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Desaintjean C, Ahmad K, Traclet J, Gerfaud-Valentin M, Durel CA, Glerant JC, Hot A, Lestelle F, Mainbourg S, Nasser M, Seve P, Turquier S, Devouassoux G, Cottin V. Mepolizumab and benralizumab in patients with severe asthma and a history of eosinophilic granulomatosis with polyangiitis. Front Med (Lausanne) 2024; 11:1341310. [PMID: 38585151 PMCID: PMC10998444 DOI: 10.3389/fmed.2024.1341310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 02/26/2024] [Indexed: 04/09/2024] Open
Abstract
Introduction Asthma associated with eosinophilic granulomatosis with polyangiitis (EGPA) is often severe and corticosteroid-dependent, leading to significant morbidity. Mepolizumab and benralizumab are humanized monoclonal antibodies targeting interleukin 5 (IL-5) and its receptor, respectively. They have been shown to be effective in steroid-sparing in patients with severe eosinophilic asthma. Objective Our aim was to evaluate the efficacy and safety of mepolizumab and benralizumab prescribed for severe asthma in patients with EGPA under "real-world" conditions. Methods This was a retrospective analysis of patients with EGPA and persistent asthma who received either mepolizumab 100 or 300 mg administered every 4 weeks, or benralizumab 30 mg administered every 4 weeks for the initial 3 injections and followed by an injection every 8 weeks thereafter, whilst combined with oral glucocorticoids. The follow-up every 6 ± 3 months included an assessment of clinical manifestations, pulmonary function tests and eosinophil cell count. The primary outcome was the proportion of patients at 12 months receiving a daily oral dose of prednisone or equivalent of 4 mg or less with a BVAS of 0. Results Twenty-six patients were included. After 12 months of treatment with mepolizumab or benralizumab, 32% of patients met the primary outcome and were receiving less than 4 mg of prednisone per day with a BVAS of 0. The median dose of prednisone was 10 mg per day at baseline, 9 mg at 6 months, and 5 mg at 12 months (p ≤ 0.01). At 12 months, 23% of patients were weaned off corticosteroids, while an increase or no change in dose was observed in 27% of patients. The median eosinophil count was significantly reduced from 365 cells/mm3 to 55 cells/mm3 at 6 months and 70 cells/mm3 at 12 months, respectively. No significant change was observed in FEV1. After 12 months of treatment, 14% of patients had had an average of 1 exacerbation of asthma, compared with 52% of patients before baseline. The tolerability profile was favorable. Conclusion In this real-world study in patients with severe asthma and a history of EGPA asthma, mepolizumab and benralizumab had a significant steroid-sparing effect and reduced asthma exacerbation, but no significant effect on lung function.
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Affiliation(s)
- Charlene Desaintjean
- Department of Respiratory Medicine, National Reference Centre for Rare Pulmonary Diseases, Member of ERN-LUNG, Louis Pradel Hospital, Hospices Civils de Lyon, Lyon, France
| | - Kaïs Ahmad
- Department of Respiratory Medicine, National Reference Centre for Rare Pulmonary Diseases, Member of ERN-LUNG, Louis Pradel Hospital, Hospices Civils de Lyon, Lyon, France
| | - Julie Traclet
- Department of Respiratory Medicine, National Reference Centre for Rare Pulmonary Diseases, Member of ERN-LUNG, Louis Pradel Hospital, Hospices Civils de Lyon, Lyon, France
| | | | - Cecile-Audrey Durel
- Department of Internal Medicine, Hôpital Saint-Joseph Saint-Luc, Lyon, France
| | - Jean-Charles Glerant
- Pulmonary Function Tests Department, Louis Pradel Hospital, Hospices Civils de Lyon, Lyon, France
| | - Arnaud Hot
- Department of Internal Medicine, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
| | - François Lestelle
- Department of Respiratory Medicine, National Reference Centre for Rare Pulmonary Diseases, Member of ERN-LUNG, Louis Pradel Hospital, Hospices Civils de Lyon, Lyon, France
| | - Sabine Mainbourg
- Department of Internal Medicine and Vascular Medicine, Lyon Sud Hospital, and Lyon Immunopathology Federation (LIFe), Hospices Civils de Lyon, Lyon, France
- UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Claude Bernard University Lyon 1, Lyon, France
| | - Mouhamad Nasser
- Department of Respiratory Medicine, National Reference Centre for Rare Pulmonary Diseases, Member of ERN-LUNG, Louis Pradel Hospital, Hospices Civils de Lyon, Lyon, France
| | - Pascal Seve
- Department of Internal Medicine, Hôpital de la Croix Rousse, Hospices Civils de Lyon, Lyon, France
- Research on Healthcare Performance (RESHAPE), INSERM U1290, Claude Bernard University Lyon 1, Lyon, France
| | - Ségolène Turquier
- Pulmonary Function Tests Department, Louis Pradel Hospital, Hospices Civils de Lyon, Lyon, France
| | - Gilles Devouassoux
- Department of Respiratory Medicine, CIERA, Hôpital de la Croix Rousse, Hospices Civils de Lyon, Lyon, France
- CRISALIS INSERM, F-CRIN Network, Toulouse, France
- VirPath, INSERM U1111-CNRS UMR 5308-ENS de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Vincent Cottin
- Department of Respiratory Medicine, National Reference Centre for Rare Pulmonary Diseases, Member of ERN-LUNG, Louis Pradel Hospital, Hospices Civils de Lyon, Lyon, France
- UMR 754, INRAE, Claude Bernard University Lyon 1, Lyon, France
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Akdime F, Habib S, Regard L, Terrier B, Cohen P, Mouthon L, Guillevin L, Burgel PR, Honore I, Puéchal X, Roche N. [Anti-IL-5 in severe asthma associated with eosinophilic granulomatosis with polyangiitis. Real-life study]. Rev Mal Respir 2023; 40:732-742. [PMID: 37923651 DOI: 10.1016/j.rmr.2023.10.003] [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: 01/02/2023] [Accepted: 08/17/2023] [Indexed: 11/07/2023]
Abstract
INTRODUCTION Eosinophilic granulomatosis with polyangiitis (EGPA) is a form of necrotizing vasculitis affecting small vessels and typically characterized by severe glucocorticoid (GC)-dependent eosinophilic asthma. While mepolizumab, which is indicated at a dose of 100mg/4weeks in severe eosinophilic asthma, has been shown to be an effective treatment for EGPA-related asthma at a dose of 300mg/4weeks, it was only recently approved at this dose. METHODS This retrospective, single-center, observational study was conducted to investigate over a 5-year period (2014-2019) the effect of mepolizumab 100mg/4weeks at 12months in patients with EGPA and glucocorticoid-dependant severe asthma. Response to treatment was defined as reduction in daily dose of oral corticosteroids to at most 5mg/day or reduction in annual exacerbation by at least 50%. RESULTS Thirty patients were included, of whom twenty-three were treated (two were not fully evaluable). Among the 21 evaluable treated patients, 13 (62%) had responded at 12months. At baseline, non-responders had lower FEV1 levels and lower blood eosinophil levels than responders. CONCLUSIONS Mepolizumab at a "severe asthma" dose (100mg/4weeks) is effective in treatment of GC-dependent severe asthma in most patients with EGPA.
