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Lewthwaite H, Gibson PG, Guerrero PDU, Smith A, Clark VL, Vertigan AE, Hiles SA, Bailey B, Yorke J, McDonald VM. Understanding Breathlessness Burden and Psychophysiological Correlates in Asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024:S2213-2198(24)00642-1. [PMID: 38906398 DOI: 10.1016/j.jaip.2024.06.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Revised: 06/05/2024] [Accepted: 06/10/2024] [Indexed: 06/23/2024]
Abstract
BACKGROUND Breathlessness is a disabling symptom, with complexity that is often under-recognized and undertreated in asthma. OBJECTIVE To highlight the burden of breathlessness in people with severe compared with mild-to-moderate asthma and identify psychophysiological correlates of breathlessness. METHODS This was a cross-sectional study of people with mild-to-severe asthma, who attended 2 in-person visits to complete a multidimensional assessment. The proportion of people with mild-to-moderate versus severe asthma who reported physically limiting breathlessness (modified Medical Research Council [mMRC] dyspnea score ≥2) was compared. Psychophysiological factors associated with breathlessness in people with asthma were identified via a directed acyclic graph and explored with multivariate logistic regression to predict breathlessness. RESULTS A total of 144 participants were included, of whom, 74 (51%) had mild-to-moderate asthma and 70 (49%) severe asthma. Participants were predominantly female (n = 103, 72%) with a median (quartile 1, quartile 3) age of 63.4 (50.5, 69.5) years and body mass index (BMI) of 31.3 (26.2, 36.0) kg/m2. The proportion of people reporting mMRC ≥2 was significantly higher in those with severe- (n = 37, 53%) than those with mild-to-moderate (n = 21, 31%) asthma (P = .013). Dyspnoea-12 Total (8.00 [4.75, 17.00] vs 5.00 [2.00, 11.00], P = .037) score was also significantly higher in the severe asthma group. Significant predictors of physically limiting breathlessness were BMI, asthma control, exercise capacity, and hyperventilation symptoms. Airflow limitation and type 2 inflammation were poor breathlessness predictors. CONCLUSIONS Over half of people with severe asthma experience physically limiting breathlessness despite treatment. Targeting psychophysiological factors, or traits, associated with breathlessness may help relieve this distressing symptom, which is of high priority to people with asthma.
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Affiliation(s)
- Hayley Lewthwaite
- Centre for Research Excellence in Treatable Traits, College of Health, Medicine, and Wellbeing, University of Newcastle, New Lambton Heights, NSW, Australia; Asthma and Breathing Research Program, Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
| | - Peter G Gibson
- Centre for Research Excellence in Treatable Traits, College of Health, Medicine, and Wellbeing, University of Newcastle, New Lambton Heights, NSW, Australia; Asthma and Breathing Research Program, Hunter Medical Research Institute, New Lambton Heights, NSW, Australia; Department of Respiratory and Sleep Medicine, John Hunter Hospital, New Lambton Heights, NSW, Australia
| | - Paola D Urroz Guerrero
- Centre for Research Excellence in Treatable Traits, College of Health, Medicine, and Wellbeing, University of Newcastle, New Lambton Heights, NSW, Australia; Asthma and Breathing Research Program, Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
| | - Amber Smith
- Centre for Research Excellence in Treatable Traits, College of Health, Medicine, and Wellbeing, University of Newcastle, New Lambton Heights, NSW, Australia; Asthma and Breathing Research Program, Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
| | - Vanessa L Clark
- Centre for Research Excellence in Treatable Traits, College of Health, Medicine, and Wellbeing, University of Newcastle, New Lambton Heights, NSW, Australia; Asthma and Breathing Research Program, Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
| | - Anne E Vertigan
- Centre for Research Excellence in Treatable Traits, College of Health, Medicine, and Wellbeing, University of Newcastle, New Lambton Heights, NSW, Australia; Asthma and Breathing Research Program, Hunter Medical Research Institute, New Lambton Heights, NSW, Australia; Speech Pathology Department, John Hunter Hospital, New Lambton Heights, NSW, Australia
| | - Sarah A Hiles
- Asthma and Breathing Research Program, Hunter Medical Research Institute, New Lambton Heights, NSW, Australia; School of Psychological Sciences, University of Newcastle, Callaghan, NSW, Australia
| | - Brooke Bailey
- Centre for Research Excellence in Treatable Traits, College of Health, Medicine, and Wellbeing, University of Newcastle, New Lambton Heights, NSW, Australia; Asthma and Breathing Research Program, Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
| | - Janelle Yorke
- School of Nursing, Faculty of Health Sciences, Polytechnic University, Hong Kong, Hong Kong; School of Nursing, Midwifery and Social Work, Faculty of Biology, Medicine and Health, the University of Manchester, Manchester, United Kingdom
| | - Vanessa M McDonald
- Centre for Research Excellence in Treatable Traits, College of Health, Medicine, and Wellbeing, University of Newcastle, New Lambton Heights, NSW, Australia; Asthma and Breathing Research Program, Hunter Medical Research Institute, New Lambton Heights, NSW, Australia; Department of Respiratory and Sleep Medicine, John Hunter Hospital, New Lambton Heights, NSW, Australia.
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Amat F. [Biologics in severe childhood asthma]. Rev Mal Respir 2023; 40:675-683. [PMID: 37749027 DOI: 10.1016/j.rmr.2023.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 06/20/2023] [Indexed: 09/27/2023]
Abstract
INTRODUCTION Severe asthma in children remains relatively rare. It is no longer considered as a single disease but rather as a syndrome corresponding to different phenotypes and distinct pathophysiological pathways. Various biomarkers can contribute to phenotyping, essentially specific IgE test results, blood eosinophil counts, the exhaled fraction of NO (FeNO) assay, as well as deep lung biomarkers from induced sputum, bronchoalveolar lavage or bronchial biopsy. STATE OF KNOWLEDGE In children, the biologics currently approved for severe asthma are omalizumab, mepolizumab and dupilumab from the age of 6, and tezepelumab from the age of 12. PERSPECTIVES Benralizumab and tezepelumab offer promising perspectives and a pediatric extension could be of interest in future treatment of severe pediatric asthma. CONCLUSIONS Based on physiopathological mechanisms, biologics represent a new and promising approach in the treatment of asthma. That said, the long-term efficacy and impact of these treatments on the natural history of the disease require further investigation. It is of paramount importance to take into account the specificities of pediatric asthma and, more particularly, to conduct clinical trials in younger patients.
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Affiliation(s)
- F Amat
- Service de pneumologie et d'allergologie pédiatrique, CRCM, hôpital Robert-Debré, AP-HP, 48, boulevard Sérurier, 75019 Paris, France; Inserm 1018, Centre de recherche en épidémiologie et santé des populations, épidémiologie respiratoire intégrative, Villejuif, France.
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Walsh GM. Recent developments in the use of monoclonal antibodies targeting the type 2 cytokines for severe asthma treatment. ADVANCES IN PHARMACOLOGY (SAN DIEGO, CALIF.) 2023; 98:31-54. [PMID: 37524491 DOI: 10.1016/bs.apha.2023.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/02/2023]
Abstract
Severe or refractory asthma is seen in approximately 5% of asthmatic subjects who have unsatisfactory symptom control despite adherence to high-dose inhaled glucocorticoid therapies resulting in significant morbidity, reduced quality of life with attendant implications for healthcare costs. Marked heterogeneity in symptoms and at the molecular phenotypic level are hallmarks of asthma resulting in the requirement of specifically targeted treatments to block the key pathways of the disease. Monoclonal antibody (mAb)-based biologics targeted at inhibition of the type 2 cytokines IL-4, IL-5 and IL-13 have become established as effective treatments for severe asthma, with significant clinical benefit seen in carefully selected patient populations that take asthma phenotypes and endotypes into account. The further development of reproducible and straightforward discriminatory biomarkers may aid identification of those patients most likely to benefit from treatment with these interventions.
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Affiliation(s)
- Garry M Walsh
- Institute of Medical Sciences, University of Aberdeen, Foresterhill, Aberdeen, United Kingdom.
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4
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Lugogo NL, Bogart M, Corbridge T, Packnett ER, Wu J, Hahn B. Impact of mepolizumab in patients with high-burden severe asthma within a managed care population. J Asthma 2023; 60:811-823. [PMID: 35853158 DOI: 10.1080/02770903.2022.2102036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVE To evaluate the real-world impact of mepolizumab on the incidence of asthma exacerbations, oral corticosteroid (OCS) use and asthma exacerbation-related costs in patients with high-burden severe asthma. METHODS This was a retrospective study of the MarketScan Commercial and Medicare Databases in patients with high-burden severe asthma (≥80th percentile of total healthcare expenditure and/or significant comorbidity burden). Patients were ≥12 years of age upon mepolizumab initiation (index date November 1, 2015-December 31, 2018) and had ≥2 mepolizumab administrations during the 6 months post-index. Asthma exacerbation frequency (primary outcome), use of OCS (secondary outcome), and asthma exacerbation-related costs (exploratory outcome) were assessed during the 12 months pre-index (baseline) and post-index (follow-up). RESULTS In total, 281 patients were analyzed. Mepolizumab significantly reduced the proportion of patients with any asthma exacerbation (P < 0.001) or exacerbations requiring hospitalization (P = 0.004) in the follow-up versus baseline period. The mean number of exacerbations decreased from 2.5 to 1.5 events/patient/year (relative reduction: 40.0%; P < 0.001). The proportion of patients with ≥1 OCS claim also decreased significantly from 94.0% to 81.9% (relative reduction: 12.9%; P < 0.001), corresponding to a decrease from 6.6 to 4.7 claims/person/year (P < 0.001). Of the 264 patients with ≥1 OCS claim during baseline, 191 (72.3%) showed a decrease in mean daily OCS use by ≥50% in 117 patients (61.3%). Total asthma exacerbation-related costs were significantly lower after mepolizumab was initiated (P < 0.001). CONCLUSIONS Mepolizumab reduced exacerbation frequency, OCS use and asthma exacerbation-related costs in patients with high-cost severe asthma. Mepolizumab provides real-world benefits to patients, healthcare systems and payers.
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Affiliation(s)
- Njira L Lugogo
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Michael Bogart
- US Value Evidence & Outcomes, US Medical Affairs, GSK, NC, USA
| | | | | | - Joanne Wu
- Life Sciences, IBM Watson Health, Cambridge, MA, USA
| | - Beth Hahn
- US Value Evidence & Outcomes, US Medical Affairs, GSK, NC, USA
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5
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Sethi S, Bogart M, Corbridge T, Cyhaniuk A, Hahn B. Impact of Mepolizumab on Exacerbations in the US Medicare Population. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:546-554.e2. [PMID: 36377070 DOI: 10.1016/j.jaip.2022.10.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 10/06/2022] [Accepted: 10/10/2022] [Indexed: 11/12/2022]
Abstract
BACKGROUND Asthma is a common chronic respiratory disorder associated with significant disease and economic burden. Mepolizumab is an anti-IL-5 mAb approved for use as an add-on treatment in patients with severe eosinophilic asthma. OBJECTIVE To assess the impact of mepolizumab initiation on asthma exacerbation frequency, oral corticosteroid (OCS) use, and asthma exacerbation-related costs in a US Medicare population. METHODS This was a retrospective cohort study of mepolizumab claims from patients with asthma in the Centers for Medicare and Medicaid Services Medicare database carried out between January 2016 and December 2018. The index date (first claim for mepolizumab) was required to occur between January and December 2017. The baseline and follow-up periods were the 12 months before and 12 months after the index, respectively. Outcomes included changes in the proportion of patients experiencing exacerbations (primary), OCS use (secondary), and asthma exacerbation-related costs during the baseline and follow-up periods. RESULTS The study identified 1,278 patients (mean age, 67.9 years; 65% female) with one or more prescription or administration claim for mepolizumab who were eligible for study inclusion. There was a significant relative reduction in the proportion of patients with an asthma exacerbation (27%; P < .0001) in the follow-up versus baseline period. Similarly, a lower proportion of patients received OCS for asthma (16% relative reduction; P < .0001), fewer patients were chronic OCS users (5 mg/day or more; 48% relative reduction; P < .0001), and there was a significant decrease in asthma exacerbation-related costs (total reduction, $888; P = .0002) during the follow-up versus the baseline period. CONCLUSION Mepolizumab reduced exacerbations, OCS use, and exacerbation-related healthcare costs in a US Medicare population, confirming its benefits in this specific population with severe asthma.
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Affiliation(s)
- Sanjay Sethi
- Jacobs School of Medicine, University at Buffalo, State University of New York, Buffalo, NY.
| | | | | | | | - Beth Hahn
- GlaxoSmithKline, Research Triangle Park, NC
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6
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Walter S, Ho J, Alvarado R, Smith G, Croucher DR, Liang S, Grayson JW, Mangussi-Gomes J, Van Es SL, Earls P, Rimmer J, Campbell R, Kalish L, Sacks R, Harvey RJ. Mepolizumab decreases tissue eosinophils while increasing type-2 cytokines in eosinophilic chronic rhinosinusitis. Clin Exp Allergy 2022; 52:1403-1413. [PMID: 35475305 DOI: 10.1111/cea.14152] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 03/14/2022] [Accepted: 04/11/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND Eosinophilic chronic rhinosinusitis is an often treatment-resistant inflammatory disease mediated by type-2 cytokines, including interleukin (IL)-5. Mepolizumab, a monoclonal antibody drug targeting IL-5, has demonstrated efficacy and safety in inflammatory airway disease, but there is negligible evidence on direct tissue response. The study's aim was to determine the local effect of mepolizumab on inflammatory biomarkers in sinonasal tissue of eosinophilic chronic rhinosinusitis patients. METHODS Adult patients with eosinophilic chronic rhinosinusitis received 100mg mepolizumab subcutaneously at four-weekly intervals for 24 weeks in this prospective phase 2 clinical trial. Tissue eosinophil counts, eosinophil degranulation (assessed as submucosal eosinophil peroxidase deposition by immunohistochemistry) and cytokine levels (measured in homogenates by immunoassay) were evaluated in ethmoid sinus tissue biopsies collected at baseline and at weeks 4, 8, 16 and 24. RESULTS Twenty patients (47.7 ± 11.7 years, 50% female) were included. Sinonasal tissue eosinophil counts decreased after 24 weeks of treatment with mepolizumab (101.64 ± 93.80 vs 41.74 ± 53.76 cells per 0.1 mm2 ; p = .035), eosinophil degranulation remained unchanged (5.79 ± 2.08 vs 6.07 ± 1.20, p = .662), and type-2 cytokine levels increased in sinonasal tissue for IL-5 (10.84 ± 18.65 vs 63.98 ± 50.66, p = .001), IL-4 (4.48 ± 3.77 vs 9.38 ± 7.56, p = .004), IL-13 (4.02 ± 2.57 vs 6.46 ± 3.99, p = .024) and GM-CSF (1.51 ± 1.74 vs 4.50 ± 2.97, p = .001). CONCLUSION Mepolizumab reduced eosinophils in sinonasal tissue, demonstrating that antagonism of IL-5 suppresses eosinophil trafficking. With reduced tissue eosinophils, a local type-2 inflammatory feedback loop may occur. The study exposes mechanistic factors which may explain incomplete treatment response.
