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Bender B, Oppenheimer J, George M, Brown R, Patel A, Hill T, Boe A, Mayen Herrera E, Dotiwala Z, Casciano J, Bernstein JA. Assessment of Real-World Escalation to Biologics in US Patients With Asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:2941-2948. [PMID: 35931363 DOI: 10.1016/j.jaip.2022.07.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 07/08/2022] [Accepted: 07/14/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Previous studies indicate that suboptimal medication adherence may contribute to uncontrolled asthma. Global Initiative for Asthma (GINA) guidelines recommend treatment escalation to biologics for patients with uncontrolled asthma despite adherence to high-dose maintenance medication and who have eosinophilic/allergic biomarkers or require maintenance oral corticosteroids. OBJECTIVE This study aimed to describe the clinical status of patients with asthma escalated to biologic therapy. METHODS This retrospective claims database analysis enrolled US patients with asthma who were escalated to biologics between January 2016 and June 2020. Exacerbations, control status, GINA step, and maintenance medication adherence during the 12 months before biologic therapy initiation were analyzed. Asthma control was assessed using both the European Respiratory Society/American Thoracic Society (ERS/ATS) and Stempel criteria. Adherence was defined as the proportion of days covered (PDC) by maintenance medication claims. RESULTS Of 1786 patients escalated to biologics, 506 were included for analysis. During the 12 months before escalation, 346 patients had confirmed exacerbations. Uncontrolled asthma status was estimated in 55% and 70% of patients (ERS/ATS and Stempel criteria, respectively). GINA step was inferred for 395 patients: 154 were at step 2, 11 at step 3, 104 at step 4, and 126 at step 5. Of 403 patients with maintenance medication claims, 63% had suboptimal maintenance medication adherence (PDC <80%). CONCLUSION In this study, most patients initiating biologic therapy had mild-to-moderate asthma or suboptimal maintenance medication adherence, possibly indicating inappropriate escalation. Incorporating objective medication adherence monitoring into existing guidelines may reduce inappropriate escalation to biologics.
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Affiliation(s)
- Bruce Bender
- Center for Health Promotion, National Jewish Health, Denver, Colo
| | - John Oppenheimer
- Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ; Pulmonary and Allergy Associates, Department of Medicine, Cedar Knolls, NJ
| | - Maureen George
- Department of Nursing, Columbia University School of Nursing, New York, NY
| | - Randall Brown
- Respiratory, Teva Branded Pharmaceutical Products R&D Inc, Parsippany, NJ
| | - Ayush Patel
- Respiratory, Teva Branded Pharmaceutical Products R&D Inc, Parsippany, NJ
| | - Tanisha Hill
- Respiratory, Teva Branded Pharmaceutical Products R&D Inc, Parsippany, NJ
| | - Amanda Boe
- Respiratory, Teva Branded Pharmaceutical Products R&D Inc, Parsippany, NJ
| | | | | | | | - Jonathan A Bernstein
- Department of Internal Medicine, Division of Immunology/Allergy Section, University of Cincinnati College of Medicine, Cincinnati, Ohio.
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The Role of Access and Cost-Effectiveness in Managing Asthma: A Systematic Review. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY: IN PRACTICE 2022; 10:2109-2116. [PMID: 35525532 PMCID: PMC9353043 DOI: 10.1016/j.jaip.2022.04.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Revised: 03/25/2022] [Accepted: 04/12/2022] [Indexed: 12/21/2022]
Abstract
Background Inconsistent and unequal access to medical care is an issue that predates the COVID19 pandemic, which only worsened the problem. Limited access to care from asthma specialists and other specialists treating comorbid diseases may adversely affect asthma. Objective The purpose of this review is to identify health disparities associated with access to care for asthma, and cost-effectiveness of therapies and interventions addressing this health disparity. Methods A narrative systematic review was undertaken using MeSH searches of English language articles published in CINAHL, Scopus, or PubMed. Results A total of 725 articles were identified. Barriers recognized from the literature included access to diagnostic spirometry, access to specialists, medication formulary restrictions, and issues leading to medical nonadherence. Telemedicine, school-based health care interventions, digital applications, and non–office-based digital spirometry could be used to address these gaps in access to asthma care while potentially being cost-effective. Conclusion With the widespread adoption of telemedicine because of the pandemic, and adoption of other mobile services, we now have potential tools that can increase access to asthma care, which can help address this health care inequity. Evidence is limited, but favorable, that some of these tools may be cost-effective.