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Affiliation(s)
- F Akdime
- Service de pneumologie, hôpital Cochin, Assistance publique-Hôpitaux de Paris-Centre, Paris, France
| | - S Habib
- Service de pneumologie, hôpital Cochin, Assistance publique-Hôpitaux de Paris-Centre, Paris, France
| | - L Regard
- Service de pneumologie, hôpital Cochin, Assistance publique-Hôpitaux de Paris-Centre, Paris, France; Institut Cochin, Inserm UMR1016, université Paris Cité, Paris, France
| | - B Terrier
- Service de médecine interne, centre de référence des maladies auto-immunes systémiques rares d'Île-de-France, hôpital Cochin, université Paris Cité, Paris, France; Institut Cochin, Inserm UMR1016, université Paris Cité, Paris, France
| | - P Cohen
- Service de médecine interne, centre de référence des maladies auto-immunes systémiques rares d'Île-de-France, hôpital Cochin, université Paris Cité, Paris, France; Institut Cochin, Inserm UMR1016, université Paris Cité, Paris, France
| | - L Mouthon
- Service de médecine interne, centre de référence des maladies auto-immunes systémiques rares d'Île-de-France, hôpital Cochin, université Paris Cité, Paris, France; Institut Cochin, Inserm UMR1016, université Paris Cité, Paris, France
| | - L Guillevin
- Service de médecine interne, centre de référence des maladies auto-immunes systémiques rares d'Île-de-France, hôpital Cochin, université Paris Cité, Paris, France; Institut Cochin, Inserm UMR1016, université Paris Cité, Paris, France
| | - P R Burgel
- Service de pneumologie, hôpital Cochin, Assistance publique-Hôpitaux de Paris-Centre, Paris, France; Institut Cochin, Inserm UMR1016, université Paris Cité, Paris, France
| | - I Honore
- Service de pneumologie, hôpital Cochin, Assistance publique-Hôpitaux de Paris-Centre, Paris, France
| | - X Puéchal
- Service de médecine interne, centre de référence des maladies auto-immunes systémiques rares d'Île-de-France, hôpital Cochin, université Paris Cité, Paris, France; Institut Cochin, Inserm UMR1016, université Paris Cité, Paris, France
| | - N Roche
- Service de pneumologie, hôpital Cochin, Assistance publique-Hôpitaux de Paris-Centre, Paris, France; Institut Cochin, Inserm UMR1016, université Paris Cité, Paris, France.
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Caminati M, Maule M, Benoni R, Micheletto C, Tecchio C, Vaia R, De Franceschi L, Guarnieri G, Vianello A, Senna G. Low-dose anti-IL 5 treatment in idiopathic hypereosinophilic syndrome: towards a precision medicine approach for remission maintenance. Orphanet J Rare Dis 2023; 18:302. [PMID: 37752586 PMCID: PMC10521477 DOI: 10.1186/s13023-023-02918-9] [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: 04/24/2023] [Accepted: 09/15/2023] [Indexed: 09/28/2023] Open
Abstract
Mepolizumab at the dose of 300 mg/4 weeks has been recently approved as an add-on therapy for patients with uncontrolled hypereosinophilic syndrome (HES) without any identifiable non-hematologic secondary cause. According to the available real-life evidence mepolizumab 300 mg and 100 mg, licensed for severe eosinophilic asthma, are comparable in terms of drug efficacy. However, the clinical rationale for selecting one dose or the other has not been explored. We investigated the efficacy and safety of mepolizumab 100 mg in idiopathic HES (I-HES) patients as a steroid sparing strategy for disease remission maintenance by assessing clinical conditions, blood eosinophil count (BEC) and adverse events at baseline and at 3-6-12 months follow-up. Overall, 11 patients were enrolled (females 4-36%) with a median age of 62 years (IQR 55.0-72.0). At 3-month visit both prednisone daily dose and BEC significantly decreased from baseline, whilst a substantial improvement of Brief fatigue inventory score (BFI) was not recorded before the 6 months assessment. More than 70% of patients completely stopped prednisone at 12-months follow-up, without any flare in terms of BEC and BFI. No adverse event was registered. Although larger studies are needed, our report firstly describes that in a well-defined population, diagnosed with I-HES and in disease remission, low dose mepolizumab is a safe and effective steroid-sparing option for remission maintenance. It suggests that a personalized treatment dose might be explored according to the disease classification and activity at the time of biologic treatment start.
