to creating a "patient-specific asthma" definition. Biological drugs have been approved over the last twenty years, improving disease management in patients with severe asthma via a "precision medicine-driven approach". This article aims to describe the evolution of scientific knowledge in childhood asthma, focusing on the most recent biological therapies and their indications for patients with severe asthma.

2022 Year in Review: Pediatric Asthma

Asthma is the most common chronic disease in children. Asthma is a heterogeneous disease characterized by variable, reversible airway obstruction and hyper-responsive airways. There is a high economic burden due to a child having poorly controlled asthma with one or more asthma exacerbations resulting in an emergency department visit or hospitalization in a year. Publications on diagnosis, treatment, and management of pediatric asthma are ongoing with over 2,549 papers published from January-November 2022. The intent of this paper is to summarize 8 key topics that have prompted discussions with local, regional, and national asthma experts due to a shift in clinical practice or lessons learned from the recent pandemic that may have future application.

The burden of systemic corticosteroid use in asthma management in Asia

For most patients, asthma can be effectively managed using inhaled medications. However, patients who have severe and/or uncontrolled asthma, or who experience exacerbations, may require systemic corticosteroids (SCSs) to maintain asthma control. Although SCS are highly effective in this regard, even modest exposure to these medications can increase the risk for long-term, adverse health outcomes, such as type 2 diabetes, renal impairment, cardiovascular disease and overall mortality. Clinical and real-world data from studies investigating asthma severity, control and treatment practices around the globe have suggested that SCS are overused in asthma management, adding to the already substantial healthcare burden experienced by patients. Throughout Asia, although data on asthma severity, control and SCS usage are limited and vary widely among countries, available data strongly suggest a pattern of overuse consistent with the broader global trend. Coordinated changes at the patient, provider, institutional and policy levels, such as increasing disease awareness, promoting better adherence to treatment guidelines and increasing availability of safe and effective alternatives to SCS, are likely necessary to reduce the SCS burden for patients with asthma in Asia.

The use of systemic corticosteroids in asthma management in Latin American countries

The stepwise treatment approach recommended by the Global Initiative for Asthma (GINA) includes systemic corticosteroids (SCS) suggested as a final step if asthma is severe and/or difficult to treat. Yet, despite the effectiveness of SCS, they are also associated with potentially irreversible adverse outcomes such as type 2 diabetes, adrenal suppression, and cardiovascular disease. Based on recent data indicating that the risk of developing these conditions can increase after as few as 4 short-term (burst) courses of SCS, even patients with mild asthma who receive SCS occasionally for exacerbations are also at risk of these events. As a result, recent updates by GINA and the Latin American Thoracic Society recommend decreasing SCS use by optimizing administration of non-SCS therapies and/or increasing the use of alternatives, such as biologic agents. Recent and ongoing studies characterizing treatment patterns among patients with asthma have revealed alarming trends suggesting the widespread overuse of SCS around the world. In Latin America, asthma prevalence is approximately 17%, and data suggest that the majority of patients have uncontrolled disease. In this review, we summarize currently available data on asthma treatment patterns in Latin America, which indicate that SCS are prescribed to 20-40% of patients with asthma considered to be well controlled and over 50% of patients with uncontrolled disease. We also offer potential strategies to help reduce SCS use for asthma in everyday clinical practice.

NORAD Promotes the Viability, Migration, and Phenotypic Switch of Human Vascular Smooth Muscle Cells during Aortic Dissection via LIN28B-Mediated TGF-β Promotion and Subsequent Enhanced Glycolysis

Glucose metabolism reprogramming is an important reason for the functional remodeling, growth, and migration of vascular smooth muscle cells (VSMCs). It is also an important basis for the occurrence and development of aortic dissection (AD), but the specific regulatory factors are not clear. Noncoding RNA activated by DNA damage (NORAD) is dysfunctional in many diseases, but the role of NORAD in AD etiology is unclear. We first established a vascular remodeling cell model of AD, and the expression of NORAD in VSMCs was significantly increased. Functional experiments showed that inhibition of NORAD could downregulate the proliferation and migration of VSMCs. Meanwhile, silencing NORAD could also inhibit the flux of glycolysis, suggesting that NORAD may aggravate AD by promoting glycolysis. In addition, mechanism studies have shown that NORAD can exert VSMCs-regulating function by recruiting LIN28B to bind to TGF-β mRNA, which subsequently facilitates the expression of TGF-β1 (transforming growth factor β1). The recovery experiment also showed that overexpression of TGF-β could reverse the inhibitory effect of NORAD knockdown on VSMCs in terms of proliferation, migration, and glycolysis. Collectively, these results indicated that the NORAD/LIN28B/TGF-β axis promoted cell proliferation and migration through regulating aerobic glycolysis in VSMCs. Therefore, NORAD may regulate the occurrence of AD by affecting the reprogramming of glucose metabolism, and NORAD can be recognized as a good target for VSMC phenotypic intervention and AD treatment.