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Couillard S, Pavord ID, Heaney LG, Petousi N, Hinks TSC. Sub-stratification of type-2 high airway disease for therapeutic decision-making: A 'bomb' (blood eosinophils) meets 'magnet' (FeNO) framework. Respirology 2022; 27:573-577. [PMID: 35591794 PMCID: PMC9541235 DOI: 10.1111/resp.14294] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 05/05/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Simon Couillard
- Respiratory Medicine Unit and Oxford Respiratory NIHR BRC, Nuffield Department of MedicineUniversity of Oxford, Old Road CampusOxfordUK
- Faculté de Médecine et des Sciences de la SantéUniversité de SherbrookeSherbrookeQuébecCanada
| | - Ian D. Pavord
- Respiratory Medicine Unit and Oxford Respiratory NIHR BRC, Nuffield Department of MedicineUniversity of Oxford, Old Road CampusOxfordUK
| | - Liam G. Heaney
- Centre for Experimental MedicineQueen's University Belfast School of Medicine Dentistry and Biomedical SciencesBelfastUK
| | - Nayia Petousi
- Respiratory Medicine Unit and Oxford Respiratory NIHR BRC, Nuffield Department of MedicineUniversity of Oxford, Old Road CampusOxfordUK
| | - Timothy S. C. Hinks
- Respiratory Medicine Unit and Oxford Respiratory NIHR BRC, Nuffield Department of MedicineUniversity of Oxford, Old Road CampusOxfordUK
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Managing T2-high severe asthma in HIV-infected patients. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:1041-1043. [PMID: 33551031 DOI: 10.1016/j.jaip.2020.11.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Accepted: 11/06/2020] [Indexed: 12/28/2022]
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Shaker M, Briggs A, Dbouk A, Dutille E, Oppenheimer J, Greenhawt M. Estimation of Health and Economic Benefits of Clinic Versus Home Administration of Omalizumab and Mepolizumab. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 8:565-572. [PMID: 31626991 DOI: 10.1016/j.jaip.2019.09.037] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 09/16/2019] [Accepted: 09/25/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Biologic therapy is a paradigm-shifting management strategy for many patients with asthma and chronic urticaria, but concerns for therapy-associated anaphylaxis may limit access to these therapies for patients unable to travel to medical clinics. OBJECTIVE To characterize the cost-effectiveness of in-clinic versus at-home biologic therapy with omalizumab and mepolizumab. METHODS Economic evaluation using microsimulations was performed from societal and health care sector perspectives for patients with asthma or chronic spontaneous urticaria receiving omalizumab or mepolizumab in an allergy clinic, primary care provider (PCP) office, or at home over a 1-year time horizon (12 injections per year in each base case with sensitivity analysis to 24 injections per year). Travel times and distances were applied to a population attending a tertiary care allergy clinic in Northern New England receiving omalizumab or mepolizumab, using a willingness-to-pay value of $10 million per death prevented and in-clinic administration reducing anaphylaxis fatality and hospitalization 10- to100-fold. Deterministic and probabilistic sensitivity analyses were performed. RESULTS One-way allergy clinic travel distances significantly exceeded local PCP offices (49 miles, 95% CI, 42-56, vs 12 miles, 95% CI, 10-15). In the omalizumab societal analysis, annual PCP and allergy clinic administration cost $1369.14 (mean) ± $51.33 (SD) and $1916.68 ± $40.86, respectively. Small reductions in medication-related fatalities with in-clinic administration were offset by the potential increase in automobile fatalities resulting from traveling to the allergy clinic (14.6 ± 15.0 per million person-years for this strategy). Compared with at-home administration, in-clinic omalizumab administration was not cost-effective, with an incremental cost-effectiveness ratio of $500,648,430 (PCP), and with allergy clinic administration dominated by higher costs and automobile-related fatalities. Routine mepolizumab clinic administration was dominated by at-home administration unless anaphylaxis rates or self-administration teaching costs were high. CONCLUSIONS For many patients, at-home administration of omalizumab or mepolizumab may be a cost-effective strategy.