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Affiliation(s)
- Marco Caminati
- Department of Medicine, University of Verona & AOUI Verona, Policlinico GB Rossi, Piazzale L.A. Scuro, 10, 37134, Verona, Italy.
| | - Matteo Maule
- Asthma Center and Allergy Unit, AOUI Verona, Policlinico GB Rossi, Verona, Italy
| | - Roberto Benoni
- Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | | | - Cristina Tecchio
- Haematology Unit, AOUI Verona, Policlinico GB Rossi, Verona, Italy
| | - Rachele Vaia
- Asthma Center and Allergy Unit, AOUI Verona, Policlinico GB Rossi, Verona, Italy
| | - Lucia De Franceschi
- Department of Medicine, University of Verona & AOUI Verona, Policlinico GB Rossi, Piazzale L.A. Scuro, 10, 37134, Verona, Italy
| | - Gabriella Guarnieri
- Department of Cardiac Thoracic Vascular Sciences and Public Health, University of Padova, Padua, Italy
| | - Andrea Vianello
- Department of Cardiac Thoracic Vascular Sciences and Public Health, University of Padova, Padua, Italy
| | - Gianenrico Senna
- Department of Medicine, University of Verona & AOUI Verona, Policlinico GB Rossi, Piazzale L.A. Scuro, 10, 37134, Verona, Italy
- Asthma Center and Allergy Unit, AOUI Verona, Policlinico GB Rossi, Verona, Italy
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Nolasco S, Portacci A, Campisi R, Buonamico E, Pelaia C, Benfante A, Triggiani M, Spadaro G, Caiaffa MF, Scioscia G, Detoraki A, Valenti G, Papia F, Tomasello A, Crimi N, Scichilone N, Pelaia G, Carpagnano GE, Crimi C. Effectiveness and safety of anti-IL-5/Rα biologics in eosinophilic granulomatosis with polyangiitis: a two-year multicenter observational study. Front Immunol 2023; 14:1204444. [PMID: 37457743 PMCID: PMC10349177 DOI: 10.3389/fimmu.2023.1204444] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 06/05/2023] [Indexed: 07/18/2023] Open
Abstract
Background Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare vasculitis characterized by asthma, systemic manifestations, and blood and tissue eosinophilia. Objective To assess the effectiveness and safety of mepolizumab (anti-IL-5) and benralizumab (anti-IL-5Rα) in EGPA for 24 months. Methods We conducted a multicenter observational study, including patients with EGPA treated with anti-IL-5/Rα biologics in 9 Italian specialized facilities. Systemic disease activity, remission and relapse rate were evaluated from 3 to 24 months after treatment initiation. Respiratory outcomes, hematological parameters, corticosteroid (OCS) and immunosuppressants consumption were also assessed. Results 49 patients with relapsing-refractory EGPA were included [26 (53.1%) benralizumab 30mg, 20 (40.8%) mepolizumab 100mg, 3 (6.1%) mepolizumab 300mg]. Overall, 38.8% and 57.1% achieved remission after 12 and 24 months, respectively (69.2% benralizumab and 43.5% mepolizumab). Lower OCS intake and higher blood eosinophil count at baseline were associated with remission at 24 months. Both biologics exerted beneficial effects on severe asthma outcomes. Indeed, 61.2% (61.5% benralizumab and 60.8% mepolizumab) remained exacerbation-free during treatment. Lung function parameters showed improvements in the overall cohort (all p<0.05), but began to decline from month 12, especially with mepolizumab. Marked reduction in blood eosinophils was registered with mepolizumab (p<0.0001), while benralizumab depleted both eosinophils (p<0.0001) and basophils (p<0.0001). In general, 69.6% (76% benralizumab and 61.9% mepolizumab) of OCS-dependent patients lowered their daily dose by 75%, while 28.3% discontinued these drugs. Immunosuppressants were suspended in 88.2% of cases. Adverse events were reported in 8.2% of patients. Conclusions These real-world data suggest that anti-IL-5/Rα biologics are effective and safe in the long-term as add-on treatments for patients with EGPA.
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Affiliation(s)
- Santi Nolasco
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
- Respiratory Medicine Unit, Policlinico “G. Rodolico-San Marco” University Hospital, Catania, Italy
| | - Andrea Portacci
- Institute of Respiratory Disease, Department of Translational Biomedicine and Neuroscience, University “Aldo Moro”, Bari, Italy
| | - Raffaele Campisi
- Respiratory Medicine Unit, Policlinico “G. Rodolico-San Marco” University Hospital, Catania, Italy
| | - Enrico Buonamico
- Institute of Respiratory Disease, Department of Translational Biomedicine and Neuroscience, University “Aldo Moro”, Bari, Italy
| | - Corrado Pelaia
- Department of Health Sciences, University “Magna Graecia” of Catanzaro, Catanzaro, Italy
| | - Alida Benfante
- Division of Respiratory Diseases, Department of Health Promotion Sciences, Maternal and Infant Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
| | - Massimo Triggiani
- Division of Allergy and Clinical Immunology, University of Salerno, Salerno, Italy
| | - Giuseppe Spadaro
- Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, Naples, Italy
| | - Maria Filomena Caiaffa
- Department of Medical and Surgical Sciences, School and Chair of Allergology and Clinical Immunology, University of Foggia, Foggia, Italy
| | - Giulia Scioscia
- Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Aikaterini Detoraki
- Division of Internal Medicine and Clinical Immunology, Department of Internal Medicine and Clinical Complexity University of Naples Federico II, Naples, Italy
| | - Giuseppe Valenti
- Allergology and Pulmonology Unit, Provincial Outpatient Center of Palermo, Palermo, Italy
| | - Francesco Papia
- Allergology and Pulmonology Unit, Provincial Outpatient Center of Palermo, Palermo, Italy
| | - Alessandra Tomasello
- Division of Respiratory Diseases, Department of Health Promotion Sciences, Maternal and Infant Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
| | - Nunzio Crimi
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Nicola Scichilone
- Division of Respiratory Diseases, Department of Health Promotion Sciences, Maternal and Infant Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
| | - Girolamo Pelaia
- Department of Health Sciences, University “Magna Graecia” of Catanzaro, Catanzaro, Italy
| | - Giovanna Elisiana Carpagnano
- Institute of Respiratory Disease, Department of Translational Biomedicine and Neuroscience, University “Aldo Moro”, Bari, Italy
| | - Claudia Crimi
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
- Respiratory Medicine Unit, Policlinico “G. Rodolico-San Marco” University Hospital, Catania, Italy
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Paroli M, Gioia C, Accapezzato D. New Insights into Pathogenesis and Treatment of ANCA-Associated Vasculitis: Autoantibodies and Beyond. Antibodies (Basel) 2023; 12:antib12010025. [PMID: 36975372 PMCID: PMC10045085 DOI: 10.3390/antib12010025] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 01/29/2023] [Accepted: 03/14/2023] [Indexed: 03/29/2023] Open
Abstract
Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis is a group of rare systemic diseases affecting small-caliber vessels. The damage caused by AAV mainly involves the lung and kidneys. AAV includes three different types: granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA), and eosinophilic granulomatosis with polyangiitis (EGPA). Although the different phenotypic forms of AAV share common features, recent studies have shown that there are significant differences in terms of pathogenetic mechanisms involving both the adaptive and innate immune systems. Advances in our understanding of pathogenesis have enabled the development of immuno-targeted therapies. This review illustrates the characteristics of the various forms of AAV and the new therapies available for this disease that can have lethal consequences if left untreated.
