1
|
Marseglia GL, Licari A, Tosca MA, Ciprandi G. Biologics to Treat Severe Asthma in Children and Adolescents: A Practical Update. PEDIATRIC ALLERGY, IMMUNOLOGY, AND PULMONOLOGY 2020; 33:168-176. [PMID: 35921565 PMCID: PMC9353987 DOI: 10.1089/ped.2020.1212] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Accepted: 10/04/2020] [Indexed: 06/15/2023]
Abstract
Background: Severe asthma represents a significant challenge for children and adolescents. At the same time, it often places a burden on patients, caregivers, and society, mainly related to morbidity, mortality, and health care resources. In children and adolescents, severe asthma is mostly characterized by type 2 inflammation, which leads to bronchial eosinophilia that may be suppressed by corticosteroids. However, in this age group, a high dosage of inhaled corticosteroids combined with systemic corticosteroids sometimes results in unacceptable side effects, such as reduced growth velocity and reduced bone mineral density. Therefore, there is increasing and enthusiastic interest in today's biologics, including omalizumab, mepolizumab, reslizumab, benralizumab, and dupilumab. There is growing evidence that they may be effective and safe add-on options for children and adolescents. In 2009, omalizumab was approved by the European Medicines Agency as the first available therapeutic option for allergic asthma in patients as young as 6 years of age, followed by a similar approval by the U.S. Food and Drug Administration in 2016. Previously, omalizumab was marketed for this indication in patients ≥ age 12. Subsequent biologics, namely mepolizumab, reslizumab, and benralizumab, are IL-5 targeted agents that are presently approved in some countries for severe eosinophilic asthma starting at 6 years of age. Dupilumab is targeted against the IL-4 receptor α-chain, and it has been approved in the United States and the European Union as an add-on maintenance therapy in patients ≥12 years of age. Conclusion: This review presents the most recent evidence on approved biologics for the treatment of severe asthma and discusses the unmet needs and future perspective, focusing on the pediatric and adolescent age groups.
Collapse
Affiliation(s)
- Gian Luigi Marseglia
- Department of Pediatrics, Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Amelia Licari
- Department of Pediatrics, Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | | | | |
Collapse
|
2
|
Tison KL, Patrawala M, Blaiss MS. Monoclonal Antibody Therapy in Childhood Asthma. Curr Allergy Asthma Rep 2020; 20:26. [PMID: 32430808 DOI: 10.1007/s11882-020-00919-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
PURPOSE OF REVIEW There has been an explosion of monoclonal antibodies in the treatment of severe uncontrolled adult asthma. Studies have now been published in severe pediatric asthma. There are numerous questions that need to be answered in determining whether these modalities are appropriate and safe in children. RECENT FINDINGS This is a narrative review examining the latest pediatric literature on monoclonal antibodies, both approved and in the pipeline, for uncontrolled asthma. Presently, all of the biologics are positioned to treat patients with underlying type 2 high disease. Two monoclonal antibodies are approved for children 6 years of age and older, omalizumab and mepolizumab, with more likely approved in the near future. The effect of these agents in controlling severe pediatric asthma is promising. Data is limited to long-term efficacy and safety, and whether any agent has an effect on the natural history of asthma.
Collapse
Affiliation(s)
- Katherine L Tison
- Emory University School of Medicine/Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Meera Patrawala
- Emory University School of Medicine/Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Michael S Blaiss
- Medical College of Georgia at Augusta University, Augusta, GA, USA. .,, Roswell, GA, USA.
| |
Collapse
|
3
|
Szefler SJ, Casale TB, Haselkorn T, Yoo B, Ortiz B, Kattan M, Busse WW. Treatment Benefit with Omalizumab in Children by Indicators of Asthma Severity. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:2673-2680.e3. [PMID: 32298853 DOI: 10.1016/j.jaip.2020.03.033] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 03/16/2020] [Accepted: 03/18/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND Greater severity in childhood asthma negatively impacts functioning and quality of life. Omalizumab is effective in children aged 6 years or older with moderate to severe persistent asthma, but predicting responsiveness in severe disease requires further study. OBJECTIVE To assess response to omalizumab treatment among children using indicators of asthma severity. METHODS Post hoc analyses of randomized placebo-controlled studies of omalizumab (Inner-City Anti-IgE Therapy for Asthma [ICATA], IA05, and Preventative Omalizumab or Step-up Therapy for Fall Exacerbations [PROSE]) stratified by body mass index, eosinophil count, fractional exhaled nitric oxide levels, and baseline severity indicators (baseline percent predicted FEV1, previous hospitalizations, asthma exacerbations). Poisson regression analysis examined exacerbation rate reductions for body mass index, biomarkers, and severity indicators. RESULTS Children aged 6 to 11 years in IA05 (N = 576; 56% white, 17% black, 26% other/missing), ICATA (N = 237; 55% black, 43% Hispanic), and PROSE (N = 342; 59% black, 35% Hispanic) were included. Trends indicative of greater exacerbation rate change ([omalizumab - placebo]/placebo) were observed for low baseline lung function (IA05 percent predicted FEV1: <90%, 36% reduction, 95% CI, -53.3 to -13.5; ≥90%, 22% reduction, 95% CI, -52.1 to 27.5), previous hospitalizations (ICATA: 46% reduction with, 95% CI, -69.7 to -3.9; 24% reduction without, 95% CI, -48.1 to 10.3), frequent baseline exacerbations (IA05: ≥3, 42% reduction, 95% CI, -60.4 to -14.1; <3, 20% reduction, 95% CI, -45.2 to -15.9), and high baseline eosinophil count (IA05: ≥300 cells/μL, 39% reduction, 95% CI, -56.4 to -14.7; <300 cells/μL, 5% reduction, 95% CI, -40.6 to 52.1). CONCLUSIONS Omalizumab reduces exacerbations in children with moderate to severe persistent allergic asthma, and may provide greater benefit in children with more severe asthma subtypes.