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Affiliation(s)
- Sophie Walter
- Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, University of New South Wales, Sydney, Australia
| | - Jacqueline Ho
- Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, University of New South Wales, Sydney, Australia.,St Vincent's Clinical School, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Raquel Alvarado
- Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, University of New South Wales, Sydney, Australia
| | - Greg Smith
- School of Medical Sciences, University of New South Wales, Sydney, Australia
| | - David R Croucher
- St Vincent's Clinical School, Faculty of Medicine, University of New South Wales, Sydney, Australia.,Garvan Institute of Medical Research, Sydney, New South Wales, Australia
| | - Sharron Liang
- Department of Anatomical Pathology, St Vincent's Hospital, Sydney, Australia
| | - Jessica W Grayson
- Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, University of New South Wales, Sydney, Australia.,Department of Otolaryngology-Head and Neck Surgery, University of Alabama at Birmingham, Birmingham, UK
| | - João Mangussi-Gomes
- Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, University of New South Wales, Sydney, Australia
| | - Simone L Van Es
- School of Medical Sciences, University of New South Wales, Sydney, Australia.,New South Wales Health Education and Training Institute, Sydney, Australia
| | - Peter Earls
- Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, University of New South Wales, Sydney, Australia.,Department of Anatomical Pathology, St Vincent's Hospital, Sydney, Australia
| | - Janet Rimmer
- Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, University of New South Wales, Sydney, Australia.,Woolcock Institute, University of Sydney, Sydney, Australia.,Faculty of Medicine, Notre Dame University, Sydney, Australia
| | - Raewyn Campbell
- Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, University of New South Wales, Sydney, Australia.,Department of Otolaryngology Head and Neck Surgery, Royal Prince Alfred Hospital, Sydney, Australia.,Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - Larry Kalish
- Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, University of New South Wales, Sydney, Australia.,Department of Otolaryngology, Head and Neck Surgery, Concord General Hospital, University of Sydney, Sydney, Australia.,Faculty of Medicine, University of Sydney, Sydney, Australia
| | - Raymond Sacks
- Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, University of New South Wales, Sydney, Australia.,Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia.,Department of Otolaryngology, Head and Neck Surgery, Concord General Hospital, University of Sydney, Sydney, Australia.,Faculty of Medicine, University of Sydney, Sydney, Australia
| | - Richard J Harvey
- Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, University of New South Wales, Sydney, Australia.,Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
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Cardet JC, Shenoy K, Baydur A, Carroll JK, Celedón JC, Cui J, Dara P, Ericson B, Forth VE, Fagan M, Fuhlbrigge AL, Gupta R, Hart MK, Hernandez ML, Hernandez PA, Kruse J, Maher NE, Manning BK, Pinto-Plata VM, Robles J, Rodriguez-Louis J, Shields JB, Telon Sosa BS, Wechsler ME, Israel E. Caribbean Latinx with moderate-severe asthma bear greater asthma morbidity than other Latinx. J Allergy Clin Immunol 2022; 150:1106-1113.e10. [PMID: 35779669 PMCID: PMC9643605 DOI: 10.1016/j.jaci.2022.05.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 05/08/2022] [Accepted: 05/17/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Hispanic/Latinx (HL) ethnicity encompasses racially and culturally diverse subgroups. Studies suggest that Puerto Ricans (PR) may bear greater asthma-related morbidity than Mexicans, but these were conducted in children or had limited clinical characterization. OBJECTIVES This study sought to determine whether disparities in asthma morbidity exist among HL adult subgroups. METHODS Adults with moderate-severe asthma were recruited from US clinics, including from Puerto Rico, for the Person Empowered Asthma Relief (PREPARE) trial. Considering the shared heritage between PR and other Caribbean HL (Cubans and Dominicans [C&D]), the investigators compared baseline self-reported clinical characteristics between Caribbean HL (CHL) (PR and C&D: n = 457) and other HLs (OHL) (Mexicans, Spaniards, Central/South Americans; n = 141), and between CHL subgroups (C&D [n = 56] and PR [n = 401]). This study compared asthma morbidity measures (self-reported exacerbations requiring systemic corticosteroids, emergency department/urgent care (ED/UC) visits, hospitalizations, health care utilization) through negative binomial regression. RESULTS CHL compared to OHL were similar in age, body mass index, poverty status, blood eosinophils, and fractional exhaled nitric oxide but were prescribed more asthma controller therapies. Relative to OHL, CHL had significantly increased odds of asthma exacerbations (odds ratio [OR]: 1.84; 95% CI: 1.4-2.4), ED/UC visits (OR: 1.88; 95% CI: 1.4-2.5), hospitalization (OR: 1.98; 95% CI: 1.06-3.7), and health care utilization (OR: 1.91; 95% CI: 1.44-2.53). Of the CHL subgroups, PR had significantly increased odds of asthma exacerbations, ED/UC visits, hospitalizations, and health care utilization compared to OHL, whereas C&D only had increased odds of exacerbations compared to OHL. PR compared to C&D had greater odds of ED/UC and health care utilization. CONCLUSIONS CHL adults, compared with OHL, adults reported nearly twice the asthma morbidity; these differences are primarily driven by PR. Novel interventions are needed to reduce morbidity in this highly impacted population.
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Affiliation(s)
- Juan Carlos Cardet
- Division of Allergy and Immunology, Department of Internal Medicine, University of South Florida, Morsani College of Medicine, Tampa, Fla
| | - Kartik Shenoy
- Temple Lung Center, Lewis Katz School of Medicine at Temple University, Philadelphia, Pa
| | - Ahmet Baydur
- Division of Pulmonary, Critical Care and Sleep Medicine, Keck School of Medicine, University of Southern California, Los Angeles, Calif
| | - Jennifer K Carroll
- American Academy of Family Physicians National Research Network, Leawood, Kan; Department of Family Medicine, University of Colorado School of Medicine, University of Colorado, Aurora, Colo
| | - Juan Carlos Celedón
- Division of Pediatric Pulmonary Medicine, University of Pittsburgh, Pittsburgh, Pa
| | - Jing Cui
- Division of Rheumatology, Inflammation and Immunity, Brigham and Women's Hospital, Boston, Mass
| | - Prajwal Dara
- Department of Internal Medicine, University of South Florida, Morsani College of Medicine, Tampa, Fla
| | - Brianna Ericson
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, Mass
| | - Victoria E Forth
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, Mass
| | | | - Anne L Fuhlbrigge
- Department of Medicine, Pulmonary Science and Critical Care Medicine, University of Colorado School of Medicine, University of Colorado, Aurora, Colo
| | - Rohit Gupta
- Temple Lung Center, Lewis Katz School of Medicine at Temple University, Philadelphia, Pa
| | | | - Michelle L Hernandez
- Division of Allergy and Immunology, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Paulina Arias Hernandez
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, Mass
| | - Jean Kruse
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, Mass
| | - Nancy E Maher
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, Mass
| | - Brian K Manning
- American Academy of Family Physicians National Research Network, Leawood, Kan
| | - Victor M Pinto-Plata
- Division of Pulmonary and Critical Care Medicine, Lahey Hospital and Medical Center, Burlington, Mass
| | | | | | - Joel B Shields
- American Academy of Family Physicians National Research Network, Leawood, Kan
| | - Bonnie S Telon Sosa
- Department of Internal Medicine, Allergy/Immunology Section, University of Puerto Rico: Medical Sciences Campus, San Juan, Puerto Rico
| | - Michael E Wechsler
- Department of Medicine, NJH Cohen Family Asthma Institute, National Jewish Health, Denver, Colo
| | - Elliot Israel
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, Mass.
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8
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Abstract
BACKGROUND This is the second update of previously published reviews in the Cochrane Library (2015, first update 2017). Interleukin-5 (IL-5) is the main cytokine involved in the proliferation, maturation, activation and survival of eosinophils, which cause airway inflammation and are a classic feature of asthma. Studies of monoclonal antibodies targeting IL-5 or its receptor (IL-5R) suggest they reduce asthma exacerbations, improve health-related quality of life (HRQoL) and lung function in appropriately selected patients, justifying their inclusion in the latest guidelines. OBJECTIVES To compare the effects of therapies targeting IL-5 signalling (anti-IL-5 or anti-IL-5Rα) with placebo on exacerbations, health-related quality-of-life (HRQoL) measures and lung function in adults and children with chronic asthma, and specifically in those with eosinophilic asthma refractory to existing treatments. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, and two trials registers, manufacturers' websites, and reference lists of included studies. The most recent search was 7 February 2022. SELECTION CRITERIA We included randomised controlled trials comparing mepolizumab, reslizumab and benralizumab versus placebo in adults and children with asthma. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and analysed outcomes using a random-effects model. We used standard methods expected by Cochrane. MAIN RESULTS Seventeen studies on about 7600 participants met the inclusion criteria. Six used mepolizumab, five used reslizumab, and six used benralizumab. One study using benralizumab was terminated early due to sponsor decision and contributed no data. The studies were predominantly on people with severe eosinophilic asthma, which was similarly but variably defined. One was in children aged 6 to 17 years; nine others included children over 12 years but did not report results by age group separately. We deemed the overall risk of bias to be low, with all studies contributing data of robust methodology. We considered the certainty of the evidence for all comparisons to be high overall using the GRADE scheme, except for intravenous (IV) mepolizumab and subcutaneous (SC) reslizumab because these are not currently licensed delivery routes. The anti-IL-5 treatments assessed reduced rates of 'clinically significant' asthma exacerbation (defined by treatment with systemic corticosteroids for three days or more) by approximately half in participants with severe eosinophilic asthma on standard care (at least medium-dose inhaled corticosteroids (ICS)) with poorly controlled disease (either two or more exacerbations in the preceding year or Asthma Control Questionnaire (ACQ) score of 1.5 or more), except for reslizumab SC. The rate ratios for these effects were 0.45 (95% confidence interval (CI) 0.36 to 0.55; high-certainty evidence) for mepolizumab SC, 0.53 (95% CI 0.44 to 0.64; moderate-certainty evidence) for mepolizumab IV, 0.43 (95% CI 0.33 to 0.55; high-certainty evidence) for reslizumab IV, and 0.59 (95% CI 0.52 to 0.66; high-certainty evidence) for benralizumab SC. Non-eosinophilic participants treated with benralizumab also showed a significant reduction in exacerbation rates, an effect not seen with reslizumab IV, albeit in only one study. No data were available for non-eosinophilic participants treated with mepolizumab. There were improvements in validated HRQoL scores with all anti-IL-5 agents in severe eosinophilic asthma. This met the minimum clinically important difference (MCID) for the broader St. George's Respiratory Questionnaire (SGRQ; 4-point change) for benralizumab only, but the improvement in the ACQ and Asthma Quality of Life Questionnaire (AQLQ), which focus on asthma symptoms, fell short of the MCID (0.5 point change for both ACQ and AQLQ) for all of the interventions. The evidence for an improvement in HRQoL scores in non-eosinophilic participants treated with benralizumab and reslizumab was weak, but the tests for subgroup difference were negative. All anti-IL-5 treatments produced small improvements in mean pre-bronchodilator forced expiratory flow in one second (FEV1) of between 0.08 L and 0.15 L in eosinophilic participants, which may not be sufficient to be detected by patients. There were no excess serious adverse events with any anti-IL-5 treatment; in fact, there was a reduction in such events with benralizumab, likely arising from fewer asthma-related hospital admissions. There was no difference compared to placebo in adverse events leading to discontinuation with mepolizumab or reslizumab, but significantly more discontinued benralizumab than placebo, although the absolute numbers were small (42/2026 (2.1%) benralizumab versus 11/1227 (0.9%) placebo). The implications for efficacy or adverse events are unclear. AUTHORS' CONCLUSIONS Overall this analysis supports the use of anti-IL-5 treatments as an adjunct to standard care in people with severe eosinophilic asthma and poor symptom control. These treatments roughly halve the rate of asthma exacerbations in this population. There is limited evidence for improved HRQoL scores and lung function, which may not meet clinically detectable levels. The studies did not report safety concerns for mepolizumab or reslizumab, or any excess serious adverse events with benralizumab, although there remains a question over adverse events significant enough to prompt discontinuation. Further research is needed on biomarkers for assessing treatment response, optimal duration and long-term effects of treatment, risk of relapse on withdrawal, non-eosinophilic patients, children (particularly under 12 years), comparing anti-IL-5 treatments to each other and, in patients meeting relevant eligibility criteria, to other biological (monoclonal antibody) therapies. For benralizumab, future studies should closely monitor rates of adverse events prompting discontinuation.
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Affiliation(s)
| | - Amanda Wilson
- School of Nursing and Midwifery, University of Technology Sydney, Sydney, Australia
| | - Stephen Milan
- Health Innovation Campus and Centre for Health Futures, Lancaster University, Lancaster, UK
| | | | - Freda Yang
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Colin Ve Powell
- Department of Emergency Medicine, Sidra Medciine, Doha, Qatar
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9
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Abstract
Obesity is a major risk factor for the development of asthma, and the prevalence of obesity is higher in people with asthma than in the general population. Obese people often have severe asthma-recent studies in the United States suggest that 60% of adults with severe asthma are obese. Multiple mechanisms link obesity and asthma, which are discussed in this article, and these pathways contribute to different phenotypes of asthma among people with obesity. From a practical aspect, changes in physiology and immune markers affect diagnosis and monitoring of disease activity in people with asthma and obesity. Obesity also affects response to asthma medications and is associated with an increased risk of co-morbidities such as gastroesophageal reflux disease, depression, and obstructive sleep apnea, all of which may affect asthma control. Obese people may be at elevated risk of exacerbations related to increased risk of severe disease in response to viral infections. Interventions that target improved dietary quality, exercise, and weight loss are likely to be particularly helpful for this patient population.