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Affiliation(s)
- Marino Paroli
- Division of Clinical Immunology, Department of Clinical, Anesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, 00185 Rome, Italy
| | - Chiara Gioia
- Division of Clinical Immunology, Department of Clinical, Anesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, 00185 Rome, Italy
| | - Daniele Accapezzato
- Division of Clinical Immunology, Department of Clinical, Anesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, 00185 Rome, Italy
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Berti A, Atzeni F, Dagna L, Del Giacco S, Emmi G, Salvarani C, Vaglio A. Targeting the interleukin-5 pathway in EGPA: evidence, uncertainties and opportunities. Ann Rheum Dis 2023; 82:164-168. [PMID: 36357156 DOI: 10.1136/ard-2022-223044] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 10/24/2022] [Indexed: 11/12/2022]
Abstract
Only a minority of patients with eosinophilic granulomatosis with polyangiitis (EGPA) can be weaned-off glucocorticoids (GC) using conventional treatment strategies. The development of biological agents specifically inhibiting the IL-5 pathway provided the opportunity to treat EGPA by targeting one of the crucial regulators of eosinophils, reducing the GC dose required to control the disease.The anti-IL-5 antibody mepolizumab at the dose of 300 mg/4 weeks has proven to be safe and effective in EGPA. While relapsing patients-who often experience recurrent respiratory manifestations-benefit from this treatment, data are not enough to support its use combined with GC alone in remission induction of severe active forms, or in remission maintenance without conventional immunosuppressants in patients with vasculitic manifestations. Ultimately, the profile of the best candidate for mepolizumab is still unclear.Several real-life reports suggest that mepolizumab at the dose of 100 mg/4 weeks, approved for eosinophilic asthma/chronic rhinosinusitis with nasal polyposis (CRSwNP), effectively maintains remission of EGPA-related asthma and, to a lesser extent, CRSwNP. Preliminary data on the IL-5 pathway-inhibitors benralizumab and reslizumab in EGPA as steroid-sparing agents are also accumulating.Overall, it remains to be proven whether targeting the IL-5 pathway could block progression of organ damage in EGPA, on top of reducing relapses and sparing GC. Other disease-related factors further complicate the understanding of the real anti-IL-5 agent efficacy, such as the lack of a clear definition of remission, of an effective tool to measure disease activity, and of well-defined treat-to-target approaches or goals of treatment.
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Affiliation(s)
- Alvise Berti
- Rheumatology Unit, Santa Chiara Hospital, APSS Trento and University of Trento, Trento, Italy
| | | | - Lorenzo Dagna
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, Vita-Salute San Raffaele University, Milano, Italy.,Department of Medicine and Clinical Immunology, San Raffaele Scientific Institute, Milano, Italy
| | - Stefano Del Giacco
- Department of Experimental and Clinical Medicine, University of Cagliari, Cagliari, Italy
| | - Giacomo Emmi
- Department of Experimental and Clinical Medicine, University of Florence, Firenze, Italy
| | - Carlo Salvarani
- Unit of Rheumatology, Azienda Unità Sanitaria Locale-IRCCS, Reggio Emilia, Italy.,Department of Surgery, Medicine, Dentistry and Morphological Sciences with interest in Transplant, Oncology and Regenerative Medicine, University of Modena and Reggio Emilia, Modena, Italy
| | - Augusto Vaglio
- Deptartment of Biomedical, Experimental and Clinical Sciences, University of Florence, Firenze, Italy
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Caminati M, Maule M, Bello F, Emmi G. Biologics for eosinophilic granulomatosis with polyangiitis. Curr Opin Allergy Clin Immunol 2023; 23:36-43. [PMID: 36413432 DOI: 10.1097/aci.0000000000000875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
PURPOSE OF REVIEW The link between severe asthma and eosinophilic granulomatosis with polyangiitis (EGPA) in terms of pathophysiological background, clinical manifestations and disease evolution has leaded to investigate the relevance of anti T2 monoclonal antibodies licensed for severe asthma patients as a treatment option for EGPA. The present review aimed to provide un update on EGPA pathophysiology and to critically summarize the most robust evidence coming from trials and real-life setting on the use of anti T2 biologics in EGPA patients. RECENT FINDINGS Mepolizumab, an anti-interleukin-5 monoclonal antibody, is the only biologic drug targeting eosinophilic inflammation currently approved for EGPA treatment at the dose of 300 mg/4 weeks. Its use is restricted by the American College of Rheumatology guidelines to specific diseases phases and severity grades. However the most appropriate mepolizumab positioning and dose is still under investigation in the real life practice, which is providing an increasing amount of evidence confirming its efficacy, alone or in combination with other options in different disease stages. The relevance of other monoclonal antibodies interfering with T2 inflammation, including omalizumab and benralizumab, is under investigation but the evidence is still scarce. SUMMARY Taking into account the suboptimal medium-long term safety profile of conventional EGPA treatments, the opportunity of selectively targeting eosinophilic inflammation certainly represents a revolutionary approach. However, further real-word evidence is required to effectively position the new treatments in the light of the disease complexity, including different immunological drivers, and individual variability.