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Affiliation(s)
- Marcus Shaker
- Dartmouth-Hitchcock Medical Center, Section of Allergy and Immunology, Lebanon, NH; Dartmouth Geisel School of Medicine, Hanover, NH.
| | - Aaron Briggs
- Dartmouth Geisel School of Medicine, Hanover, NH
| | - Ahmad Dbouk
- Dartmouth Geisel School of Medicine, Hanover, NH
| | - Emily Dutille
- Dartmouth-Hitchcock Medical Center, Section of Allergy and Immunology, Lebanon, NH; Dartmouth Geisel School of Medicine, Hanover, NH
| | | | - Matthew Greenhawt
- Children's Hospital Colorado, University of Colorado School of Medicine, Section of Allergy and Immunology, Food Challenge and Research Unit, Aurora, Colo
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Farzan N, Vijverberg SJ, Kabesch M, Sterk PJ, Maitland-van der Zee AH. The use of pharmacogenomics, epigenomics, and transcriptomics to improve childhood asthma management: Where do we stand? Pediatr Pulmonol 2018; 53:836-845. [PMID: 29493882 DOI: 10.1002/ppul.23976] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2017] [Accepted: 02/01/2018] [Indexed: 01/11/2023]
Abstract
Asthma is a complex multifactorial disease and it is the most common chronic disease in children. There is a high variability in response to asthma treatment, even in patients with good adherence to maintenance treatment, and a correct inhalation technique. Distinct underlying disease mechanisms in childhood asthma might be the reason of this heterogeneity. A deeper knowledge of the underlying molecular mechanisms of asthma has led to the recent development of advanced and mechanism-based treatments such as biologicals. However, biologicals are recommended only for patients with specific asthma phenotypes who remain uncontrolled despite high dosages of conventional asthma treatment. One of the main unmet needs in their application is lack of clinically available biomarkers to individualize pediatric asthma management and guide treatment. Pharmacogenomics, epigenomics, and transcriptomics are three omics fields that are rapidly advancing and can provide tools to identify novel asthma mechanisms and biomarkers to guide treatment. Pharmacogenomics focuses on variants in the DNA, epigenomics studies heritable changes that do not involve changes in the DNA sequence but lead to alteration of gene expression, and transcriptomics investigates gene expression by studying the complete set of mRNA transcripts in a cell or a population of cells. Advances in high-throughput technologies and statistical tools together with well-phenotyped patient inclusion and collaborations between different centers will expand our knowledge of underlying molecular mechanisms involved in disease onset and progress. Furthermore, it could help to select and stratify appropriate therapeutic strategies for subgroups of patients and hopefully bring precision medicine to daily practice.
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Affiliation(s)
- Niloufar Farzan
- Department of Respiratory Medicine, Academic Medical Center (AMC), University of Amsterdam, Amsterdam, The Netherlands
| | - Susanne J Vijverberg
- Department of Respiratory Medicine, Academic Medical Center (AMC), University of Amsterdam, Amsterdam, The Netherlands
| | - Michael Kabesch
- Department of Pediatric Pneumology and Allergy, University Children's Hospital Regensburg (KUNO), Regensburg, Germany
| | - Peter J Sterk
- Department of Respiratory Medicine, Academic Medical Center (AMC), University of Amsterdam, Amsterdam, The Netherlands
| | - Anke H Maitland-van der Zee
- Department of Respiratory Medicine, Academic Medical Center (AMC), University of Amsterdam, Amsterdam, The Netherlands
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Lee J, Tay TR, Radhakrishna N, Hore-Lacy F, Mackay A, Hoy R, Dabscheck E, O'Hehir R, Hew M. Nonadherence in the era of severe asthma biologics and thermoplasty. Eur Respir J 2018. [PMID: 29519922 PMCID: PMC5884695 DOI: 10.1183/13993003.01836-2017] [Citation(s) in RCA: 79] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Nonadherence to inhaled preventers impairs asthma control. Electronic monitoring devices (EMDs) can objectively measure adherence. Their use has not been reported in difficult asthma patients potentially suitable for novel therapies, i.e. biologics and bronchial thermoplasty.Consecutive patients with difficult asthma were assessed for eligibility for novel therapies. Medication adherence, defined as taking >75% of prescribed doses, was assessed by EMD and compared with standardised clinician assessment over an 8-week period.Among 69 difficult asthma patients, adherence could not be analysed in 13, due to device incompatibility or malfunction. Nonadherence was confirmed in 20 out of 45 (44.4%) patients. Clinical assessment of nonadherence was insensitive (physician 15%, nurse 28%). Serum eosinophils were higher in nonadherent patients. Including 11 patients with possible nonadherence (device refused or not returned) increased the nonadherence rate to 31 out of 56 (55%) patients. Severe asthma criteria were fulfilled by 59 out of 69 patients. 47 were eligible for novel therapies, with confirmed nonadherence in 16 out of 32 (50%) patients with EMD data; including seven patients with possible nonadherence increased the nonadherence rate to 23 out of 39 (59%).At least half the patients eligible for novel therapies were nonadherent to preventers. Nonadherence was often undetectable by clinical assessments. Preventer adherence must be confirmed objectively before employing novel severe asthma therapies.