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Affiliation(s)
- Anne E Dixon
- Department of Medicine, Larner College of Medicine, University of Vermont, Burlington, Vermont
| | - Loretta G Que
- Department of Medicine, Duke Health, Rm 279 MSRB1, Durham, North Carolina
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Silver J, Molfino N, Bogart M, Packnett ER, McMorrow D, Wu J, Hahn B. Real-world impact of mepolizumab in patients with life-threatening asthma: US insurance claims database analysis. Clin Ther 2021; 43:2064-2073. [PMID: 34893348 DOI: 10.1016/j.clinthera.2021.10.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 10/11/2021] [Accepted: 10/14/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE Patients with life-threatening asthma typically experience recurrent exacerbations, are dependent on oral corticosteroids (OCSs), and have considerable asthma-related health care costs. Data on the impact of mepolizumab on exacerbations and OCS use in patients with life-threatening asthma in real-world clinical practice are limited. This study assessed the impact of mepolizumab on exacerbation rates and OCS use in patients with life-threatening asthma in a real-word setting. METHODS This retrospective study utilized data from US administrative claims from patients with life-threatening asthma. Eligible patients were treated between November 1, 2015, and December 31, 2017; were ≥12 years of age upon mepolizumab initiation (index date); and had undergone at least two mepolizumab administrations during the 6 months postindex. Data from the 12 months before (baseline) and after (follow-up) index were collected, with each patient serving as his or her own control. Life-threatening asthma was defined as at least three exacerbations and/or at least one asthma-related hospitalization during baseline, and/or a history of endotracheal intubation. Asthma exacerbation frequency and OCS use were assessed. FINDINGS The analysis included 327 patients who received a mean (SD) of 10.6 (4.3) mepolizumab doses during follow-up. The percentage of patients experiencing at least one exacerbation and the mean exacerbation rate were significantly reduced from baseline to follow-up with mepolizumab, from 94.5% to 67.9% (P < 0.001), and from 3.2 to 1.5 events per patient per year, corresponding to a 53.1% relative reduction (P < 0.001). The percentage of patients with OCS claims was reduced by 12.6%, from 99.1% to 86.5% (P < 0.001). Of the patients who had a reduction in mean daily OCS use, most (57.9%, 140/242) had a reduction in mean daily OCS use of at least 50%. IMPLICATIONS These data from patients with life-threatening asthma in clinical practice demonstrated that asthma exacerbation and OCS use were significantly reduced with mepolizumab treatment.
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Affiliation(s)
- Jared Silver
- US Value Evidence & Outcomes, US Medical Affairs, GlaxoSmithKline, Research Triangle Park, North Carolina
| | - Nestor Molfino
- US Value Evidence & Outcomes, US Medical Affairs, GlaxoSmithKline, Research Triangle Park, North Carolina
| | - Michael Bogart
- US Value Evidence & Outcomes, US Medical Affairs, GlaxoSmithKline, Research Triangle Park, North Carolina
| | | | | | - Juan Wu
- Life Sciences, IBM Watson Health, Bethesda, Maryland
| | - Beth Hahn
- US Value Evidence & Outcomes, US Medical Affairs, GlaxoSmithKline, Research Triangle Park, North Carolina.
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11
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de Freitas Nakata KC, Marques LD, de Oliveira HC, Magalhães GCB, de Oliveira RG, Botelho C. Anti-interleukin-5 in the Management of Eosinophilic Asthma: A Review of Effectiveness, Safety, and Budgetary Impact From the Perspective of the Brazilian Health System. Value Health Reg Issues 2021; 26:169-181. [PMID: 34547665 DOI: 10.1016/j.vhri.2021.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 03/30/2021] [Accepted: 06/12/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To evaluate the efficacy and safety of anti-interleukin-5 class therapy agents in the treatment of eosinophilic asthma and the financial impact of these drugs on the Brazilian and Mato Grosso public health systems. METHODS The literature review in important databases was guided by a structured research question including patient or population, intervention, comparator, outcome and type of study. The retrieved studies went through a screening, selection, data extraction, and methodological quality assessment process. A model with two scenarios, one with mepolizumab and the other with benralizumab, was created for budget impact analysis. RESULTS Evidence indicated that anti-interleukins-5 have an acceptable safety profile and can reduce exacerbation rates by up to 50% in the population with eosinophilic asthma; however, they showed no significant difference in quality of life. The adoption of these drugs in the Brazilian health system can impact the budget from R$ 40,379,731.50 to R$ 140,301,211.34 depending on the drug incorporated, considering a time horizon of 5 years. From the perspective of the state of Mato Grosso, the budget impact may reach, in the fifth year, an amount of R$ 1,301,210.58 and R$ 2,050.687.62 for the scenarios with mepolizumab and benralizumab, respectively. CONCLUSION Anti-interleukins-5 are promising treatments for eosinophilic asthma because they minimise exacerbations and are well tolerated and safe. The financial impact is large, implying that technology costs may be a barrier to accessing this treatment class.
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Affiliation(s)
| | - Luisa Daige Marques
- Núcleo de Avaliação de Tecnologias em Saúde - NATS/SES/MT, Cuiabá-MT, Brasil
| | - Helder Cássio de Oliveira
- Núcleo de Avaliação de Tecnologias em Saúde - NATS/SES/MT, Cuiabá-MT, Brasil; Coordenador do NATS-HUJM - Hospital Universitário Júlio Muller, Cuiabá-MT, Brasil
| | - Graciane Catarina Batista Magalhães
- Núcleo de Avaliação de Tecnologias em Saúde - NATS/SES/MT, Cuiabá-MT, Brasil; Centro Estadual de Referência em Média e Alta Complexidade - Cermac/SES MT, Cuiabá-MT, Brasil
| | - Ruberlei Godinho de Oliveira
- Hospital Universitário Júlio Muller - Programa de Pós-Graduação Mestrado em Ciências Aplicadas a Atenção Hospitalar, Cuiabá-MT, Brasil
| | - Clóvis Botelho
- Universidade Federal de Mato Grosso - UFMT/Universidade de Várzea Grande-MT, Cuiabá-MT, Brasil
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Huang C, Li F, Wang J, Tian Z. Innate-like Lymphocytes and Innate Lymphoid Cells in Asthma. Clin Rev Allergy Immunol 2021; 59:359-370. [PMID: 31776937 DOI: 10.1007/s12016-019-08773-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Asthma is a chronic pulmonary disease, highly associated with immune disorders. The typical symptoms of asthma include airway hyperresponsiveness (AHR), airway remodeling, mucus overproduction, and airflow limitation. The etiology of asthma is multifactorial and affected by genetic and environmental factors. Increasing trends toward dysbiosis, smoking, stress, air pollution, and a western lifestyle may account for the increasing incidence of asthma. Based on the presence or absence of eosinophilic inflammation, asthma is mainly divided into T helper 2 (Th2) and non-Th2 asthma. Th2 asthma is mediated by allergen-specific Th2 cells, and eosinophils activated by Th2 cells via the secretion of interleukin (IL)-4, IL-5, and IL-13. Different from Th2 asthma, non-Th2 asthma shows little eosinophilic inflammation, resists to corticosteroid treatment, and occurs mainly in severe asthmatic patients. Previous studies of asthma primarily focused on the function of Th2 cells, but, with the discovery of non-Th2 asthma and the involvement of innate lymphoid cells (ILCs) in the pathogenesis of asthma, tissue-resident innate immune cells in the lung have become the focus of attention in asthma research. Currently, innate-like lymphocytes (ILLs) and ILCs as important components of the innate immune system in mucosal tissues are reportedly involved in the pathogenesis of or protection against both Th2 and non-Th2 asthma. These findings of the functions of different subsets of ILLs and ILCs may provide clues for the treatment of asthma.
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Affiliation(s)
- Chao Huang
- Institute of Immunology, University of Science and Technology of China, Hefei, 230027, Anhui, China
| | - Fengqi Li
- Institute of Molecular Health Sciences, ETH Zürich, 8093, Zürich, Switzerland
| | - Jian Wang
- Neuroimmunology and MS Research Section (NIMS), Neurology Clinic, University of Zürich, University Hospital Zürich, 8091, Zürich, Switzerland.
| | - Zhigang Tian
- Institute of Immunology, University of Science and Technology of China, Hefei, 230027, Anhui, China.
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13
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Pavord ID, Chapman KR, Bafadhel M, Sciurba FC, Bradford ES, Schweiker Harris S, Mayer B, Rubin DB, Yancey SW, Paggiaro P. Mepolizumab for Eosinophil-Associated COPD: Analysis of METREX and METREO. Int J Chron Obstruct Pulmon Dis 2021; 16:1755-1770. [PMID: 34163157 PMCID: PMC8215850 DOI: 10.2147/copd.s294333] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 05/09/2021] [Indexed: 12/05/2022] Open
Abstract
Background A pre-specified meta-analysis of individual patient data from the 52-week METREX and METREO trials, which investigated mepolizumab for chronic obstructive pulmonary disease (COPD) in patients with blood eosinophil counts ≥150 cells/µL (screening) or ≥300 cells/µL (prior year) and frequent exacerbations, enables more robust characterization of mepolizumab efficacy in COPD and exploration of the relationship between blood eosinophil count and treatment responses. Methods In METREX (117106/NCT02105948) and METREO (117113/NCT02105961), randomized patients received mepolizumab or placebo added to existing inhaled corticosteroid (ICS)–based triple maintenance therapy. The annual rate of moderate/severe exacerbations (primary endpoint) was compared between subcutaneous (SC) mepolizumab 100 mg versus placebo (primary comparison of interest) and all doses (100 mg and 300 mg SC) versus placebo in patients with blood eosinophil counts ≥150 cells/µL at screening or ≥300 cells/µL in the prior year. Secondary/other endpoints included time to first moderate/severe exacerbation, exacerbations leading to emergency department visit/hospitalization and health-related quality of life (HRQoL). A predictive model of the relationship between screening blood eosinophil counts and exacerbation rates included data from all randomized patients. Results In total, 1510 patients were randomized in METREX and METREO and 1136 patients were included in the pre-specified meta-analysis. From the meta-analysis, mepolizumab 100 mg SC significantly reduced annual moderate/severe exacerbation rates versus placebo by 18% (rate ratio: 0.82; 95% confidence interval: 0.71, 0.95; p=0.006) and delayed time to first moderate/severe exacerbation (hazard ratio: 0.80 [0.68, 0.94]; p=0.006). Mepolizumab 100 mg SC versus placebo numerically reduced exacerbations leading to ED visits/hospitalization and improved HRQoL. A modelling approach demonstrated increasing efficacy for moderate/severe exacerbations with increasing screening blood eosinophil count; this relationship was more pronounced for exacerbations requiring oral corticosteroids (post hoc). The all-doses comparison had similar results. Conclusion Mepolizumab reduces exacerbations in patients with eosinophil-associated COPD. Results suggest that blood eosinophil counts (≥150 cells/µL at screening or ≥300 cells/µL in the prior year) allow for identification of patients with COPD who experience exacerbations while treated with maximal ICS-based triple maintenance therapy who are likely to benefit from mepolizumab. ![]()
Point your SmartPhone at the code above. If you have a QR code reader the video abstract will appear. Or use: https://youtu.be/YCq1mqQ5Xl4
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Affiliation(s)
- Ian D Pavord
- Nuffield Department of Medicine and Oxford Respiratory NIHR BRC, University of Oxford, Oxford, UK
| | - Kenneth R Chapman
- Asthma & Airway Centre, UHN and University of Toronto, Toronto, ON, Canada
| | - Mona Bafadhel
- Nuffield Department of Medicine and Oxford Respiratory NIHR BRC, University of Oxford, Oxford, UK
| | - Frank C Sciurba
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Eric S Bradford
- Respiratory Therapeutic Area, GSK, Research Triangle Park, NC, USA
| | | | | | - David B Rubin
- Respiratory Therapeutic Area, GSK, Research Triangle Park, NC, USA
| | - Steven W Yancey
- Respiratory Therapeutic Area, GSK, Research Triangle Park, NC, USA
| | - Pierluigi Paggiaro
- Department of Surgery, Medicine, Molecular Biology, and Critical Care, University of Pisa, Pisa, Italy
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14
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The Current State of Biologic Therapies for Treatment of Refractory Asthma. Clin Rev Allergy Immunol 2021; 59:195-207. [PMID: 31981048 DOI: 10.1007/s12016-020-08776-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Asthma is a heterogeneous disease, with the immune processes behind the chronic inflammation underlying this disorder differing between the various identified asthma endotypes. In addition to heterogeneity in underlying disease pathophysiology, asthmatics fall across a broad spectrum of disease severity and can vary greatly in their response to convention asthma therapies. A small percentage of patients with severe persistent asthma will remain uncontrolled despite treatment with high-dose inhaled corticosteroids and a long-acting beta-agonist. Less than two decades ago, there were few options for these treatment-refractory asthmatics beyond chronic systemic steroids, with their myriad of treatment-limiting side effects. However, in recent years, there have been a growing number of Food and Drug Administration (FDA)-approved biologic medications with targets that include immunoglobulin E (IgE), interleukin-5 (IL-5), the IL-5 receptor and the IL-4/IL-13 receptor-alpha subunit. The current FDA-approved biologics for severe persistent asthma are omalizumab, mepolizumab, reslizumab, benralizumab, and dupilumab. These monoclonal antibodies have been shown to improve asthma control, decrease asthma exacerbations and decrease glucocorticoid dependence in certain subsets of patients with asthma. The optimal biologic for treatment of severe asthma varies from patient to patient, depending on the underlying pathophysiology of the patient's disease. For each of these medications, there are certain biomarkers that can help predict whether a patient is likely to respond favorably to the medication. This review will discuss the currently approved biologics for severe persistent asthma, including their indications, efficacy and side effects.