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Affiliation(s)
- Marco Caminati
- Allergy, Asthma, Clinical Immunology, Department of Medicine, University of Verona, Verona
| | - Matteo Maule
- Allergy, Asthma, Clinical Immunology, Department of Medicine, University of Verona, Verona
| | - Federica Bello
- Department of Experimental and Clinical Medicine, University of Firenze, Firenze, Italy
| | - Giacomo Emmi
- Centre for Inflammatory Diseases, Monash University Department of Medicine, Monash Medical Centre, Clayton, Victoria, Australia
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Abstract
PURPOSE OF REVIEW To provide a literature review of what is on the market and under study for some diseases treated with drugs targeting type 2 (T2) inflammation. RECENT FINDINGS Literature data have shown that drugs targeting type 2 inflammation are effective in asthma and nasal polyposis, conditions for which they are on the market, and have promising expectations in the case of eosinophilic esophagitis, especially using anti-IL-5/IL-5 receptor and IL-4 receptor antibodies, while concerning eosinophilic granulomatosis with polyangitis (EGPA), mepolizumab (MEP) was approved by FDA and EMA as a drug for the treatment of this condition because of the promising results obtained in trials and in real life. SUMMARY The use of these drugs is certainly an important achievement in the treatment of complex diseases such as those mentioned above, which are too often orphaned from innovative treatments and limited to the use of immunosuppressants and systemic corticosteroid for their control.
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Bond M, Fagni F, Moretti M, Bello F, Egan A, Vaglio A, Emmi G, Dejaco C. At the Heart of Eosinophilic Granulomatosis with Polyangiitis: into Cardiac and Vascular Involvement. Curr Rheumatol Rep 2022; 24:337-351. [PMID: 36194339 DOI: 10.1007/s11926-022-01087-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/23/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW To provide an overview of existing literature on pathogenetic and clinical aspects of cardiac and vascular involvement in eosinophilic granulomatosis with polyangiitis (EGPA). RECENT FINDINGS In EGPA, cardiac and vascular involvement are more common than previously thought. However, no international recommendations on the topic are available yet. Herein, we summarize the existing evidence on the topic and propose a diagnostic approach for cardiac involvement in EGPA. The prevalence of cardiovascular involvement in patients with EGPA varies greatly among published studies, ranging between 3.1-18.7% for occlusive arterial disease, 5.8-30% for venous thrombosis and 17-92% for heart involvement. Cardiac involvement in EGPA is associated with high mortality even though manifestations are heterogeneous. In principle, every anatomical structure of the heart can be involved, and EGPA-related heart disease may be completely asymptomatic at first. A careful diagnostic work-up for early detection and prompt treatment initiation is therefore required. While cardiac manifestations are more common in anti-neutrophil cytoplasmic antibodies (ANCA)-negative patients, arterial and venous thrombotic events are not linked to ANCA status but correlate closely with disease activity and accumulate at disease onset. Thrombotic events (mainly venous) are considerably more frequent in EGPA than in the general population contributing substantially to morbidity and highlighting the importance of developing specific prevention strategies for patients who are diagnosed with EGPA.
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Affiliation(s)
- Milena Bond
- Department of Rheumatology, Hospital of Brunico (SABES-ASDAA), Brunico, Italy
| | - Filippo Fagni
- Department of Internal Medicine 3 - Rheumatology and Immunology, Friedrich-Alexander University Erlangen-Nuremberg and Universitätsklinikum Erlangen, Erlangen, Germany
| | - Michele Moretti
- Department of Cardiology - Azienda Provinciale Per I Servizi Sanitari Di Trento, Trento, Italy
| | - Federica Bello
- Department of Experimental and Clinical Medicine, University of Firenze, and Internal Interdisciplinary Medicine Unit, Careggi University Hospital, Florence, Italy
| | - Allyson Egan
- Vasculitis & Lupus Unit, Department of Medicine, Addenbrookes Hospital, Cambridge, UK
| | - Augusto Vaglio
- Nephrology and Dialysis Unit, Meyer Children's Hospital, Florence, Italy.,Department of Biomedical, Experimental and Clinical Sciences "Mario Serio", University of Firenze, Florence, Italy
| | - Giacomo Emmi
- Department of Experimental and Clinical Medicine, University of Firenze, and Internal Interdisciplinary Medicine Unit, Careggi University Hospital, Florence, Italy
| | - Christian Dejaco
- Department of Rheumatology, Hospital of Brunico (SABES-ASDAA), Brunico, Italy. .,Department of Rheumatology and Immunology, Medical University of Graz, Graz, Austria.