Collapse
Affiliation(s)
- Stanley J Szefler
- Pediatric Asthma Research Program, Breathing Institute, Children's Hospital Colorado, and University of Colorado School of Medicine, Aurora, Colo.
| | | | | | - Bongin Yoo
- Genentech, Inc, South San Francisco, Calif
| | | | - Meyer Kattan
- Columbia University College of Physicians and Surgeons, New York, NY
| | - William W Busse
- University of Wisconsin School of Medicine and Public Health, Madison, Wis
| |
Collapse
|
4
|
Pajno GB, Castagnoli R, Arasi S, Licari A, Caminiti L, Marseglia GL. Pediatric use of omalizumab for allergic asthma. Expert Opin Biol Ther 2020; 20:695-703. [PMID: 32241196 DOI: 10.1080/14712598.2020.1751115] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Severe pediatric asthma is associated with significant morbidity as well as with a high economic burden. It represents a heterogeneous disease with multiple clinical phenotypes. Currently, physicians are facing the challenge to provide a 'personalized medicine approach', which is tailored to the diverse pathomechanisms underlying clinical presentations. Three main endotypes of airway inflammation have been described in children with severe asthma. While neutrophilic and paucigranulocytic inflammatory patterns are quite uncommon in childhood, type Th2 inflammation asthma with elevated IgE is the most prevalent in pediatric asthma. Considering the pivotal role of IgE in type Th2 inflammation asthma, the blockade of IgE using anti-IgE therapy represents a potent therapeutic option for severe pediatric asthma in children. AREAS COVERED This review aims to focus on the role of omalizumab as a treatment option in pediatric patients (aged six years and above) with severe allergic asthma. EXPERT OPINION The clinical efficacy and safety of omalizumab for the treatment of pediatric asthma is well documented in clinical trials and observational studies. Further studies are still required to characterize the potential benefit of anti-IgE therapy in airway remodeling, identify additional biomarkers of clinical response and address current unmet needs, including the limit on omalizumab use in children younger than six years.
Collapse
Affiliation(s)
| | - Riccardo Castagnoli
- Department of Pediatrics, Foundation IRCCS Policlinico San Matteo, University of Pavia , Pavia, Italy
| | - Stefania Arasi
- Pediatric Allergology Unit, Bambino Gesù Hospital (IRCCS) , Rome, Italy
| | - Amelia Licari
- Department of Pediatrics, Foundation IRCCS Policlinico San Matteo, University of Pavia , Pavia, Italy
| | - Lucia Caminiti
- Department of Pediatrics, Allergy Unit, University of Messina , Messina, Italy
| | - Gian Luigi Marseglia
- Department of Pediatrics, Foundation IRCCS Policlinico San Matteo, University of Pavia , Pavia, Italy
| |
Collapse
|
5
|
Castagnoli R, Marseglia A, Brambilla I, Marseglia GL, Licari A. Severe uncontrolled asthma in children: practical approach on diagnosis and management. Minerva Pediatr 2020; 72:196-205. [PMID: 32108455 DOI: 10.23736/s0026-4946.20.05818-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Severe uncontrolled asthma in children is a complex and heterogeneous disease and is considered a challenge for the pediatricians. Although nearly 5% of children with asthma present with a severe uncontrolled disease, these patients and their caregivers face a significant burden, including troublesome persistent symptoms, life-threatening acute attacks, medication side effects, impaired school performance, neuropsychological problems, and lower quality of life (QoL). Moreover, these patients also account for substantially higher healthcare resource use and costs than average patients with asthma. Thus, it is essential to accurately define and diagnose severe asthma in children as they potentially need close monitoring and additional treatment with advanced therapies. This review aims to update knowledge on diagnosis and management of severe uncontrolled asthma in childhood. We describe a practical approach to differentiate children with difficult-to-treat asthma from those with true severe therapy-resistant asthma. Moreover, the recent advances in the understanding of the pathogenetic mechanisms and inflammatory mediators involved in asthma have paved the way for the development of a precision medicine approach. In this context, we analyze approved personalized therapies for severe uncontrolled asthma, focusing on the pediatric indications.