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15
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Casale T, Molfino NA, Silver J, Bogart M, Packnett E, McMorrow D, Wu J, Hahn B. Real-world effectiveness of mepolizumab in patients with severe asthma and associated comorbidities. Ann Allergy Asthma Immunol 2021; 127:354-362.e2. [PMID: 34038773 DOI: 10.1016/j.anai.2021.05.021] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 04/28/2021] [Accepted: 05/18/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Patients with severe asthma frequently have associated comorbidities, which can compound existing symptoms, complicating asthma management. OBJECTIVE To describe the real-world effectiveness of mepolizumab in patients with severe asthma stratified by common overlapping comorbidities. METHODS This was a retrospective analysis of patients with asthma from the MarketScan Commercial and Medicare Supplemental Database initiating mepolizumab treatment (index date). Eligible patients had more than or equal to 1 claim (excluding claims for diagnostic tests) with a diagnosis code for more than or equal to 1 of 7 comorbidities (atopic disease, nasal polyps, chronic sinusitis, obesity, respiratory infections, chronic obstructive pulmonary disease, and depression/anxiety) during the 12-month preindex baseline period; these were used to stratify patients into 7 nonmutually exclusive subgroups. Outcomes included asthma exacerbations and exacerbation-related health care resource utilization during the 12-month baseline and follow-up periods. Each patient acted as their own control. RESULTS Of the 639 patients included, the most common comorbidities were atopic diseases (73.2%), respiratory infections (55.6%), and chronic sinusitis (45.1%). Across all 7 comorbidity subgroups, there were significant (P < .05) reductions of 38% to 55% and 57% to 83% in exacerbations and exacerbations requiring hospitalization, respectively, during the follow-up vs baseline period, except for exacerbations requiring hospitalization in the nasal polyp subgroup, owing to the small subgroup sample size. During the follow-up vs baseline periods, mean number of oral corticosteroids claims was significantly (P < .001) reduced by 29% to 38%; 39% to 47% of patients achieved greater than or equal to 50% oral corticosteroids dose reduction. Significant reductions in exacerbation-related health care resource utilization were also observed. CONCLUSION Mepolizumab treatment provided real-world clinical benefits in patients.
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Affiliation(s)
- Thomas Casale
- Division of Allergy and Immunology, Department of Internal Medicine, University of South Florida Health Morsani College of Medicine, Tampa, Florida
| | - Nestor A Molfino
- US Value Evidence and Outcomes, US Medical Affairs, GlaxoSmithKline, Research Triangle Park, North Carolina
| | - Jared Silver
- US Medical Affairs, GlaxoSmithKline, Research Triangle Park, North Carolina
| | - Michael Bogart
- US Value Evidence and Outcomes, US Medical Affairs, GlaxoSmithKline, Research Triangle Park, North Carolina
| | | | | | - Joanne Wu
- Life Sciences, IBM Watson Health, Cambridge, Maryland
| | - Beth Hahn
- US Value Evidence and Outcomes, US Medical Affairs, GlaxoSmithKline, Research Triangle Park, North Carolina.
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16
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Real-World Effectiveness of Mepolizumab in Severe Eosinophilic Asthma: A Systematic Review and Meta-analysis. Clin Ther 2021; 43:e192-e208. [PMID: 33962763 DOI: 10.1016/j.clinthera.2021.03.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 03/04/2021] [Accepted: 03/29/2021] [Indexed: 12/29/2022]
Abstract
PURPOSE Mepolizumab is a human monoclonal antibody against interleukin 5 (IL-5) used to treat severe eosinophilic asthma. Several studies have evaluated the effectiveness of mepolizumab in the real world. We conducted a systematic review and meta-analysis in the context of heterogeneity among patients, clinicians, and treatment regimens to study the effectiveness of mepolizumab in the real world. METHODS We searched the PubMed and Embase databases for real-world studies on severe asthma treatment with mepolizumab as of June 30, 2020. Exacerbations, asthma-related hospitalizations, forced expiratory volume in 1 second (FEV1), Asthma Control Questionnaire (ACQ) or Asthma Control Test (ACT), corticosteroid use, peripheral blood eosinophil counts, and the fraction of exhaled nitric oxide were selected as indicators to evaluate the effectiveness. Standardized mean differences by the Cohen method and mean differences were chosen as indicators of effect size. Cohen d values of 0.2, 0.5, and 0.8 are considered as small, medium, and large effects, respectively. We used the Dersimonian-Laird random-effect model to quantify pooled effectiveness estimates. FINDINGS A total of 1457 patients from 13 studies were included in this review. At all time points, mepolizumab was associated with reductions in exacerbations (2.92 and 2.73 events per patient per year fewer at 6 and 12 months, respectively) and hospitalizations (0.36 events per patient per year fewer at 12 months); improvements in asthma control (ACQ scores reductions of 1.32 and 1.03 at 6 and 12 months, respectively; ACT scores increase of 6.52 at 6-12 months); slight improvements in pulmonary function (FEV1 increase of 0.23 L at 1-3 months and 6-12 months, respectively); reductions in oral corticosteroid use (9.02- and 7.68-mg decrease at 6 and 12 months, respectively); and reductions in peripheral blood eosinophil counts (decreases of 559.11 cells/μL and 599.17 cells/μL at 1-3 months and 6-12 months, respectively) and fraction of exhaled nitric oxide (13-ppb reduction at 6-12 months). IMPLICATIONS Our study suggests that mepolizumab is associated with improvements in several clinically meaningful real-world outcomes. This study is a supplement to and extension of the efficacy of randomized controlled trials of mepolizumab. (Clin Ther. 2021;XX:XXX-XXX) © 2021 Elsevier HS Journals, Inc.
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Chiu CJ, Huang MT. Asthma in the Precision Medicine Era: Biologics and Probiotics. Int J Mol Sci 2021; 22:4528. [PMID: 33926084 PMCID: PMC8123613 DOI: 10.3390/ijms22094528] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 04/23/2021] [Accepted: 04/24/2021] [Indexed: 02/07/2023] Open
Abstract
Asthma is a major global health issue. Over 300 million people worldwide suffer from this chronic inflammatory airway disease. Typical clinical symptoms of asthma are characterized by a recurrent wheezy cough, chest tightness, and shortness of breath. The main goals of asthma management are to alleviate asthma symptoms, reduce the risk of asthma exacerbations, and minimize long-term medicinal adverse effects. However, currently available type 2 T helper cells (Th2)-directed treatments are often ineffective due to the heterogeneity of the asthma subgroups, which manifests clinically with variable and poor treatment responses. Personalized precision therapy of asthma according to individualized clinical characteristics (phenotype) and laboratory biomarkers (endotype) is the future prospect. This mini review discusses the molecular mechanisms underlying asthma pathogenesis, including the hot sought-after topic of microbiota, add-on therapies and the potential application of probiotics in the management of asthma.
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Affiliation(s)
- Chiao-Juno Chiu
- Graduate Institute of Clinical Medicine, School of Medicine, National Taiwan University, Taipei 100, Taiwan;
| | - Miao-Tzu Huang
- Graduate Institute of Clinical Medicine, School of Medicine, National Taiwan University, Taipei 100, Taiwan;
- Department of Medical Research, National Taiwan University Hospital, No. 7 Chung-Shan South Road, Taipei 100, Taiwan
- Department of Pediatrics, National Taiwan University Hospital, No. 7 Chung-Shan South Road, Taipei 100, Taiwan
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de Benedictis FM, Carloni I, Guidi R. Safety of anti-inflammatory drugs in children with asthma. Curr Opin Allergy Clin Immunol 2021; 21:144-150. [PMID: 33470588 DOI: 10.1097/aci.0000000000000730] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Inhaled corticosteroids (ICS) are widely used as the first-line treatment of asthma. When the disease is not controlled by standard doses of ICS, other anti-inflammatory drugs should be considered. The aim of this report is to review the main adverse events induced by anti-inflammatory drugs in children with asthma and discuss possible actions to prevent or mitigate these effects. RECENT FINDINGS Proper interpretation of ICS safety studies requires knowledge of the pharmaceutical properties and delivery device systems of the different ICS available. Genetic variants affecting susceptibility to corticosteroid-induced adrenal suppression were found in children and adults who use ICS to treat their asthma. There is evidence of the association between montelukast use and neuropsychiatric events. SUMMARY Benefits of ICS, properly prescribed and used, outweigh their potential adverse effects. There is substantial evidence that the combination of ICS with long-acting beta2 agonists is safe for asthmatic children. Awareness of the potential risks of neuropsychiatric events in children taking montelukast should inform the clinicians' prescribing practices. Omalizumab is generally well-tolerated, but the evidence on the safety of other biologic agents in children is scanty. The risk of systemic adverse events with anti-inflammatory drugs must be balanced against the risks of uncontrolled asthma and/or frequent oral steroid use.
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Affiliation(s)
| | | | - Roberto Guidi
- Pediatric Emergency Unit, Department of Mother and Child Health, Salesi Children's Hospital, Ancona, Italy
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19
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The burden of corticosteroid overload in severe and difficult to treat asthma: how to reduce this? Curr Opin Pulm Med 2021; 26:90-96. [PMID: 31599753 DOI: 10.1097/mcp.0000000000000635] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
PURPOSE OF REVIEW Severe asthma is a serious condition that requires an individualized approach combining several treatment agents administered simultaneously in order to reach adequate control. Glucocorticosteroid treatment, as the cornerstone of asthma pharmacotherapy, has great disease-controlling capability, although it may induce a vast amount of severe adverse effects. This review describes our current knowledge of the monitoring and managing options of these adverse effects and possibilities to prevent them, including new therapeutic options. RECENT FINDINGS A large amount of new drugs is emerging, which may offer a better control of glucocorticosteroid-induced adverse effects. At the same time, major achievements in our understanding of the underlying mechanisms in severe asthma and in the field of biologic agents may help to substantially reduce the need of glucocorticosteroids in the first-line treatment. SUMMARY We discuss new insights and approaches to treatment strategy of severe asthma allowing less oral glucocorticosteroid use and hence, substantial less severe adverse effects of the treatment.
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20
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García G, Bergna M, Vásquez JC, Cano Salas MC, Miguel JL, Celis Preciado C, Acuña Izcaray A, Barros Monge M, García Batista N, Zabert I, Mayorga JL, Casanova Mendoza R, Gutierrez M, Montero Arias MF, Urtecho Perez L, Antúnez M, Williams Derby V, Villatoro Azméquita A, Motiño L, De Oliveira MA, Rey Sanchez D, Arroyo M, Rodriguez M. Severe asthma: adding new evidence - Latin American Thoracic Society. ERJ Open Res 2021; 7:00318-2020. [PMID: 33532459 PMCID: PMC7836469 DOI: 10.1183/23120541.00318-2020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 09/21/2020] [Indexed: 01/08/2023] Open
Abstract
This document constitutes a summary of the clinical practice guidelines (CPGs) prepared at the initiative of the Latin American Thoracic Society (ALAT). Due to new evidence in the treatment of severe asthma, it was agreed to select six clinical questions, and the corresponding recommendations are provided herein. After considering the quality of the evidence, the balance between desirable and undesirable impacts and the feasibility and acceptance of procedures, the following recommendations were established. 1) We do not recommend the use of an inhaled corticosteroid (ICS) plus formoterol as rescue medication in the treatment of severe asthma. 2) We suggest performing many more high-quality randomised studies to evaluate the efficacy and safety of tiotropium in patients with severe asthma. 3) Omalizumab is recommended in patients with severe uncontrolled allergic asthma with serum IgE levels above 30 IU. 4) Anti-interleukin (IL)-5 drugs are recommended in patients with severe uncontrolled eosinophilic asthma (cut-off values above 150 cells·µL−1 for mepolizumab and above 400 cells·µL−1 for reslizumab). 5) Benralizumab is recommended in adult patients with severe uncontrolled eosinophilic asthma (cut-off values above 300 cells·µL−1). 6) Dupilumab is recommended in adult patients with severe uncontrolled allergic and eosinophilic asthma and in adult patients with severe corticosteroid-dependent asthma. Severe #asthma: evidence @ALAToraxhttps://bit.ly/34jYhg2
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Affiliation(s)
- Gabriel García
- Asthma Dept, Latin American Thoracic Society, Montevideo, Uruguay
| | - Miguel Bergna
- Respiratory Unit, Hospital Centrángolo, Vicente López, Argentina
| | - Juan C Vásquez
- Respiratory Unit, Instituto Nacional de Enfermedades Respiratorias, México, DF, Mexico
| | - Maria C Cano Salas
- Respiratory Unit, Instituto Nacional de Enfermedades Respiratorias, México, DF, Mexico
| | - José L Miguel
- Respiratory Unit, Instituto Nacional de Enfermedades Respiratorias, México, DF, Mexico
| | | | | | - Manuel Barros Monge
- Escuela de Medicina, Universidad de Valparaíso, Hospital Van Buren, Valparaiso, Chile
| | | | - Ignacio Zabert
- Asociación Argentina de Medicina Respiratoria, Neuquén, Argentina
| | - José L Mayorga
- A2DAHT Iberoamerican Agency for Development and Assessment of Health Technology, Mexico, DF, Mexico
| | | | | | | | | | - Miguel Antúnez
- Sociedad Chilena de Enfermedades Respiratorias, Santiago, Chile
| | | | | | - Luis Motiño
- Asociación Hondureña de Neumología y Cirugía de Tórax, Honduras, Honduras
| | | | - Diana Rey Sanchez
- Asociación Colombiana de Neumología y Cirugía de Tórax, Bogotá, Colombia
| | - Marisol Arroyo
- A2DAHT Iberoamerican Agency for Development and Assessment of Health Technology, Mexico, DF, Mexico
| | - Mario Rodriguez
- A2DAHT Iberoamerican Agency for Development and Assessment of Health Technology, Mexico, DF, Mexico
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Alves JM, Prota FE, Villagelin D, Bley F, Bernardo WM. Mepolizumab in Hypereosinophilic Syndrome: A Systematic Review and Meta-analysis. Clinics (Sao Paulo) 2021; 76:e3271. [PMID: 34644737 PMCID: PMC8478134 DOI: 10.6061/clinics/2021/e3271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 08/26/2021] [Indexed: 11/21/2022] Open
Abstract
We aimed to evaluate the efficacy and safety of mepolizumab (MEP) in the management of hypereosinophilic syndrome (HES). A systematic search was performed, and articles published until March 2021 were analyzed. The primary efficacy results evaluated were hospitalization rate related to HES, morbidity (new or worsening), relapses/failure, treatment-related adverse effects, prednisone dosage ≤10 mg/day for ≥8 weeks, and eosinophil count <600/μL for ≥8 weeks. A meta-analysis was conducted, when appropriate. Three randomized controlled trials (RCTs), with a total of 255 patients, were included. The studies contemplated the use of MEP 300 mg/SC or 750 mg/IV. According to the evaluation of the proposed outcomes, when relapse rates/therapeutic failures were assessed, there was a 26% reduction with MEP 300 mg/SC (RD=-0.26; 95% CI: -0.44 to -0.08; p=0.04) and 48% reduction with MEP 750 mg/IV (RD=-0.48; 95% CI: -0.67, -0.30; p<0.00001). For the outcomes, prednisone dosage ≤10 mg/day for ≥8 weeks was 48% (RD=0.48; 95% CI: 0.35 to 0.62; p<0.00001), and the eosinophil count <600/μL for ≥8 weeks was 51% (RD=0.51; 95% CI: 0.38 to 0.63; p<0.00001), both showed a reduction with MEP 300 mg/IV and 750 mg/IV. No statistically significant differences in treatment-related adverse effects outcomes were observed for either dosage (RD=0.09; 95% CI: -0.05 to 0.24; p=0.20; RD=0.09; 95% CI: -0.11 to 0.29; p=0.39). Despite the positive effects observed for the studied outcomes, the exact significance remains unclear.