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10
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Can Bostan O, Duran E, Tuncay G, Cihanbeylerden M, Karadag O, Damadoglu E, Karakaya G, Kalyoncu AF. Sinonasal and respiratory outcomes of eosinophilic granulomatosis with polyangiitis patients receiving 100 mg mepolizumab in real-life clinical practice: 1-year follow up study. J Asthma 2022; 60:931-937. [PMID: 35912568 DOI: 10.1080/02770903.2022.2109165] [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: 10/16/2022]
Abstract
Background: Mepolizumab 300 mg is an approved treatment option for patients with eosinophilic granulomatosis with polyangiitis (EGPA), yet, the adequacy of 100 mg of mepolizumab in disease control is controversial.Objective: To evaluate the sinonasal and respiratory outcomes of EGPA patients treated with 100 mg mepolizumab for one year.Methods: Evaluations of 11 patients were made of the sinonasal outcome test (SNOT-22) (nasal, otologic, sleep, and emotional domains), asthma control test (ACT), forced expiratory volume in 1s (FEV1), blood eosinophil counts and oral steroid doses before mepolizumab treatment (T0) and at the 6th (T6) and 12th (T12) months.Results: A significant decrease was observed in the total SNOT-22 scores in the 6th month, after which the scores continued to be stable until the 12th month. (SNOT-22 median (IQR); T0: 70(53-82); T6: 19(4-35); T12: 11(6-40); T0-T6, p = 0.02; T6-T12, p = 0.85). In the subdomains of SNOT-22, nasal and sleep-related domains improved significantly in the first 6 months, and the otologic and emotional domains only improved from baseline in the 12th month. There was a significant decrease in blood eosinophil counts in the 6th month and oral steroid dose in the 12th month (eosinophils, median(IQR), T0: 1000(700-1800), T6: 100(0-200), p = 0.02; OCS dose, median(IQR), T0: 16(8-16); T6: 4(0-4); T12: 0(0-4); T0-T12, p = 0.002). A significant improvement was observed in ACT values in the 6th month (ACT median (IQR); T0:16(8-18); T6: 22(21-25); p = 0.01).Conclusion: Mepolizumab 100 mg provided a significant decrease in SNOT-22 values, especially in nasal and sleep domains, eosinophil counts and OCS dose in the 6th month.
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Affiliation(s)
- Ozge Can Bostan
- Hacettepe University School of Medicine, Department of Chest Diseases, Division of Allergy and Clinical Immunology, Ankara, Turkey
| | - Emine Duran
- Hacettepe University School of Medicine, Department of Internal Medicine, Division of Rheumatology, Ankara, Turkey.,Hacettepe University School of Medicine, Vasculitis Research Centre, Ankara, Turkey
| | - Gulseren Tuncay
- Hacettepe University School of Medicine, Department of Chest Diseases, Division of Allergy and Clinical Immunology, Ankara, Turkey
| | - Melek Cihanbeylerden
- Hacettepe University School of Medicine, Department of Chest Diseases, Division of Allergy and Clinical Immunology, Ankara, Turkey
| | - Omer Karadag
- Hacettepe University School of Medicine, Department of Internal Medicine, Division of Rheumatology, Ankara, Turkey.,Hacettepe University School of Medicine, Vasculitis Research Centre, Ankara, Turkey
| | - Ebru Damadoglu
- Hacettepe University School of Medicine, Department of Chest Diseases, Division of Allergy and Clinical Immunology, Ankara, Turkey
| | - Gul Karakaya
- Hacettepe University School of Medicine, Department of Chest Diseases, Division of Allergy and Clinical Immunology, Ankara, Turkey
| | - Ali F Kalyoncu
- Hacettepe University School of Medicine, Department of Chest Diseases, Division of Allergy and Clinical Immunology, Ankara, Turkey
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11
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Abstract
PURPOSE OF REVIEW In recent years, therapeutic advances in eosinophilic granulomatosis with polyangiitis (EGPA) have changed our treatment paradigm. This review will summarize and discuss updates in management of EGPA, with a particular focus on biologic therapies. RECENT FINDINGS The anti-interleukin (IL)-5 agent mepolizumab (the first FDA-approved drug specifically for EGPA) is effective in induction and maintenance of remission particularly in patients with predominantly asthma and allergic manifestations, though efficacy in ANCA-positive, vasculitic disease is unclear; additional anti-IL-5 agents are under study. Rituximab is currently recommended for remission induction in severe disease, particularly in ANCA-positive patients with vasculitic manifestations, though the supportive evidence is mostly observational. Evidence supporting use of traditional DMARDs and other biologic agents such as omalizumab remains limited and observational. SUMMARY Although management of this heterogeneous disease remains challenging and unanswered questions remain, advances in biologics (particularly anti-IL-5 agents and an evolving interest in rituximab) have expanded our treatment armamentarium in EGPA.
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12
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Bettiol A, Urban ML, Dagna L, Cottin V, Franceschini F, Del Giacco S, Schiavon F, Neumann T, Lopalco G, Novikov P, Baldini C, Lombardi C, Berti A, Alberici F, Folci M, Negrini S, Sinico RA, Quartuccio L, Lunardi C, Parronchi P, Moosig F, Espígol-Frigolé G, Schroeder J, Kernder AL, Monti S, Silvagni E, Crimi C, Cinetto F, Fraticelli P, Roccatello D, Vacca A, Mohammad AJ, Hellmich B, Samson M, Bargagli E, Cohen Tervaert JW, Ribi C, Fiori D, Bello F, Fagni F, Moroni L, Ramirez GA, Nasser M, Marvisi C, Toniati P, Firinu D, Padoan R, Egan A, Seeliger B, Iannone F, Salvarani C, Jayne D, Prisco D, Vaglio A, Emmi G. Mepolizumab for Eosinophilic Granulomatosis with Polyangiitis (EGPA): a European multicenter observational study. ARTHRITIS & RHEUMATOLOGY (HOBOKEN, N.J.) 2021; 74:295-306. [PMID: 34347947 PMCID: PMC9305132 DOI: 10.1002/art.41943] [Citation(s) in RCA: 65] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 06/18/2021] [Accepted: 07/29/2021] [Indexed: 11/05/2022]
Abstract
OBJECTIVE Mepolizumab proved efficacious for eosinophilic granulomatosis with polyangiitis (EGPA, former Churg-Strauss) at the dosage of 300mg/4 weeks in the randomized controlled MIRRA trial. Few successful real-life experiences with the dosage approved for severe eosinophilic asthma (100mg/4 weeks) were recently reported. We retrospectively assessed the effectiveness and safety of mepolizumab 100 and 300mg/4 weeks in a large European EGPA cohort. METHODS We included all EGPA patients treated with mepolizumab at the recruiting centres in 2015-2020. Treatment response was evaluated from month 3 through 24 (T3-T24) after mepolizumab starting. Complete response (CR) was defined as no disease activity (Birmingham Vasculitis Activity Score, BVAS=0) and a prednisone dose ≤4mg/day. Respiratory outcomes included asthma and ear-nose-throat (ENT) exacerbations. RESULTS We included 203 patients, of whom 191 at stable dosage (158 mepolizumab 100mg/4 weeks, 33 300mg/4 weeks). At T3, 25 patients (12.3%) had a CR. CR rates increased to 30.4% and 35.7% at T12 and T24 and were comparable between mepolizumab 100 and 300mg/4 weeks. Mepolizumab led to a significant reduction in BVAS, prednisone dose, eosinophil counts from T3 through T24, with no significant differences between 100 and 300 mg/4weeks. Eighty-two patients (40.4%) experienced asthma exacerbations [57/158 (36%) on 100mg/4 weeks; 17/33 (52%) on 300mg/4 weeks]. Thirty-one (15.3%) experienced ENT exacerbations. Forty-four patients (21.7%) experienced adverse events, most being non-serious (38/44). CONCLUSION Mepolizumab both at 100 and 300mg/4 weeks is effective for EGPA. The two dosages should be compared in the setting of a controlled trial.