Biologic Therapies in Pediatric Asthma

Undeniably, childhood asthma is a multifactorial and heterogeneous chronic condition widespread in children. Its management, especially of the severe form refractory to standard therapy remains challenging. Over the past decades, the development of biologic agents and their subsequent approval has provided an advanced and very promising treatment alternative, eventually directing toward a successful precision medicine approach. The application of currently approved add-on treatments for severe asthma in children, namely omalizumab, mepolizumab, benralizumab, dupilumab, and tezepelumab have been shown to be effective in terms of asthma control and exacerbation rate. However, to date, information is still lacking regarding its long-term use. As a result, data are frequently extrapolated from adult studies. Thus, the selection of the appropriate biologic agent, the potential predictors of good asthma response, and the long-term outcome in the pediatric population are still to be further investigated. The aim of the present study was to provide an overview of the current status of the latest evidence about all licensed monoclonal antibodies (mAbs) that have emerged and been applied to the field of asthma management. The innovative future targets are also briefly discussed.

House Dust Mite Subcutaneous Immunotherapy and Lung Function Trajectory in Children and Adolescents with Asthma

Background: Allergen-specific immunotherapy is currently the only disease-modifying treatment for allergic asthma, and it has been shown to improve control of asthma while reducing both drug use and asthma exacerbations. However, its effects on lung function—especially its long-term effects—remain controversial. We aimed to identify factors associated with a possible beneficial effect of allergen-specific immunotherapy on lung function in asthma by retrospectively evaluating the long-term changes in lung function in children with asthma who received house dust mite subcutaneous immunotherapy (HDM-SCIT). Methods: We enrolled children with asthma who had undergone HDM-SCIT for more than 1 year. Clinical information and lung function measurements were retrieved from the electronic chart system. To characterize the trajectory of lung function change, we performed linear regression analysis to evaluate the maximal expiratory flow at 50% of the forced vital capacity during two periods: before and during HDM-SCIT. Slopes from a least-squares regression line for the two periods, i.e., S1 before HDM-SCIT and S2 during HDM-SCIT, were compared. The subjects were then classified into two groups: an improving group (Group I) defined as S2 − S1 > 0, and a declining group (Group D) defined as S2 − S1 < 0. The clinical factors at the start of HDM-SCIT were compared between the two groups. Results: A total of 16 patients were analyzed. Eight patients were classified into each of Group I and Group D. The mean ages were 10.5 and 11.8 years, and the mean treatment periods were 4.1 and 3.9 years. Group I had a significantly lower blood eosinophil count and a significantly higher HDM-specific IgE level than Group D. Logistic regression showed a strong relationship between those two markers and the lung function trajectory. Conclusion: Control of the blood eosinophil count in highly HDM-sensitized patients may increase the beneficial effect of HDM-SCIT on lung function.

Precision medicine in pediatric severe asthma: Targeted blockade of type 2 inflammation

A study by Bacharier et al. demonstrated that children with uncontrolled moderate-to-severe asthma with elevated type 2 biomarkers who received dupilumab had fewer exacerbations and better lung function.¹ These results highlight precision medicine approaches in pediatric asthma.