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Affiliation(s)
- José Mario Alves
- Unimed Campinas Cooperativa de Trabalho Medico - Gestao e Valor em Saude, Campinas, SP, BR
- Corresponding author. E-mail:
| | | | - Danilo Villagelin
- Unimed Campinas Cooperativa de Trabalho Medico - Gestao e Valor em Saude, Campinas, SP, BR
| | - Fernanda Bley
- Ebenezer Gestao em Saude - Medicina Baseada em Evidencia, Sao Paulo, SP, BR
| | - Wanderley Marques Bernardo
- Ebenezer Gestao em Saude - Medicina Baseada em Evidencia, Sao Paulo, SP, BR
- Unimed Fesp - Federacao das Unimeds do Estado de Sao Paulo, Sao Paulo, SP, BR
- Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
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22
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Schleich FN, Malinovschi A, Chevremont A, Seidel L, Louis R. Risk factors associated with frequent exacerbations in asthma. RESPIRATORY MEDICINE: X 2020. [DOI: 10.1016/j.yrmex.2020.100022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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23
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Vom Hove M, Neininger MP, Bertsche T, Prenzel F. Biologicals in the Treatment of Pediatric Atopic Diseases. Handb Exp Pharmacol 2020; 261:131-151. [PMID: 32076895 DOI: 10.1007/164_2019_307] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
The management of atopic diseases such as severe asthma, severe atopic dermatitis, and severe food allergy in childhood is challenging. In particular, there are safety concerns regarding the use of high-dose corticosteroids. The recent development of biologicals and their approval for the treatment of children offer a new, very promising, and more personalized therapy option. Omalizumab, mepolizumab, and dupilumab are currently approved as add-on treatments of severe asthma in children and have been shown to be effective in improvement of asthma control and reduction of exacerbations. Dupilumab is the only biological approved for the treatment of atopic dermatitis in adolescents so far. It has been demonstrated to significantly improve symptoms of atopic dermatitis.However, safety data for biologicals used in atopic diseases in children and adolescents are still very limited. Biologicals are generally considered to be safe in adults. These data are often extrapolated to children. Additionally, data for long-term use are lacking. Thus, the safety profiles of those biologicals cannot yet be conclusively assessed.
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Affiliation(s)
- Maike Vom Hove
- Hospital for Children and Adolescents, Leipzig University Medical Center, Leipzig, Germany
| | - Martina P Neininger
- Drug Safety Center, Institute of Pharmacy, Leipzig University, Leipzig, Germany
| | - Thilo Bertsche
- Drug Safety Center, Institute of Pharmacy, Leipzig University, Leipzig, Germany
| | - Freerk Prenzel
- Hospital for Children and Adolescents, Leipzig University Medical Center, Leipzig, Germany.
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24
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Romanova J, Chikina E, Rydlovskaya A, Pohl W, Renner A, Zeifman A, Chuchalin A, Nebolsin V. New Anti-Chemokine Oral Drug XC8 in the Treatment of Asthma Patients with Poor Response to Corticosteroids: Results of a Phase 2A Randomized Controlled Clinical Trial. Pulm Ther 2020; 6:351-369. [PMID: 33095411 PMCID: PMC7671956 DOI: 10.1007/s41030-020-00134-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 09/26/2020] [Indexed: 11/26/2022] Open
Abstract
Introduction A significant number of patients with moderate asthma remain symptomatic despite treatment with inhaled corticosteroids (ICS). These patients do not yet meet the criteria for oral corticosteroids (OCS) and monoclonal antibodies. The new anti-chemokine oral drug XC8 could represent an alternative treatment option for these patients. The objective of this trial was to evaluate the effect of different doses of the XC8 in patients with partly controlled asthma in a phase 2a clinical trial. Methods A double-blind, parallel-group, randomized, multicenter, phase 2a trial was conducted at 12 sites in Russia. Patients with asthma were randomized into four groups (n = 30 each) to receive XC8 at 2 mg, 10 mg, 100 mg or placebo once-daily for 12 weeks in addition to low-dose ICS with or without LABA. Efficacy and safety parameters were evaluated at weeks 0, 2, 6, and 12. Results No statistically significant difference between the treatment arms in the number of patients with adverse events was observed. The primary endpoint, improvement of forced expiratory volume in 1 s (FEV1) % predicted over 12 weeks compared to placebo, was not statistically significant. The treatment of patients with XC8 (100 mg) resulted in statistically and clinically significant improvements in FEV1 compared to baseline (7.40% predicted, p < 0.001). Patients with elevated peripheral blood eosinophil count (PBEC, > 300 cells/μl) or serum interferon-γ (IFN-γ) level (> 100 pg/mL) treated with XC8 (100 mg) achieved a statistically significant improvement in FEV1 (11.33% predicted or 8.69% predicted, respectively, p < 0.05) as compared to the baseline versus the placebo. The strongest effect was observed in patients with both high PBEC and IFN-γ level. Pharmacodynamic engagement was demonstrated through the reduction of serum levels of C–C motif ligand 2 (CCL2) and C–X–C motif chemokine 10 (CXCL10). Treatment with XC8 (100 mg) alleviated resistance to maintenance ICS therapy in patients with elevated IFN-γ level. Conclusions Given the high safety, oral route of administration, and efficacy, XC8 may provide a promising treatment option for patients with mild-to-moderate asthma. Trial Registration 795–30/12/2015 (Ministry of Health Russian Federation), NCT03450434 (ClinicalTrials.gov). Electronic supplementary material The online version of this article (10.1007/s41030-020-00134-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | | | | | - Wolfgang Pohl
- Karl Landsteiner Institute for Clinical and Experimental Pneumology, Hietzing Hospital, Vienna, Austria
| | - Andreas Renner
- Karl Landsteiner Institute for Clinical and Experimental Pneumology, Hietzing Hospital, Vienna, Austria
| | | | - Alexander Chuchalin
- Institute of Pulmonology, Federal Medical and Biological Agency, Moscow, Russia
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25
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Pavord ID, Menzies-Gow A, Buhl R, Chanez P, Dransfield M, Lugogo N, Keene ON, Bradford ES, Yancey SW. Clinical Development of Mepolizumab for the Treatment of Severe Eosinophilic Asthma: On the Path to Personalized Medicine. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 9:1121-1132.e7. [PMID: 32889223 DOI: 10.1016/j.jaip.2020.08.039] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 07/15/2020] [Accepted: 08/12/2020] [Indexed: 12/31/2022]
Abstract
The development of mepolizumab, an anti-IL-5 monoclonal antibody for the treatment of severe eosinophilic asthma, is an example of a clinical development program that evolved over time based on sound, basic scientific principles. Initial clinical data on the effects of mepolizumab on lung function in a general asthmatic population were disappointing. However, it became clear that mepolizumab may be more effective against other clinical endpoints, particularly asthma exacerbations, in patients with more severe disease. Furthermore, a developing understanding of asthma disease pathobiology led to the identification of an appropriate target population and predictive biomarker for mepolizumab treatment: patients with severe eosinophilic asthma and blood eosinophil count. Mepolizumab use provides clinically meaningful benefits in this target population, fulfilling an unmet need. This Clinical Commentary Review describes the clinical development of mepolizumab and details of how this program informed the development of other biologic therapies in patients with severe asthma. This account highlights how a personalized approach toward treatment of patients with severe eosinophilic asthma, supported by a large body of scientific evidence, ultimately led to new and effective treatments and improved patient outcomes.
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Affiliation(s)
- Ian D Pavord
- Nuffield Department of Medicine and Oxford Respiratory NIHR BRC, University of Oxford, Oxford, United Kingdom
| | | | - Roland Buhl
- Pulmonary Department, Mainz University Hospital, Mainz, Germany
| | - Pascal Chanez
- Aix-Marseille Université, INSERM CV2N, APHM CIC NORD, Marseille, France
| | - Mark Dransfield
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, Ala
| | - Njira Lugogo
- Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, Mich
| | - Oliver N Keene
- Biostatistics, GSK, Stockley Park, Uxbridge, Middlesex, United Kingdom
| | - Eric S Bradford
- Respiratory Therapeutic Area, GSK, Research Triangle Park, NC
| | - Steve W Yancey
- Respiratory Therapeutic Area, GSK, Research Triangle Park, NC.
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Yousuf A, Ibrahim W, Greening NJ, Brightling CE. T2 Biologics for Chronic Obstructive Pulmonary Disease. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 7:1405-1416. [PMID: 31076058 DOI: 10.1016/j.jaip.2019.01.036] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 11/30/2018] [Accepted: 01/10/2019] [Indexed: 12/19/2022]
Abstract
Chronic obstructive pulmonary disease (COPD) is a significant cause of morbidity and mortality worldwide. In contrast to other chronic diseases, COPD is increasing in prevalence and is projected to be the third leading cause of death and disability worldwide by 2030. Recent advances in understanding the underlying pathophysiology of COPD has led to the development of novel targeted therapies (biologics and small molecules) that address the underlying pathophysiology of the disease. In severe asthma, biologics targeting type 2 (T2)- mediated immunity have been successful and have changed the treatment paradigm. In contrast, no biologics are currently licensed for the treatment of COPD. Those targeting non-T2 pathways have not demonstrated efficacy and in some cases raised concerns related to safety. With the increasing recognition of the eosinophil and perhaps T2-immunity possibly playing a role in a subgroup of patients with COPD, T2 biologics, specifically anti-IL-5(R), have been tested and demonstrated modest reductions in exacerbation frequency. Potential benefit was related to the baseline blood eosinophil count. These benefits were small compared with asthma. Thus, whether a subgroup of COPD sufferers might respond to anti-IL-5 or other T2-directed biologics remains to be fully addressed and requires further investigation.
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Affiliation(s)
- Ahmed Yousuf
- Institute for Lung Health, NIHR Leicester Biomedical Research Centre, Department of Infection, Immunity & Inflammation, University of Leicester and University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Wadah Ibrahim
- Institute for Lung Health, NIHR Leicester Biomedical Research Centre, Department of Infection, Immunity & Inflammation, University of Leicester and University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Neil J Greening
- Institute for Lung Health, NIHR Leicester Biomedical Research Centre, Department of Infection, Immunity & Inflammation, University of Leicester and University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Christopher E Brightling
- Institute for Lung Health, NIHR Leicester Biomedical Research Centre, Department of Infection, Immunity & Inflammation, University of Leicester and University Hospitals of Leicester NHS Trust, Leicester, United Kingdom.
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27
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Upham JW, Jurak LM. How do biologicals and other novel therapies effect clinically used biomarkers in severe asthma? Clin Exp Allergy 2020; 50:994-1006. [PMID: 32569412 DOI: 10.1111/cea.13694] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 06/11/2020] [Accepted: 06/14/2020] [Indexed: 12/13/2022]
Abstract
While there has been much interest in using biomarkers to select patients for particular targeted therapies, there has been much less attention paid to how these biomarkers change in patients once treatment begins. This is an area of great interest to practising clinicians, especially respiratory physicians and allergists who manage severe asthma. In this article, we review monoclonal antibodies and related targeted therapies, especially those that are currently available or in late stage clinical trials, focussing on the differential effects such agents have on biomarkers in widespread clinical practice such as eosinophils, FeNO and total IgE. Serial measurements of biomarkers can be useful in determining whether a particular targeted therapy is having its expected biological effect and invaluable in assessing the reasons for treatment failure should that occur.
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Affiliation(s)
- John W Upham
- Lung and Allergy Research Centre, The University of Queensland Diamantina Institute, Brisbane, QLD, Australia.,Department of Respiratory Medicine, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Lisa M Jurak
- Lung and Allergy Research Centre, The University of Queensland Diamantina Institute, Brisbane, QLD, Australia
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Walsh GM. Anti-IL-5 monoclonal antibodies for the treatment of asthma: an update. Expert Opin Biol Ther 2020; 20:1237-1244. [PMID: 32529893 DOI: 10.1080/14712598.2020.1782381] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Asthma exhibits marked heterogeneity in symptoms with severe or refractory asthma representing a clear area of unmet medical need. These patients require more specifically targeted treatments with monoclonal antibody-based biologics targeted at inhibition of the type 2 cytokines IL-4, IL-5 and IL-13 having considerable potential as effective treatments for severe asthma. For the most part, anti-cytokine-based biologic therapies are more likely to give significant clinical benefit in carefully selected patient populations that take asthma phenotypes and endotypes into account. AREAS COVERED This review is based on recent English-language original articles in Pub Med or MedLine that reported significant clinical findings on the current status, therapeutic potential and safety of the anti-IL-5 biologics mepolizumab, reslizumab and benralizumab in the treatment of severe refractory asthma. EXPERT OPINION Anti-IL-5 treatment appears effective in patients with eosinophilic asthma through exacerbation prevention with accumulating evidence of glucocorticoid-sparing effects with an acceptable safety profile for these biologics.
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Affiliation(s)
- Garry M Walsh
- School of Medicine, Medical Sciences and Nutrition, Institute of Medical Sciences, University of Aberdeen , Aberdeen, UK
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29
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Abstract
Asthma, a chronic respiratory disease characterized by chronic airway inflammation, bronchial hyperresponsiveness, and reversible airflow obstruction, poses a substantial economic burden on patients and caregivers alike. Moreover, the heterogeneous nature of the disease and the presence of various phenotypes make the treatment of asthma challenging and nuanced. Despite the availability of several approved pharmacological treatments, approximately half of patients with asthma in the United States experienced exacerbations in 2016, highlighting the need for effective add-on treatments. Furthermore, asthma control remains suboptimal due to low adherence to medications, poor inhaler technique, and several patient-related factors. Importantly, the primary care setting, in which pharmacists play an integral role, represents a critical environment for providing long-term follow-up care for the effective management of chronic diseases, such as asthma. Pharmacists are uniquely positioned to ensure optimal clinical outcomes in patients with asthma since they have the clinical expertise to educate patients on their disease state and the role of asthma medications, provide training on inhalation technique, address patients’ concerns about potential side effects of medications, and improve adherence to therapy. Therefore, in this review article, we discuss the overall role of pharmacists in effective asthma care and management.