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Affiliation(s)
- Alessandra Bettiol
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Maria Letizia Urban
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Lorenzo Dagna
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Vincent Cottin
- Department of Respiratory Medicine, Hospices Civils de Lyon, University of Lyon, Lyon, France
| | - Franco Franceschini
- Rheumatology and Clinical Immunology Unit, ASST Spedali Civili of Brescia, Brescia, Italy.,Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Stefano Del Giacco
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Franco Schiavon
- Unit of Rheumatology, Department of Systems Medicine, Azienda Ospedaliera-Universitaria di Padova, Padova, Italy
| | - Thomas Neumann
- Department of Rheumatology and Immunology, Cantonal Hospital St, Gallen St, Gallen Switzerland.,Department of Internal Medicine III, Jena University Hospital, Jena, Germany
| | - Giuseppe Lopalco
- Rheumatology Unit, Department of Emergency and Organ Transplantation (DETO), Polyclinic Hospital, University of Bari, Bari, Italy
| | - Pavel Novikov
- Tareev Clinic of Internal Diseases, Sechenov First Moscow State Medical University, Moscow, Russia
| | | | - Carlo Lombardi
- Departmental Unit of Allergology-Clinical Immunology & Pneumology, Fondazione Poliambulanza Istituto Ospedaliero, Brescia
| | - Alvise Berti
- Santa Chiara Hospital, Department of Cellular, Computational and Integrative Biology - CIBIO, University of Trento, Trento, Italy
| | - Federico Alberici
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy.,Nephrology Unit, Spedali Civili Hospital, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Marco Folci
- Humanitas Clinical and Research Center-IRCCS, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Simone Negrini
- Internal Medicine, Clinical Immunology and Translational Medicine Unit, IRCCS Ospedale Policlinico San Martino, Genoa, Italy.,Centre of Excellence for Biomedical Research and Department of Internal Medicine, University of Genoa, Genoa, Italy
| | | | - Luca Quartuccio
- Department of Medicine, Rheumatology Clinic, University of Udine, ASUFC Udine, Udine, Italy
| | | | - Paola Parronchi
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Frank Moosig
- Rheumazentrum Schleswig-Holstein Mitte, Neumünster, Germany
| | - Georgina Espígol-Frigolé
- Department of Autoimmune Diseases, Hospital Clínic, University of Barcelona, Barcelona, Spain.,Institut d'investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | - Jan Schroeder
- Unit of Allergy and Immunology, ASST GOM Niguarda, Milan, Italy
| | | | - Sara Monti
- Department of Rheumatology, IRCCS Policlinico S. Matteo Fondazione, University of Pavia, Pavia, Italy
| | - Ettore Silvagni
- Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Claudia Crimi
- Respiratory Medicine Unit, Policlinico-Vittorio Emanuele San Marco" University Hospital, Catania, Italy
| | | | - Paolo Fraticelli
- Department of Internal Medicine, University Hospital "Ospedali Riuniti", Ancona, Italy
| | - Dario Roccatello
- Nephrology and Dialysis Unit (ERKnet Member)-CMID, Center of Research of Immunopathology and Rare Diseases, San Giovanni Bosco Hospital and University of Turin, Turin, Italy
| | - Angelo Vacca
- Guido Baccelli Unit of Internal Medicine, Department of Biomedical Sciences and Human Oncology, School of Medicine, Aldo Moro University of Bari, Bari, Italy
| | - Aladdin J Mohammad
- Lund University, Department of Clinical Sciences Lund, Rheumatology, Skåne University Hospital, Lund, Sweden.,Department of Medicine, University of Cambridge, Cambridge, UK
| | - Bernhard Hellmich
- Klinik für Innere Medizin, Rheumatologie und Immunologie, Vaskulitiszentrum Süd, Medius Kliniken, University of Tübingen, Kirchheim unter Teck, Germany
| | - Maxime Samson
- Department of Internal Medicine and Clinical Immunology, Dijon University Hospital, Dijon, France
| | | | - Jan Willem Cohen Tervaert
- Division of Rheumatology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.,Maastricht University, Maastricht, Netherlands
| | - Camillo Ribi
- Division of Immunology and Allergy, University Hospital Center of Lausanne, Lausanne, Switzerland
| | - Davide Fiori
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Federica Bello
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Filippo Fagni
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Luca Moroni
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Giuseppe Alvise Ramirez
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Mouhamad Nasser
- Department of Respiratory Medicine, Hospices Civils de Lyon, University of Lyon, Lyon, France
| | - Chiara Marvisi
- Rheumatology Unit, Azienda USL-IRCCS di Reggio Emilia.,Università di Modena e Reggio Emilia, Reggio Emilia and Modena, Italy
| | - Paola Toniati
- Rheumatology and Clinical Immunology Unit, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Davide Firinu
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Roberto Padoan
- Unit of Rheumatology, Department of Systems Medicine, Azienda Ospedaliera-Universitaria di Padova, Padova, Italy
| | - Allyson Egan
- Department of Medicine, University of Cambridge, Cambridge, UK
| | | | - Florenzo Iannone
- Rheumatology Unit, Department of Emergency and Organ Transplantation (DETO), Polyclinic Hospital, University of Bari, Bari, Italy