Collapse
Affiliation(s)
- Riccardo Castagnoli
- Department of Pediatrics, Pediatric Clinic, Policlinico San Matteo IRCCS Foundation, University of Pavia, Pavia, Italy
| | - Alessia Marseglia
- Department of Pediatrics, Pediatric Clinic, Policlinico San Matteo IRCCS Foundation, University of Pavia, Pavia, Italy
| | - Ilaria Brambilla
- Department of Pediatrics, Pediatric Clinic, Policlinico San Matteo IRCCS Foundation, University of Pavia, Pavia, Italy
| | - Gian Luigi Marseglia
- Department of Pediatrics, Pediatric Clinic, Policlinico San Matteo IRCCS Foundation, University of Pavia, Pavia, Italy
| | - Amelia Licari
- Department of Pediatrics, Pediatric Clinic, Policlinico San Matteo IRCCS Foundation, University of Pavia, Pavia, Italy -
| |
Collapse
|
6
|
Licari A, Castagnoli R, Tondina E, Testa G, Parisi GF, Marseglia A, Brambilla I, Marseglia GL. Novel Biologics for the Treatment of Pediatric Severe Asthma. CURRENT RESPIRATORY MEDICINE REVIEWS 2020. [DOI: 10.2174/1573398x15666190521111816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Estimated to represent less than 5% of all asthmatic patients, children with severe asthma
experience troublesome persistent symptoms, life-threatening attacks and side effects by oral
corticosteroid treatment, that significantly impact on the quality of life and on economic costs. An
accurate understanding of the mechanisms of the disease has been crucial for the discovery and
development of biological therapies, for which children with severe asthma are candidates. The aim
of this review is to discuss the use of approved biologics for severe asthma, providing updated evidence
of novel targeted therapies in the pediatric age range.
Collapse
Affiliation(s)
- Amelia Licari
- S.C. Pediatria, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | | | - Enrico Tondina
- Department of Pediatrics, University of Pavia, Pavia, Italy
| | - Giorgia Testa
- S.C. Pediatria, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Giuseppe Fabio Parisi
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | | | - Ilaria Brambilla
- S.C. Pediatria, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | | |
Collapse
|
7
|
Licari A, Manti S, Marseglia A, De Filippo M, De Sando E, Foiadelli T, Marseglia GL. Biologics in Children with Allergic Diseases. Curr Pediatr Rev 2020; 16:140-147. [PMID: 31660839 DOI: 10.2174/1573396315666191029123822] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 09/23/2019] [Accepted: 09/24/2019] [Indexed: 11/22/2022]
Abstract
The prevalence of allergic diseases has been remarkably increased in the last decades. The global health burden of these conditions is substantial, since patients may experience disability, anxiety and emotional distress, social restrictions, and reduced quality of life and productivity, in particular, in the most severe cases. Recent advances in understanding the pathophysiology of allergic disorders have allowed identifying novel therapeutic strategies for the treatment of severe and uncontrolled allergic diseases. Although most studies have been performed in allergic asthma, biological drugs targeting other allergic diseases such as chronic spontaneous urticaria, atopic dermatitis, and food allergy are showing promising results. In this review, the most recent evidence on biologic therapies for allergic diseases, focusing on the pediatric age has been presented.