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Affiliation(s)
- Mary B Bridgeman
- Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, 5751Rutgers, The State University of New Jersey, NJ, USA
| | - Lori A Wilken
- Pharmacy Practice, 14681University of Illinois at Chicago College of Pharmacy, IL, USA
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30
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Agache I, Beltran J, Akdis C, Akdis M, Canelo‐Aybar C, Canonica GW, Casale T, Chivato T, Corren J, Del Giacco S, Eiwegger T, Firinu D, Gern JE, Hamelmann E, Hanania N, Mäkelä M, Hernández‐Martín I, Nair P, O'Mahony L, Papadopoulos NG, Papi A, Park H, Pérez de Llano L, Posso M, Rocha C, Quirce S, Sastre J, Shamji M, Song Y, Steiner C, Schwarze J, Alonso‐Coello P, Palomares O, Jutel M. Efficacy and safety of treatment with biologicals (benralizumab, dupilumab, mepolizumab, omalizumab and reslizumab) for severe eosinophilic asthma. A systematic review for the EAACI Guidelines - recommendations on the use of biologicals in severe asthma. Allergy 2020; 75:1023-1042. [PMID: 32034960 DOI: 10.1111/all.14221] [Citation(s) in RCA: 210] [Impact Index Per Article: 52.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 01/31/2020] [Indexed: 12/13/2022]
Abstract
Five biologicals have been approved for severe eosinophilic asthma, a well-recognized phenotype. Systematic reviews (SR) evaluated the efficacy and safety of benralizumab, dupilumab, mepolizumab, omalizumab and reslizumab (alphabetical order) compared to standard of care for severe eosinophilic asthma. PubMed, Embase and Cochrane Library were searched to identify RCTs and health economic evaluations, published in English. Critical and important asthma-related outcomes were evaluated for each of the biologicals. The risk of bias and the certainty of the evidence were assessed using GRADE. 19 RCTs (three RCTs for benralizumab, three RCTs for dupilumab, three RCTs for mepolizumab, five RCTs for omalizumab and five RCTs for reslizumab), including subjects 12 to 75 years old (except for omalizumab including also subjects 6-11 years old), ranging from 12 to 56 weeks were evaluated. All biologicals reduce exacerbation rates with high certainty of evidence: benralizumab incidence rate ratio (IRR) 0.53 (95% CI 0.39 to 0.72), dupilumab (IRR) 0.43 (95% CI 0.32 to 0.59), mepolizumab IRR 0.49 (95% CI 0.38 to 0.66), omalizumab (IRR) 0.56 (95% CI 0.40 to 0.77) and reslizumab (IRR) 0.46 (95% CI 0.37 to 0.58). Benralizumab, dupilumab and mepolizumab reduce the daily dose of oral corticosteroids (OCS) with high certainty of evidence. All evaluated biologicals probably improve asthma control, QoL and FEV1 , without reaching the minimal important difference (moderate certainty). Benralizumab, mepolizumab and reslizumab slightly increase drug-related adverse events (AE) and drug-related serious AE (low to very low certainty of evidence). The incremental cost-effectiveness ratio per quality-adjusted life year value is above the willingness to pay threshold for all biologicals (moderate certainty). Potential savings are driven by decrease in hospitalizations, emergency and primary care visits. There is high certainty that all approved biologicals reduce the rate of severe asthma exacerbations and for benralizumab, dupilumab and mepolizumab for reducing OCS. There is moderate certainty for improving asthma control, QoL, FEV1 . More data on long-term safety are needed together with more efficacy data in the paediatric population.
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31
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Schleich F, Graff S, Nekoee H, Moermans C, Henket M, Sanchez C, Paulus V, Guissard F, Donneau AF, Louis R. Real-word experience with mepolizumab: Does it deliver what it has promised? Clin Exp Allergy 2020; 50:687-695. [PMID: 32198794 DOI: 10.1111/cea.13601] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 03/02/2020] [Accepted: 03/15/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Randomized control trials performed in selected populations of severe eosinophilic asthmatics have shown that mepolizumab, an anti-IL5 therapy, was able to reduce exacerbations and OCS maintenance dose and in some studies, to improve asthma control and lung function. OBJECTIVE The aim of this study was to confirm the results of the RCTs in real-life in a population of 116 severe eosinophilic asthmatics treated with mepolizumab and who were followed up at the asthma clinic every month for at least 18 months. Severe asthmatics underwent FENO, lung function, asthma control and quality of life questionnaires, sputum induction and gave a blood sample at baseline, after 6 months and then every year. RESULTS We found a significant reduction in exacerbations by 85% after 6 months (P < .0001), which was maintained over time. We also found a significant and maintained reduction by 50% in the dose of oral corticosteroids (P < .001). Patients improved their ACT (+5.31pts, p<0.0001) ACQ (-1.13pts, P < .0001) and their AQLQ score (+1.24, P < .0001) at 6 months and this was maintained during follow-up. Only 37% reached asthma control (ACQ <1.5, ACT> 20). We observed a progressive increase in post-BD FEV1 that reached significance after 18 months (190ml or 11%, P < .01). Patients improving their FEV1had higher baseline sputum eosinophils than those not improving airway caliber. We found a significant reduction in sputum eosinophil counts by 60% after 6 months (P < .01) and a maintained reduction in blood eosinophil counts by 98% (P < .0001). CONCLUSION In our real-life study, we confirm the results published in the RCTs showing a sharp reduction in exacerbation and oral corticosteroids dose and an improvement in asthma control and quality of life. CLINICAL RELEVANCE Mepolizumab is efficient in severe eosinophilic asthma in real life.
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Affiliation(s)
- Florence Schleich
- Department of Pulmonary Medicine, CHU Sart-Tilman, Liege, Belgium.,I3 GIGA Research Group, University of Liege, Liege, Belgium
| | - Sophie Graff
- Department of Pulmonary Medicine, CHU Sart-Tilman, Liege, Belgium.,I3 GIGA Research Group, University of Liege, Liege, Belgium
| | - Haleh Nekoee
- Medical Informatics and Biostatistics, University of Liege, Liege, Belgium
| | - Catherine Moermans
- Department of Pulmonary Medicine, CHU Sart-Tilman, Liege, Belgium.,I3 GIGA Research Group, University of Liege, Liege, Belgium
| | - Monique Henket
- Department of Pulmonary Medicine, CHU Sart-Tilman, Liege, Belgium.,I3 GIGA Research Group, University of Liege, Liege, Belgium
| | - Carole Sanchez
- Department of Pulmonary Medicine, CHU Sart-Tilman, Liege, Belgium.,I3 GIGA Research Group, University of Liege, Liege, Belgium
| | - Virginie Paulus
- Department of Pulmonary Medicine, CHU Sart-Tilman, Liege, Belgium.,I3 GIGA Research Group, University of Liege, Liege, Belgium
| | - Françoise Guissard
- Department of Pulmonary Medicine, CHU Sart-Tilman, Liege, Belgium.,I3 GIGA Research Group, University of Liege, Liege, Belgium
| | | | - Renaud Louis
- Department of Pulmonary Medicine, CHU Sart-Tilman, Liege, Belgium.,I3 GIGA Research Group, University of Liege, Liege, Belgium
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Hoshi M, Matsunaga M, Nogami K, Hamada K, Kobori T, Kainuma K, Nagao M, Fujisawa T. Three cases of severe adolescent asthma treated with mepolizumab: lung function trajectories. Asia Pac Allergy 2020; 10:e13. [PMID: 32411578 PMCID: PMC7203436 DOI: 10.5415/apallergy.2020.10.e13] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 04/02/2020] [Indexed: 12/19/2022] Open
Abstract
Real-world experience with mepolizumab for pediatric asthma is still limited. We report 3 patients who were treated with mepolizumab for severe adolescent asthma. Two patients, a 12-year-old boy and a 14-year-old girl, responded well to mepolizumab and showed apparent improvement in lung function from a downward trend over time before treatment. The third patient, a 16-year-old boy, whose treatment was switched from omalizumab to mepolizumab, did not have satisfactory response. The 2 successful cases had eosinophil counts of 440 and 371/μL and multiple comorbid allergic diseases including food allergies. The clinical benefit to them included elimination of both exacerbation and exercise-induced asthma. Interestingly, the boy's food-induced gastrointestinal symptoms disappeared following start of mepolizumab treatment.
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Affiliation(s)
- Miyuki Hoshi
- Department of Clinical Research, National Hospital Organization Mie National Hospital, Tsu, Japan
| | - Mayumi Matsunaga
- Department of Clinical Research, National Hospital Organization Mie National Hospital, Tsu, Japan
| | - Kazutaka Nogami
- Department of Clinical Research, National Hospital Organization Mie National Hospital, Tsu, Japan
| | - Kana Hamada
- Department of Clinical Research, National Hospital Organization Mie National Hospital, Tsu, Japan
| | - Taiga Kobori
- Department of Clinical Research, National Hospital Organization Mie National Hospital, Tsu, Japan
| | - Keigo Kainuma
- Department of Clinical Research, National Hospital Organization Mie National Hospital, Tsu, Japan
| | - Mizuho Nagao
- Department of Clinical Research, National Hospital Organization Mie National Hospital, Tsu, Japan
| | - Takao Fujisawa
- Department of Clinical Research, National Hospital Organization Mie National Hospital, Tsu, Japan
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Abstract
PURPOSE OF REVIEW Children with poor asthma control despite maximal maintenance therapy have problematic severe asthma (PSA). A step-wise approach including objective adherence monitoring and a detailed multidisciplinary team assessment to identify modifiable factors contributing to poor control is needed prior to considering therapy escalation. Pathophysiological phenotyping in those with true severe therapy-resistant asthma (STRA) and the current array of add-on therapies will be discussed. RECENT FINDINGS Adherence monitoring using electronic devices has shown that only 20-30% of children with PSA have STRA and need additional therapies. Omalizumab and mepolizumab are licensed for children with STRA aged 6 years and older. Although robust safety and efficacy data, with reduced exacerbations, are available for omalizumab, biomarkers predicting response to treatment are lacking. Paediatric safety data are available for mepolizumab, but efficacy data are unknown for those aged 6-11 years and minimal for those 12 years and older. A sub-group of children with STRA have neutrophilia, but the clinical significance and contribution to disease severity remains uncertain. SUMMARY Most children with PSA have steroid sensitive disease which improves with adherence to maintenance inhaled corticosteroids. Add-on therapies are only needed for the minority with STRA. Paediatric efficacy data of novel biologics and biomarkers that identify the optimal add-on for each child are lacking. If we are to progress toward individualized therapy for STRA, pragmatic clinical trials of biologics in accurately phenotyped children are needed.
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34
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Mepolizumab prefilled syringe and autoinjector: a profile of their use in severe eosinophilic asthma. DRUGS & THERAPY PERSPECTIVES 2020. [DOI: 10.1007/s40267-020-00711-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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35
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Lambrecht BN, Hammad H, Fahy JV. The Cytokines of Asthma. Immunity 2019; 50:975-991. [PMID: 30995510 DOI: 10.1016/j.immuni.2019.03.018] [Citation(s) in RCA: 592] [Impact Index Per Article: 118.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 03/15/2019] [Accepted: 03/18/2019] [Indexed: 01/13/2023]
Abstract
Asthma is a chronic inflammatory airway disease associated with type 2 cytokines interleukin-4 (IL-4), IL-5, and IL-13, which promote airway eosinophilia, mucus overproduction, bronchial hyperresponsiveness (BHR), and immunogloubulin E (IgE) synthesis. However, only half of asthma patients exhibit signs of an exacerbated Type 2 response. "Type 2-low" asthma has different immune features: airway neutrophilia, obesity-related systemic inflammation, or in some cases, few signs of immune activation. Here, we review the cytokine networks driving asthma, placing these in cellular context and incorporating insights from cytokine-targeting therapies in the clinic. We discuss established and emerging paradigms in the context of the growing appreciation of disease heterogeneity and argue that the development of new and improved therapeutics will require understanding the diverse mechanisms underlying the spectrum of asthma pathologies.
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Affiliation(s)
- Bart N Lambrecht
- Laboratory of Immunoregulation, VIB Center for Inflammation Research, Ghent, Belgium; Department of Internal Medicine and Pediatrics, Ghent University, Ghent, Belgium; Department of Pulmonary Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands.
| | - Hamida Hammad
- Laboratory of Immunoregulation, VIB Center for Inflammation Research, Ghent, Belgium; Department of Internal Medicine and Pediatrics, Ghent University, Ghent, Belgium
| | - John V Fahy
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA; Cardiovascular Research Institute, University of California, San Francisco, San Francisco, USA
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Abstract
Current management of severe asthma relying either on guidelines (bulk approach) or on disease phenotypes (stratified approach) did not improve the burden of the disease. Several severe phenotypes are described: clinical, functional, morphological, inflammatory, molecular and microbiome-related. However, phenotypes do not necessarily relate to or give insights into the underlying pathogenetic mechanisms which are described by the disease endotypes. Based on the major immune-inflammatory pathway involved type-2 high, type-2 low and mixed endotypes are described for severe asthma, with several shared pathogenetic pathways such as genetic and epigenetic, metabolic, neurogenic and remodelling subtypes. The concept of multidimensional endotyping as un unbiased approach to severe asthma is discussed, together with new tools and targets facilitating the shift from the stratified to the precision medicine approach.