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Affiliation(s)
- Joy Lee
- Allergy, Asthma and Clinical Immunology, The Alfred Hospital, Melbourne, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Tunn Ren Tay
- Allergy, Asthma and Clinical Immunology, The Alfred Hospital, Melbourne, Australia
| | - Naghmeh Radhakrishna
- Allergy, Asthma and Clinical Immunology, The Alfred Hospital, Melbourne, Australia
| | - Fiona Hore-Lacy
- Allergy, Asthma and Clinical Immunology, The Alfred Hospital, Melbourne, Australia
| | - Anna Mackay
- Allergy, Asthma and Clinical Immunology, The Alfred Hospital, Melbourne, Australia
| | - Ryan Hoy
- Allergy, Asthma and Clinical Immunology, The Alfred Hospital, Melbourne, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Eli Dabscheck
- Allergy, Asthma and Clinical Immunology, The Alfred Hospital, Melbourne, Australia.,Allergy, Immunology and Respiratory Medicine, Central Clinical School, Monash University, Melbourne, Australia
| | - Robyn O'Hehir
- Allergy, Asthma and Clinical Immunology, The Alfred Hospital, Melbourne, Australia.,Allergy, Immunology and Respiratory Medicine, Central Clinical School, Monash University, Melbourne, Australia
| | - Mark Hew
- Allergy, Asthma and Clinical Immunology, The Alfred Hospital, Melbourne, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
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Desai M, Oppenheimer J. Biologics in allergic and immunologic diseases: Promises and challenges in the era of personalized medicine. Ann Allergy Asthma Immunol 2018; 120:350-353. [PMID: 29421313 DOI: 10.1016/j.anai.2018.01.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Revised: 01/29/2018] [Accepted: 01/30/2018] [Indexed: 12/20/2022]
Affiliation(s)
- Mauli Desai
- Division of Clinical Immunology, Icahn School of Medicine at Mount Sinai, New York, New York.
| | - John Oppenheimer
- Department of Medicine, Rutgers New Jersey Medical School, Newark, New Jersey
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Matera MG, Calzetta L, Rinaldi B, Cazzola M. Pharmacokinetic/pharmacodynamic drug evaluation of benralizumab for the treatment of asthma. Expert Opin Drug Metab Toxicol 2017; 13:1007-1013. [PMID: 28737051 DOI: 10.1080/17425255.2017.1359253] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION In many severe asthmatics, eosinophils cause inflammation and airways hyperresponsiveness, resulting in frequent exacerbations, impaired lung function, and reduced quality of life. Interleukin-5 (IL-5) is a key cytokine for eosinophil growth, differentiation, recruitment, activation, and survival. Anti-IL-5-based therapies (mepolizumab and reslizumab are humanized monoclonal antibodies (hmAbs) that recognize free IL-5, benralizumab is a hmAb directed at the α subunit of the IL-5R) target the IL-5-signaling in eosinophilic asthma. Areas covered: The pharmacodynamic/pharmacokinetic profile of benralizumab and how it provided indications that permitted optimization of the design and timelines of the pivotal trials are described. Expert opinion: Benralizumab has the advantage over other anti-IL-5 therapies to target the IL-5Rα itself. Afucosylation enhances its interaction with its binding site and facilitates its pharmacological activity. Other benefits of benralizumab are fast (within 24 h) depletion of peripheral blood eosinophils, potent suppressive activity of bone marrow eosinophils and eosinophil precursors, tissue eosinophil apoptosis regardless of the presence of eosinophil survival factors and even at low IL-5R densities. The fact that benralizumab is dosed subcutaneously and is equally effective when given every eight weeks instead than every four weeks provides patients with convenience of self-administration and make it appealing for patients who dislike injections.
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Affiliation(s)
- Maria Gabriella Matera
- a Department of Experimental Medicine , University of Campania Luigi Vanvitelli , Naples , Italy
| | - Luigino Calzetta
- b Department of Systems Medicine , University of Rome Tor Vergata , Rome , Italy
| | - Barbara Rinaldi
- a Department of Experimental Medicine , University of Campania Luigi Vanvitelli , Naples , Italy
| | - Mario Cazzola
- b Department of Systems Medicine , University of Rome Tor Vergata , Rome , Italy
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10
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O'Byrne PM. Rebuttal From Dr O'Byrne. Chest 2016; 151:20-21. [PMID: 27746206 DOI: 10.1016/j.chest.2016.09.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Accepted: 09/20/2016] [Indexed: 11/19/2022] Open
Affiliation(s)
- Paul M O'Byrne
- Firestone Institute of Respiratory Health and the Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada.
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