Collapse
Affiliation(s)
- Amelia Licari
- Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, University of Pavia, viale Golgi 19, 27100 Pavia, Italy
| | - Sara Manti
- Department of Pediatric, Pediatric Unit, University of Messina, via Consolare Valeria, 1, 98125, Messina, Italy.,Respiratory Unit, AOU Policlinico-Vittorio Emanuele, Department of Clinical and Experimental Medicine, University of Catania, Via Santa Sofia 78, I-95123 Catania, Italy
| | - Alessia Marseglia
- Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, University of Pavia, viale Golgi 19, 27100 Pavia, Italy
| | - Maria De Filippo
- Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, University of Pavia, viale Golgi 19, 27100 Pavia, Italy
| | - Elisabetta De Sando
- Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, University of Pavia, viale Golgi 19, 27100 Pavia, Italy
| | - Thomas Foiadelli
- Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, University of Pavia, viale Golgi 19, 27100 Pavia, Italy
| | - Gian Luigi Marseglia
- Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, University of Pavia, viale Golgi 19, 27100 Pavia, Italy
| |
Collapse
|
8
|
Abstract
Severe asthma in children remains a significant issue. It places a heavy burden on affected individuals and society as a whole in terms of high morbidity, mortality, consumption of healthcare resources, and side effects from high-dose corticosteroid therapy. New, targeted biologic therapies for asthma have emerged as effective add-on options, complementing our expanding understanding of asthma phenotypes/endotypes and the underlying immunopathology of the disease spectrum. They include omalizumab, mepolizumab, reslizumab, benralizumab, and dupilumab. Omalizumab represents the first available therapeutic option for allergic asthma in patients as young as 6 years of age. Its efficacy and safety have been established by several randomized controlled trials specifically conducted in pediatric patients, leading to its final registration > 10 years ago. Three new interleukin (IL)-5 targeted agents, mepolizumab, reslizumab, and benralizumab, have been approved for the treatment of severe eosinophilic asthma starting from 6 years of age, and varying by country. More recently, dupilumab, a targeted agent against the IL-4 receptor α-chain, was approved for patients ≥12 years of age in the United States after pivotal trials were completed. The late-stage clinical testing of these targeted agents has mostly involved patients aged 12 years and up, and the application of those data to younger children can be inappropriate and carry risk. The efficacy and safety of these newer biologics in children should be supported by adequate research within this targeted age group. In this review, we will present the most recent evidence on these five biological therapies for severe asthma and will discuss dosage and administration, their efficacy, safety, and future prospects, with a focus on the pediatric age group, defined as age < 18 years.
Collapse
|
9
|
Licari A, Manti S, Castagnoli R, Marseglia A, Foiadelli T, Brambilla I, Marseglia GL. Immunomodulation in Pediatric Asthma. Front Pediatr 2019; 7:289. [PMID: 31355170 PMCID: PMC6640202 DOI: 10.3389/fped.2019.00289] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Accepted: 06/27/2019] [Indexed: 01/20/2023] Open
Abstract
Childhood asthma is actually defined as a heterogeneous disease, including different clinical variants and partially sharing similar immune mechanisms. Asthma management is mainly focused on maintaining the control of the disease and reducing the risk of adverse outcomes. Most children achieve good control with standard therapies, such as low doses of inhaled corticosteroids (ICS) and/or one or more controller. These medications are targeted to suppress bronchial inflammation and to restore airway responsiveness. However, they are not disease-modifying and do not specifically target inflammatory pathways of asthma; in addition, they are not significantly effective in patients with severe uncontrolled asthma. The aim of this review is to update knowledge on current and novel therapeutic options targeted to immunomodulate inflammatory pathways underlying pediatric asthma, with particular reference on biologic therapies.
Collapse
Affiliation(s)
- Amelia Licari
- Department of Pediatrics, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Sara Manti
- Unit of Pediatric Genetics and Immunology, Department of Pediatrics, University of Messina, Messina, Italy.,Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Riccardo Castagnoli
- Department of Pediatrics, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Alessia Marseglia
- Department of Pediatrics, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Thomas Foiadelli
- Department of Pediatrics, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Ilaria Brambilla
- Department of Pediatrics, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Gian Luigi Marseglia
- Department of Pediatrics, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| |
Collapse
|
10
|
Abrams EM, Becker AB, Szefler SJ. Current State and Future of Biologic Therapies in the Treatment of Asthma in Children. PEDIATRIC ALLERGY IMMUNOLOGY AND PULMONOLOGY 2018; 31:119-131. [PMID: 30283711 DOI: 10.1089/ped.2018.0901] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 07/26/2018] [Indexed: 02/06/2023]
Abstract
There is increasing recognition of phenotypic variability in pediatric asthma, providing the opportunity for a more personalized approach to therapy. Increasingly biologic therapies, in particular those targeting the "allergic" (or T helper 2) pathway, are being considered for children with severe asthma. However, there is a great deal of variability in the extent these biologic therapies have been studied in children, as well as efficacy of results thus far. The goal of this article is to review the mechanism of action, efficacy, and potential predictive and monitoring biomarkers of the biologic medications focusing on the pediatric population, in an effort to establish a more personalized approach to asthma in the pediatric population for the 21st century.
Collapse
Affiliation(s)
- Elissa M Abrams
- Section of Allergy and Clinical Immunology, Department of Pediatrics, University of Manitoba, Winnipeg, Canada
| | - Allan B Becker
- Section of Allergy and Clinical Immunology, Department of Pediatrics, University of Manitoba, Winnipeg, Canada
| | - Stanley J Szefler
- Department of Pediatrics, Section of Pulmonary Medicine, Breathing Institute, University of Colorado School of Medicine, Aurora, Colorado
| |
Collapse
|