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Mkorombindo T, Dransfield MT. Mepolizumab in the treatment of eosinophilic chronic obstructive pulmonary disease. Int J Chron Obstruct Pulmon Dis 2019; 14:1779-1787. [PMID: 31496677 PMCID: PMC6689550 DOI: 10.2147/copd.s162781] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 07/10/2019] [Indexed: 11/23/2022] Open
Abstract
Despite maximal medical therapy, a subset of patients with chronic obstructive pulmonary disease continue to suffer acute exacerbations. It is also clear that a subset of this population has elevated blood eosinophils. In addition to clearly responding better to inhaled corticosteroids, it is also possible that this subgroup may benefit from biologic treatments targeting eosinophilic inflammation. Mepolizumab, a humanized monoclonal antibody against interleukin-5 (IL-5), may have a therapeutic effect in a subgroup of patients with COPD and eosinophilic airway inflammation. In this review, we discuss the biologic rationale for mepolizumab targeting IL-5 in eosinophilic COPD as well as the results of recently published clinical trials.
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Affiliation(s)
- Takudzwa Mkorombindo
- Lung Health Center, Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Mark T Dransfield
- Lung Health Center, Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
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Nagakumar P, Puttur F, Gregory LG, Denney L, Fleming L, Bush A, Lloyd CM, Saglani S. Pulmonary type-2 innate lymphoid cells in paediatric severe asthma: phenotype and response to steroids. Eur Respir J 2019; 54:1801809. [PMID: 31164437 PMCID: PMC6713888 DOI: 10.1183/13993003.01809-2018] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Accepted: 05/26/2019] [Indexed: 12/22/2022]
Abstract
Children with severe therapy-resistant asthma (STRA) have poor control despite maximal treatment, while those with difficult asthma (DA) have poor control from failure to implement basic management, including adherence to therapy. Although recognised as clinically distinct, the airway molecular phenotype, including the role of innate lymphoid cells (ILCs) and their response to steroids in DA and STRA is unknown.Immunophenotyping of sputum and blood ILCs and T-cells from STRA, DA and non-asthmatic controls was undertaken. Leukocytes were analysed longitudinally pre- and post-intramuscular triamcinolone in children with STRA. Cultured ILCs were evaluated to assess steroid responsiveness in vitroAirway eosinophils, type 2 T-helper (Th2) cells and ILC2s were significantly higher in STRA patients compared to DA and disease controls, while IL-17+ lymphoid cells were similar. ILC2s and Th2 cells were significantly reduced in vivo following intramuscular triamcinolone and in vitro with steroids. Furthermore, asthma attacks and symptoms reduced after systemic steroids despite persistence of steroid-resistant IL-17+ cells and eosinophils.Paediatric STRA and DA have distinct airway molecular phenotypes with STRA characterised by elevated type-2 cells. Systemic corticosteroids, but not maintenance inhaled steroids resulted in improved symptom control and exacerbations concomitant with a reduction in functional ILC2s despite persistently elevated IL-17+ lymphoid cells.
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Affiliation(s)
- Prasad Nagakumar
- National Heart and Lung Institute, Imperial College London, London, UK
- Respiratory Paediatrics, Royal Brompton Hospital and National Heart and Lung Institute, Imperial College London, London, UK
- Both authors contributed equally
| | - Franz Puttur
- National Heart and Lung Institute, Imperial College London, London, UK
- Both authors contributed equally
| | - Lisa G Gregory
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Laura Denney
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Louise Fleming
- Respiratory Paediatrics, Royal Brompton Hospital and National Heart and Lung Institute, Imperial College London, London, UK
| | - Andrew Bush
- Respiratory Paediatrics, Royal Brompton Hospital and National Heart and Lung Institute, Imperial College London, London, UK
| | - Clare M Lloyd
- National Heart and Lung Institute, Imperial College London, London, UK
- Both authors contributed equally
| | - Sejal Saglani
- National Heart and Lung Institute, Imperial College London, London, UK
- Respiratory Paediatrics, Royal Brompton Hospital and National Heart and Lung Institute, Imperial College London, London, UK
- Both authors contributed equally
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Proportion of Severe Asthma Patients Eligible for Mepolizumab Therapy by Age and Age of Onset of Asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 7:2689-2696.e2. [PMID: 31201938 DOI: 10.1016/j.jaip.2019.05.053] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 05/27/2019] [Accepted: 05/28/2019] [Indexed: 01/21/2023]
Abstract
BACKGROUND Mepolizumab is an anti-IL-5 antibody approved for the treatment of severe eosinophilic asthma. However, the prevalence of patients with severe asthma eligible for mepolizumab remains unknown, especially among children. OBJECTIVE To determine, in a population of patients with severe asthma from a tertiary referral center, the proportion of patients with an eosinophilic phenotype who would be eligible for mepolizumab, when stratified for the age of onset of asthma, and the prevalence of phenotypic features that favor mepolizumab therapy. METHODS An extensive database of 245 adults and children referred for severe asthma was used. The prevalence of severe asthma was estimated by using the European Respiratory Society/American Thoracic Society criteria. Patients with an eosinophilic uncontrolled phenotype qualified for mepolizumab. RESULTS In our cohort, 216 (88%) had severe asthma. Based on blood eosinophils of either greater than or equal to 150 cells/μL or greater than or equal to 300 cells/μL, 61%/41% had an eosinophilic phenotype, while 49%/34% were eligible for mepolizumab therapy. A greater percentage of adults (60%/47% of adults with asthma onset in adulthood [AoA] and 48%/26% adults with childhood-onset asthma [<18 years, CoA]) were eligible compared with children (33%/24%), for eosinophil counts of ≥150 and ≥300 cells/μL, respectively; P < .05. Compared with adults, children had a similar number of exacerbations while having better lung function (P < .05). Among adults, those with AoA were older, were more likely to have nasal polyps (28% vs 5%; P < .05), and had higher blood eosinophil counts (272 vs 150 cells/μL; P < .05) compared with those with CoA, with no difference in lung function noted between the 2 groups. Subjects showing greater than or equal to 500 eosinophils/μL, a strong indicator for mepolizumab therapy, had more nasal polyps, higher inhaled steroid dose, lower lung function, and AoA predominance than did those with less than 500 eosinophils/μL (P < .05). CONCLUSIONS A smaller percentage of children with severe asthma were eligible for mepolizumab compared with their adult peers. Severe AoA has distinct phenotypic features that favor treatment with mepolizumab, including greater eosinophilia and nasal polyposis, in contrast to CoA, which appears to have fewer features of type 2 mucosal inflammation.
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Upham JW, Chung LP. Optimising treatment for severe asthma. Med J Aust 2019; 209:S22-S27. [PMID: 30453869 DOI: 10.5694/mja18.00175] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 05/30/2018] [Indexed: 11/17/2022]
Abstract
The treatment landscape in severe asthma is changing rapidly, with multiple new therapies emerging that promise to transform patient outcomes. In a patient who is not responding to conventional therapy with inhaled corticosteroids and long-acting β2-agonists, it is important to first consider if the diagnosis of asthma is correct and, second, to reflect on whether readily modifiable factors are contributing to poor asthma control. In selected patients it may be appropriate to consider a modified n-of-1 trial of add-on therapies such as long-acting anti-muscarinic agents, leukotriene blockers, theophylline or low dose macrolide antibiotics. A number of monoclonal antibodies are now available that target the molecular pathways that contribute to asthma pathogenesis, and more such agents are likely to emerge in the near future. These biologicals can be transformative in selected patients, markedly reducing the frequency of asthma exacerbations, and allowing many patients to reduce or eliminate their use of long term oral corticosteroids. If the promise of personalised treatment is to be fully realised, it is important that better methods are developed to target these new and expensive treatments to patients most likely to respond. The ultimate goal of inducing remission or cure of asthma is still some distance away.
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Affiliation(s)
- John W Upham
- Diamantina Institute, University of Queensland, Brisbane, QLD
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Morjaria JB, Emma R, Fuochi V, Polosa R, Caruso M. An evaluation of mepolizumab for the treatment of severe asthma. Expert Opin Biol Ther 2019; 19:491-500. [PMID: 31009582 DOI: 10.1080/14712598.2019.1610382] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Introduction: Asthma is considered one of the most common chronic conditions globally, characterized by variable airflow obstruction and symptoms. Severe asthma is diagnosed when asthma control requires high-intensity therapy or continues to remain uncontrolled despite treatment. Eosinophilic inflammation is known to be perpetuated by the activity of IL-5 in a proportion of severe asthma subjects, and targeting IL-5 may offer a therapeutic option. Areas covered: In this review, we discuss the role and pathogenesis of IL-5 and eosinophils in asthma and rationale of antagonizing IL-5 in severe eosinophilic asthma. Mepolizumab is the first of three anti-IL-5 biologics licensed in 2015 for use in this subgroup of patients. We discuss clinical and real-life studies leading up to its approval and post-marketing outcomes in terms of efficacy and safety to-date, as well as its pros and cons. Expert opinion: IL-5 antagonism has paved the way for an additional personalized therapeutic opportunity for use in severe asthma with eosinophilic inflammation, though there is limited evidence on the long-term implications of suppressing/depleting eosinophils and the duration for which they should be administered.
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Affiliation(s)
- Jaymin B Morjaria
- a Department of Respiratory Medicine , Royal Brompton & Harefield Hospital Foundation Trust, Harefield Hospital , Harefield , UK.,b Honorary Senior Clinical Lecturer, Respiratory Medicine , Imperial College , London , UK
| | - Rosalia Emma
- c Department of Clinical and Experimental Medicine , University of Catania , Catania (CT) , Italy
| | - Virginia Fuochi
- d Department of Biomedical and Biotechnological Sciences , University of Catania, Catania (CT) , Italy
| | - Riccardo Polosa
- c Department of Clinical and Experimental Medicine , University of Catania , Catania (CT) , Italy
| | - Massimo Caruso
- c Department of Clinical and Experimental Medicine , University of Catania , Catania (CT) , Italy.,d Department of Biomedical and Biotechnological Sciences , University of Catania, Catania (CT) , Italy
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Emma R, Morjaria JB, Fuochi V, Polosa R, Caruso M. Mepolizumab in the management of severe eosinophilic asthma in adults: current evidence and practical experience. Ther Adv Respir Dis 2019; 12:1753466618808490. [PMID: 30354852 PMCID: PMC6204623 DOI: 10.1177/1753466618808490] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Asthma is a chronic inflammatory condition involving the airways with varying pathophysiological mechanisms, clinical symptoms and outcomes, generally controlled by conventional therapies including inhaled corticosteroids and long-acting β2 agonists. However, these therapies are unable to successfully control symptoms in about 5–10% of severe asthma patients. Atopic asthma, characterized by high immunoglobulin (Ig)E or eosinophilia, represents about 50% of asthmatic patients. Interleukin (IL)-5 is the main cytokine responsible of activation of eosinophils, hence therapeutic strategies have been investigated and developed for clinical use. Biologics targeting IL-5 and its receptor (first mepolizumab and subsequently, reslizumab and benralizumab), have been recently approved and used as add-on therapy for severe eosinophilic asthma resulting in a reduction in the circulating eosinophil count, improvement in lung function and exacerbation reduction in asthma patients. Despite these biologics having been approved for stratified severe asthma patients that remain uncontrolled with high doses of conventional therapy, a number of patients may be eligible for more than one biologic. Presently, the lack of head-to-head studies comparing the biological agents among themselves and with conventional therapy make the choice of optimal therapy for each patient a challenge for clinicians. Moreover, discontinuation of these treatments, implications for efficacy or adverse events, in particular in long-term treatment, and needs for useful biomarkers are still matters of debate. In this review we evaluate to date, the evidence on mepolizumab that seems to demonstrate it is a well-tolerated and efficacious regimen for use in severe eosinophilic asthma, though more studies are still required.
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Affiliation(s)
- Rosalia Emma
- Department of Clinical and Experimental Medicine, University of Catania, Catania (CT), Italy
| | - Jaymin B Morjaria
- Department of Respiratory Medicine, Royal Brompton & Harefield Hospital Foundation Trust, Harefield Hospital, Hill End Road, Harefield, UK.,Honorary Senior Clinical Lecturer, Respiratory Medicine, Imperial College, London, UK
| | - Virginia Fuochi
- Department of Biomedical and Biotechnological Sciences, University of Catania, Catania (CT), Italy
| | - Riccardo Polosa
- Department of Clinical and Experimental Medicine, University of Catania, Catania (CT), Italy
| | - Massimo Caruso
- Department of Biomedical and Biotechnological Sciences, Department of Clinical and Experimental Medicine, University of Catania, Via S. Sofia, 97, 95123 Catania (CT), Italy
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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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Llanos JP, Bell CF, Packnett E, Thiel E, Irwin DE, Hahn B, Ortega H. Real-world characteristics and disease burden of patients with asthma prior to treatment initiation with mepolizumab or omalizumab: a retrospective cohort database study. J Asthma Allergy 2019; 12:43-58. [PMID: 30774390 PMCID: PMC6354698 DOI: 10.2147/jaa.s189676] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Purpose Patients with severe asthma are eligible for asthma-specific biologics as add-on therapies, such as mepolizumab and omalizumab, when optimized controller therapies are unable to control their symptoms. However, few real-world data are available to describe the characteristics and associated economic burden of patients considered to be candidates for mepolizumab or omalizumab therapy. Methods This retrospective cohort study investigated patients with asthma (≥12 years of age) identified at the time of first mepolizumab or omalizumab administration (index date) in the MarketScan™ Commercial Database. Data were collected during the 12-month period before the index date (baseline period) for two mutually exclusive patient groups (patients prescribed mepolizumab and omalizumab, respectively). Baseline demographics, history of exacerbations, healthcare resource utilization (HCRU), and medical costs were investigated. Results In total, 413 and 1,834 patients who had been prescribed mepolizumab or omalizumab, respectively, were identified. During the baseline period, patients prescribed mepolizumab experienced more exacerbations (81.4% vs 57.5%, P<0.001), had higher asthma-related HCRU for outpatient services (all P<0.01), and had higher total asthma-related healthcare costs (US$11,000 vs US$7,400, P<0.001) compared with patients prescribed omalizumab. Allergic rhinitis, atopic dermatitis, and chronic idiopathic urticaria were more common among patients prescribed omalizumab vs mepolizumab. In contrast, sinusitis, nasal polyps, and comorbid COPD were more common among patients prescribed mepolizumab vs omalizumab. Prescriptions of fixed-dose inhaled corticosteroids (ICSs) with long-acting β2-agonists (LABAs) and ICS/LABA/long-acting muscarinic antagonist triple therapy during the baseline period were higher among patients prescribed mepolizumab vs omalizumab (80.4% vs 56.8% and 27.1% vs 14.4%, respectively, both P<0.001). Conclusion In the 12 months prior to initiation of asthma-specific biologics, patients prescribed mepolizumab had a different prevalence of certain comorbidities, higher disease burden, higher HCRU, and higher healthcare costs compared with patients prescribed omalizumab.