Asthma in paediatric intensive care in England residents: observational study

Despite high prevalence of asthma in children in the UK, there were no prior report on asthma admissions in paediatric intensive care units (PICU). We investigated the epidemiology and healthcare resource utilisation in children with asthma presenting to PICUs in England. PICANet, a UK national PICU database, was queried for asthma as the primary reason for admission, of children resident in England from April 2006 until March 2013. There were 2195 admissions to PICU for a median stay of 1.4 days. 59% were males and 51% aged 0–4 years. The fourth and fifth most deprived quintiles represented 61% (1329) admissions and 73% (11) of the 15 deaths. Deaths were most frequent in 10–14 years age (n = 11, 73%), with no deaths in less than 5 years age. 38% of admissions (828/2193) received invasive ventilation, which was more frequent with increasing deprivation (13% (108/828) in least deprived to 31% (260/828) in most deprived) and with decreasing age (0–4-year-olds: 49%, 409/828). This first multi-centre PICU study in England found that children from more deprived neighbourhoods represented the majority of asthma admissions, invasive ventilation and deaths in PICU. Children experiencing socioeconomic deprivation could benefit from enhanced asthma support in the community.

Expert meeting report: towards a joint European roadmap to address the unmet needs and priorities of paediatric asthma patients on biologic therapy

A digital multidisciplinary European expert meeting took place on the 9 July 2020 to identify the unmet needs of paediatric severe asthma patients, and set the priorities for clinical and research activities ahead https://bit.ly/3CeLBHB.

Are we overcoming our inability to have pediatric patients properly use inhaled corticosteroids by inappropriately escalating their therapy?

OBJECTIVE

To perform a narrative review to describe and discuss potential methods and strategies for effectively assessing and dealing with poor adherence and/or misuse of inhalers in difficult-to-treat pediatric asthmatic patients.

DATA SOURCES

Articles available in electronic databases, published from inception to April 2021.

STUDY SELECTIONS

Relevant articles in the literature that discuss and analyze potential methods and strategies for effectively assessing and dealing with poor adherence and/or misuse of inhalers in difficult-to-treat pediatric asthmatic patients.

RESULTS

Validated self-reported questionnaires, weighing inhaler canisters, and pharmacy records might be the most suitable methods for assessing adherence to inhaled controller therapy in clinical practice. Additionally, validated instruments could be used as an objective measurement of the adequacy of inhaler technique. Finally, empathy and a true and strong physician-parent/patient partnership have a more powerful influence on adherence than almost any other factor, and they are probably the most cost-effective methods not only for detecting poor adherence to controller therapy but also for dealing with and improving it.

CONCLUSIONS

Failure to detect or effectively handle nonadherence and/or inhaler misuse in a patient with uncontrolled asthma can mislead clinicians into thinking that the patient is nonresponsive to the original less-intensive therapy, resulting in unneeded dosage increases and/or escalation of controller therapy to more costly medications, in some cases reaching the level of biologic therapy.

Risk factors associated with health-related quality of life in pediatric asthma

To evaluate the quality of life (QOL) of children with asthma and analyze the related factors. A total of 360 children diagnosed with asthma were enrolled. We conducted the pediatric asthma quality of life questionnaire (PAQLQ). The differences in clinical characteristics between the two groups were compared. Clinical characteristics were compared between high and low QOL. More female was observed in low QOL group (p = 0.013). Patients with higher income (p = 0.003) were shown with higher QOL. Female patients presented significantly lower values for activity limitation (p = 0.016) and emotional function (p = 0.016) as compared to male patients. For patients who have low income, the QOL scores for dimensions of activity limitation was significantly worse than those have higher income (p = 0.001). Univariable results showed that gender (p = 0.013) and income (p = 0.001) were factors associated with QOL in asthma children. However, multivariate analysis suggested that only gender (OR = 0.558, p = 0.008) and income (OR = 1.762, p < 0.001) were the independent factors that affected the QOL levels. In this study, we found that the QOL dimensions of pediatric asthma differed between various subpopulations. For patients with risk factors of poor QOL, target intervention is advised in order to increase QOL.

Combination Anti-IgE and Anti-IL5 Therapy in a Pediatric Patient With Severe Persistent Asthma

Biologic agents, including anti-immunoglobulin E (omalizumab) and anti-interleukin 5 (mepolizumab), target different mediators involved in the inflammatory process and may work synergistically to decrease symptoms in patients with severe asthma. Here we describe a 12-year-old female on 2 biologic agents, omalizumab and mepolizumab, to control severe persistent asthma. Omalizumab was started years earlier with an initial response; however, her asthma again became uncontrolled and mepolizumab was added. Both biologics were administered concomitantly for over 6 months with marked improvement of asthma symptoms without significant side effects. A combination of biologic agents may be a potential therapy for pediatric patients with severe persistent asthma that remains uncontrolled on a single agent.

German regional variation of acute and high oral corticosteroid use for asthma

OBJECTIVE: 

To improve understanding of real-world asthma treatment and inform physician education, we evaluated regional variation in asthma prevalence and oral corticosteroid (OCS) use across Germany.

METHODS: 

We developed a machine learning gradient-boosted tree model with IMS® Disease Analyzer electronic medical records, which cover 3% of German patients. This model had a 91% accuracy in predicting the presence of asthma and chronic obstructive pulmonary disease. We applied the model to the IMS^® Longitudinal Prescription database, with 82% national coverage, to classify patients receiving treatment for airflow obstruction from October 2017-September 2018 in 63 regions in Germany.

RESULTS: 

Of 2.4 million individuals under statutory health insurance predicted to have asthma, 13.7%, 18.7%, 36.5%, 29.4%, and 1.7% received treatment classified as Global Initiative for Asthma (GINA) Steps 1, 2, 3, 4, and 5, respectively. Approximately 7-15% of those at GINA Steps 1-4 and 35% at Step 5 treatment received ≥1 acute OCS prescription (duration <10 days). Of patients receiving GINA Steps 1-4 and Step 5 treatments, 1-3% and 86%, respectively, received ≥1 high-dosage OCS prescription. Cumulative OCS dosage and percentages of patients receiving OCS differed substantially across regions, and regions with lower OCS use had greater use of biologic therapies.

CONCLUSIONS: 

Both acute and high OCS use varied regionally across Germany, with overall use suggesting patients are considerable risk of adverse effects and long-term health consequences.

Supplemental data for this article can be accessed at publisher's website.

Biologics to Treat Severe Asthma in Children and Adolescents: A Practical Update

Background: Severe asthma represents a significant challenge for children and adolescents. At the same time, it often places a burden on patients, caregivers, and society, mainly related to morbidity, mortality, and health care resources. In children and adolescents, severe asthma is mostly characterized by type 2 inflammation, which leads to bronchial eosinophilia that may be suppressed by corticosteroids. However, in this age group, a high dosage of inhaled corticosteroids combined with systemic corticosteroids sometimes results in unacceptable side effects, such as reduced growth velocity and reduced bone mineral density. Therefore, there is increasing and enthusiastic interest in today's biologics, including omalizumab, mepolizumab, reslizumab, benralizumab, and dupilumab. There is growing evidence that they may be effective and safe add-on options for children and adolescents. In 2009, omalizumab was approved by the European Medicines Agency as the first available therapeutic option for allergic asthma in patients as young as 6 years of age, followed by a similar approval by the U.S. Food and Drug Administration in 2016. Previously, omalizumab was marketed for this indication in patients ≥ age 12. Subsequent biologics, namely mepolizumab, reslizumab, and benralizumab, are IL-5 targeted agents that are presently approved in some countries for severe eosinophilic asthma starting at 6 years of age. Dupilumab is targeted against the IL-4 receptor α-chain, and it has been approved in the United States and the European Union as an add-on maintenance therapy in patients ≥12 years of age. Conclusion: This review presents the most recent evidence on approved biologics for the treatment of severe asthma and discusses the unmet needs and future perspective, focusing on the pediatric and adolescent age groups.

Challenges in managing difficult-to-treat asthma in children: Stop, look, and listen

It is recognized that asthma places a significant economic burden on the United States, with a total cost of $81.9 billion total costs including costs incurred by absenteeism and mortality. Severe asthma places a large burden of morbidity on children and their caregivers, including severe exacerbations, medication side effects, increased missed school days leading to impaired school performance, and lower caregiver quality of life. Therefore, we need to take a careful look at how we can make asthma care more efficient and cost effective, especially for those children with severe asthma. The 2019 American Thoracic Society symposium reported in this theme issue presented four aspects of managing severe asthma in children that merit attention including patient variables that affect severe asthma, understanding patient behaviors around medications, the appropriate use of bronchoscopy in diagnosis and management of severe asthma, and also the rational use of biologic therapy. This editorial will summarize key points in each of these reviews and prompt a more careful reading of each contribution.