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Affiliation(s)
| | | | - Elizabeth Packnett
- Truven Health Analytics, An IBM Watson Health Company, Ann Arbor, MI, USA
| | - Ellen Thiel
- Truven Health Analytics, An IBM Watson Health Company, Ann Arbor, MI, USA
| | - Debra E Irwin
- Truven Health Analytics, An IBM Watson Health Company, Ann Arbor, MI, USA
| | - Beth Hahn
- Respiratory, US Medical Affairs, GSK, Research Triangle Park, NC, USA,
| | - Hector Ortega
- Respiratory, US Medical Affairs, GSK, La Jolla, CA, USA
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Lima-Matos A, Ponte EV, de Jesus JPV, Almeida PCA, Lima VB, Kwon N, Riley J, de Mello LM, Cruz ÁA. Eosinophilic asthma, according to a blood eosinophil criterion, is associated with disease severity and lack of control among underprivileged urban Brazilians. Respir Med 2018; 145:95-100. [PMID: 30509723 DOI: 10.1016/j.rmed.2018.10.025] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2018] [Revised: 08/10/2018] [Accepted: 10/22/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Asthma is a syndrome with multiple phenotypes. Peripheral blood eosinophil counts might be the ideal biomarker to identify subjects with eosinophilic asthma. It is available, inexpensive, and it is associated with eosinophilia in sputum. OBJECTIVE The aim of this study was to evaluate whether blood eosinophilia is associated with asthma severity and to evaluate whether blood eosinophilia is associated with lack of control of asthma symptoms and airway obstruction. METHODS Case control study. The cases were subjects recruited from a cohort of patients with severe asthma, in Salvador-BR, demanding continuous inhaled corticosteroids and LABA. There were two control groups: 1) subjects with mild/moderate asthma, 2) subjects with no asthma. Subjects enrolled in the study answered questionnaires, had their blood and stool samples collected, performed spirometry and SPT. We established a cutoff ≥ 260 cells/mm3 for blood eosinophilia. RESULTS We evaluated 544 subjects in the case group, 452 subjects with mild to moderate asthma and 450 subjects with no asthma. The subjects of the case group had higher odds of presenting the eosinophilic phenotype in comparison to subjects with mild to moderate asthma [OR 1.60 95CI(1.19-2.16)] and no asthma [OR 3.93; 95CI(2.90-5.33)]. The eosinophilic phenotype, according to blood count, is associated with uncontrolled asthma [OR 1.56; 95CI(1.06-2.28)], but it is not associated with airway obstruction [OR 0.87; 95CI(0.61-1.24)]. CONCLUSION We conclude that the blood eosinophilia is a biomarker associated with asthma severity and poor symptom control, but we found no association with reduced lung function.
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Affiliation(s)
- Aline Lima-Matos
- ProAR, Núcleo de Excelência Em Asma, Universidade Federal da Bahia, Brazil.
| | | | | | | | - Valmar Bião Lima
- ProAR, Núcleo de Excelência Em Asma, Universidade Federal da Bahia, Brazil.
| | | | - John Riley
- Global Medical Affairs, GSK, Brentford, UK.
| | | | - Álvaro A Cruz
- ProAR, Núcleo de Excelência Em Asma, Universidade Federal da Bahia, Brazil.
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Walsh GM. Recent developments in the use of biologics targeting IL-5, IL-4, or IL-13 in severe refractory asthma. Expert Rev Respir Med 2018; 12:957-963. [PMID: 30193532 DOI: 10.1080/17476348.2018.1520095] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
INTRODUCTION Severe or refractory asthma is seen in approximately 5% of asthmatic subjects who have unsatisfactory symptom control despite adherence to high-dose inhaled glucocorticoid therapies resulting in significant morbidity, reduced quality of life and health-care cost implications. Asthma exhibits marked heterogeneity both clinically and at the molecular phenotypic level requiring specifically targeted treatments to block the key pathways of the disease. Monoclonal antibody-based biologics targeted at inhibition of the type 2 cytokines IL-4, IL-5, and IL-13 have considerable potential as effective treatments for severe asthma. Areas covered: This review is based on recent English-language original articles in PubMed or Medline that reported significant clinical findings on the current status, therapeutic potential, and safety of biologics targeted at IL-4, IL-5, and IL-13 in the treatment of asthma together with the potential utility of simple reproducible non-invasive biomarkers to guide the effective use of biologic-based therapy that do not require direct sampling of the airways Expert commentary: The further development of reproducible and straightforward discriminatory non-invasive biomarkers may aid identification of those patients most likely to benefit from treatment with these interventions.
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Affiliation(s)
- Garry M Walsh
- a School of Medicine, Medical Sciences and Nutrition , Institute of Medical Sciences, University of Aberdeen , Aberdeen , UK
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47
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Grayson MH, Feldman S, Prince BT, Patel PJ, Matsui EC, Apter AJ. Advances in asthma in 2017: Mechanisms, biologics, and genetics. J Allergy Clin Immunol 2018; 142:1423-1436. [PMID: 30213625 DOI: 10.1016/j.jaci.2018.08.033] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 08/22/2018] [Accepted: 08/31/2018] [Indexed: 02/07/2023]
Abstract
This review summarizes some of the most significant advances in asthma research over the past year. We first focus on novel discoveries in the mechanism of asthma development and exacerbation. This is followed by a discussion of potential new biomarkers, including the use of radiographic markers of disease. Several new biologics have become available to the clinician in the past year, and we summarize these advances and how they can influence the clinical delivery of asthma care. After this, important findings in the genetics of asthma and heterogeneity in phenotypes of the disease are explored, as is the role the environment plays in shaping the development and exacerbation of asthma. Finally, we conclude with a discussion of advances in health literacy and how they will affect asthma care.
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Affiliation(s)
- Mitchell H Grayson
- Division of Allergy and Immunology, Department of Pediatrics, Nationwide Children's Hospital, Ohio State University College of Medicine, Columbus, Ohio.
| | - Scott Feldman
- Section of Allergy and Immunology, Division of Pulmonary Allergy Critical Care Medicine, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, Pa
| | - Benjamin T Prince
- Division of Allergy and Immunology, Department of Pediatrics, Nationwide Children's Hospital, Ohio State University College of Medicine, Columbus, Ohio
| | - Priya J Patel
- Section of Allergy and Immunology, Division of Pulmonary Allergy Critical Care Medicine, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, Pa
| | - Elizabeth C Matsui
- Department of Population Health, Dell Medical School, University of Texas-Austin, Austin, Tex
| | - Andrea J Apter
- Section of Allergy and Immunology, Division of Pulmonary Allergy Critical Care Medicine, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, Pa
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Maselli DJ, Hardin M, Christenson SA, Hanania NA, Hersh CP, Adams SG, Anzueto A, Peters JI, Han MK, Martinez FJ. Clinical Approach to the Therapy of Asthma-COPD Overlap. Chest 2018; 155:168-177. [PMID: 30077690 DOI: 10.1016/j.chest.2018.07.028] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 07/07/2018] [Accepted: 07/09/2018] [Indexed: 10/28/2022] Open
Abstract
Over the last few years, there has been a renewed interest in patients with characteristics of both asthma and COPD. Although the precise definition of asthma-COPD overlap (ACO) is still controversial, patients with overlapping features are frequently encountered in clinical practice, and may indeed have worse clinical outcomes and increased health-care utilization than those with asthma or COPD. Therefore, there is a critical need to set a framework for the therapeutic approach of such patients. There are key distinctions in the therapy between asthma and COPD, particularly regarding the initial choice of therapy. However, there is considerable overlap in the use of existing medications for both diseases. Furthermore, novel therapies approved for asthma, such as monoclonal antibodies, may have a role in patients with COPD and ACO. The use of biomarkers, such as peripheral blood eosinophils, exhaled nitric oxide, and serum IgE, may help in selecting appropriate therapies for ACO. In this review, we provide an overview of available treatments for both asthma and COPD and explore their potential role in the treatment of patients with ACO.
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Affiliation(s)
- Diego J Maselli
- Division of Pulmonary Diseases & Critical Care Medicine, Department of Medicine, University of Texas Health at San Antonio, San Antonio, TX.
| | | | - Stephanie A Christenson
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine and Cardiovascular Research Institute, University of California, San Francisco, San Francisco, CA
| | - Nicola A Hanania
- Section of Pulmonary and Critical Care Medicine, Baylor College of Medicine, Houston, TX
| | - Craig P Hersh
- Channing Division of Network Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Sandra G Adams
- Division of Pulmonary Diseases & Critical Care Medicine, Department of Medicine, University of Texas Health at San Antonio, San Antonio, TX; South Texas Veterans Health Care System, San Antonio, TX
| | - Antonio Anzueto
- Division of Pulmonary Diseases & Critical Care Medicine, Department of Medicine, University of Texas Health at San Antonio, San Antonio, TX; South Texas Veterans Health Care System, San Antonio, TX
| | - Jay I Peters
- Division of Pulmonary Diseases & Critical Care Medicine, Department of Medicine, University of Texas Health at San Antonio, San Antonio, TX; South Texas Veterans Health Care System, San Antonio, TX
| | - MeiLan K Han
- Division of Pulmonary and Critical Care Medicine, University of Michigan Health System, Ann Arbor, MI
| | - Fernando J Martinez
- Department of Medicine, Weill Cornell Medical College, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY
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Kerkhof M, Tran TN, van den Berge M, Brusselle GG, Gopalan G, Jones RCM, Kocks JWH, Menzies-Gow A, Nuevo J, Pavord ID, Rastogi S, Price DB. Association between blood eosinophil count and risk of readmission for patients with asthma: Historical cohort study. PLoS One 2018; 13:e0201143. [PMID: 30044863 PMCID: PMC6059485 DOI: 10.1371/journal.pone.0201143] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 07/08/2018] [Indexed: 11/18/2022] Open
Abstract
Background Recent studies have demonstrated an association between high blood eosinophil counts and greater risk of asthma exacerbations. We sought to determine whether patients hospitalized for an asthma exacerbation were at greater risk of readmission if they had a high blood eosinophil count documented before the first hospitalization. Methods This historical cohort study drew on 2 years of medical record data (Clinical Practice Research Datalink with Hospital Episode Statistics linkage) of patients (aged ≥5 years) admitted to hospital in England for asthma, with recorded blood eosinophil count within 1 baseline year before admission. We analyzed the association between high blood eosinophil count (≥0.35x109 cells/L) and readmission risk during 1 year of follow-up after hospital discharge, with adjustment for predefined, relevant confounders using forward selection. Results We identified 2,613 eligible patients with asthma-related admission, of median age 51 years (interquartile range, 36–69) and 76% women (1,997/2,613). Overall, 835/2,613 (32.0%) had a preadmission high blood eosinophil count. During the follow-up year, 130/2,613 patients (5.0%) were readmitted for asthma, including 55/835 (6.6%) with vs. 75/1,778 (4.2%) without high blood eosinophil count at baseline (adjusted hazard ratio [HR] 1.49; 95% CI 1.04–2.13, p = 0.029). The association was strongest in never-smokers (n = 1,296; HR 2.16, 95% CI 1.27–3.68, p = 0.005) and absent in current smokers (n = 547; HR 1.00, 95% CI 0.49–2.04, p = 0.997). Conclusions A high blood eosinophil count in the year before an asthma-related hospitalization is associated with increased risk of readmission within the following year. These findings suggest that patients with asthma and preadmission high blood eosinophil count require careful follow-up, with treatment optimization, after discharge.
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Affiliation(s)
- Marjan Kerkhof
- Observational & Pragmatic Research Institute Pte Ltd, Singapore, Singapore
| | - Trung N Tran
- AstraZeneca, Gaithersburg, MD, United States of America
| | - Maarten van den Berge
- University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | | | - Gokul Gopalan
- AstraZeneca, Gaithersburg, MD, United States of America
| | - Rupert C M Jones
- The Peninsula College of Medicine and Dentistry, Plymouth, United Kingdom
| | - Janwillem W H Kocks
- Observational & Pragmatic Research Institute Pte Ltd, Singapore, Singapore.,University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Andrew Menzies-Gow
- Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom
| | | | - Ian D Pavord
- Respiratory Medicine Unit and Oxford Respiratory NIHR BRC, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | | | - David B Price
- Observational & Pragmatic Research Institute Pte Ltd, Singapore, Singapore.,Academic Primary Care, University of Aberdeen, Aberdeen, United Kingdom
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50
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Boggu PR, Cho J, Kim Y, Jung SH. Identification of novel 2-benzyl-1-indanone analogs as interleukin-5 inhibitors. Eur J Med Chem 2018; 152:65-75. [PMID: 29689475 DOI: 10.1016/j.ejmech.2018.04.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 04/06/2018] [Accepted: 04/14/2018] [Indexed: 11/25/2022]
Abstract
A novel series of 2-benzyl-1-indanone analogs were investigated as IL-5 inhibitory activity. Among the synthesized compounds, 7-(cyclohexylmethoxy)-2-(4-hydroxybenzyl)-2,3-dihydro-1H-inden-1-one (7s, 100.0% inhibition at 30 μM, IC50 = 4.0 μM), and 7-(cyclohexylmethoxy)-2-(3-hydroxybenzyl)-2,3-dihydro-1H-inden-1-one (7t, 95.0% inhibition at 30 μM, IC50 = 6.0 μM) showed the best inhibitory activity against IL-5. The 2-benzyl-1-indanone analogs showed moderate to strong IL-5 inhibitory activity. Especially, hydroxyl (HBD/HBA) substituent at position 3 or 4 on phenyl ring B showed potent IL-5 inhibition. Additionally, the bulky hydrophobic cyclohexylmethoxy group at position 7 of the 1-indanone ring is favorable for the inhibitory activity.
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Affiliation(s)
- Pulla Reddy Boggu
- College of Pharmacy and Institute of Drug Research and Development, Chungnam National University, Daejeon, 34134, Republic of Korea
| | - Jungsuk Cho
- College of Pharmacy and Institute of Drug Research and Development, Chungnam National University, Daejeon, 34134, Republic of Korea
| | - Youngsoo Kim
- College of Pharmacy, Chungbuk National University, Cheongju, 19421, Republic of Korea
| | - Sang-Hun Jung
- College of Pharmacy and Institute of Drug Research and Development, Chungnam National University, Daejeon, 34134, Republic of Korea.
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