| | - Carlo Salvarani
- Rheumatology Unit, Azienda USL-IRCCS di Reggio Emilia.,Università di Modena e Reggio Emilia, Reggio Emilia and Modena, Italy
| | - David Jayne
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Domenico Prisco
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Augusto Vaglio
- Department of Biomedical, Experimental and Clinical Sciences "Mario Serio", University of Firenze, Florence, Italy.,Nephrology and Dialysis Unit, Meyer Children's Hospital, Florence, Italy
| | - Giacomo Emmi
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
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13
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Reply to "Mepolizumab in patients with eosinophilic granulomatosis with polyangiitis in remission: What is the right dose?". THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:2943-2944. [PMID: 34246445 DOI: 10.1016/j.jaip.2021.04.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 04/08/2021] [Indexed: 10/20/2022]
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14
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Akdime F, Puéchal X, Roche N. Mepolizumab in patients with eosinophilic granulomatosis with polyangiitis in remission: What is the right dose? THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2021; 9:2942-2943. [PMID: 34246444 DOI: 10.1016/j.jaip.2021.03.061] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 03/28/2021] [Accepted: 03/29/2021] [Indexed: 06/13/2023]
Affiliation(s)
- Florie Akdime
- Respiratory Medicine, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris Centre, Université de Paris, Paris, France.
| | - Xavier Puéchal
- National Referral Center for Rare Systemic Autoimmune Diseases, Department of Internal Medicine, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France
| | - Nicolas Roche
- Respiratory Medicine, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris Centre, Université de Paris, Paris, France
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Menzella F, Galeone C, Ghidoni G, Ruggiero P, Capobelli S, Simonazzi A, Catellani C, Scelfo C, Livrieri F, Facciolongo N. Successful treatment with benralizumab in a patient with eosinophilic granulomatosis with polyangiitis refractory to mepolizumab. Multidiscip Respir Med 2021; 16:779. [PMID: 34221399 PMCID: PMC8239622 DOI: 10.4081/mrm.2021.779] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 06/15/2021] [Indexed: 12/15/2022] Open
Abstract
Introduction Eosinophilic granulomatosis with polyangiitis (EGPA) is characterized by necrotizing eosinophilic granulomatous inflammation that frequently involves the respiratory tract (90% of cases). Asthma in EGPA is systematically severe and often refractory to common treatment, it is corticosteroid resistant and can often anticipate the onset of systemic vasculitis by many years. A release of cytokines necessary for the activation, maturation and survival of eosinophils, such as IL-4, IL-5 and IL-13 occurs in the activated Th-2 phenotype. In particular, IL-5 level is high in active EGPA and its inhibition has become a key therapeutic target. Oral glucocorticoids (OCS) are effective treatment options but unfortunately, frequent relapses occur in many patients and they lead to frequent side effects. As for now, there are currently no official recommendations on doses and treatment schedules in the management of EGPA. Case presentation In this article, we describe the case of a man with EGPA, severe asthma and chronic rhinosinusitis with nasal polyps (CRSwNP), with poor asthma and CRSwNP control despite OCS and mepolizumab treatment. Respiratory and vasculitis symptoms improved markedly after therapeutic switch to benralizumab. During the treatment, in addition to clinical effects, we witnessed a depletion of blood eosinophils, as well as an improvement in both pulmonary function tests, CT scan and skin lesions present initially. Conclusions While there are many studies confirming the efficacy of benralizumab in EGPA, the most interesting aspect of our report is that efficacy was confirmed in a patient previously unresponsive to mepolizumab, known to be effective in EGPA.
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Affiliation(s)
- Francesco Menzella
- Pneumology Unit, Arcispedale Santa Maria Nuova, Azienda USL di Reggio Emilia IRCCS, Reggio Emilia, Italy
| | - Carla Galeone
- Pneumology Unit, Arcispedale Santa Maria Nuova, Azienda USL di Reggio Emilia IRCCS, Reggio Emilia, Italy
| | - Giulia Ghidoni
- Pneumology Unit, Arcispedale Santa Maria Nuova, Azienda USL di Reggio Emilia IRCCS, Reggio Emilia, Italy
| | - Patrizia Ruggiero
- Pneumology Unit, Arcispedale Santa Maria Nuova, Azienda USL di Reggio Emilia IRCCS, Reggio Emilia, Italy
| | - Silvia Capobelli
- Pneumology Unit, Arcispedale Santa Maria Nuova, Azienda USL di Reggio Emilia IRCCS, Reggio Emilia, Italy
| | - Anna Simonazzi
- Pneumology Unit, Arcispedale Santa Maria Nuova, Azienda USL di Reggio Emilia IRCCS, Reggio Emilia, Italy
| | - Chiara Catellani
- Pneumology Unit, Arcispedale Santa Maria Nuova, Azienda USL di Reggio Emilia IRCCS, Reggio Emilia, Italy
| | - Chiara Scelfo
- Pneumology Unit, Arcispedale Santa Maria Nuova, Azienda USL di Reggio Emilia IRCCS, Reggio Emilia, Italy
| | - Francesco Livrieri
- Pneumology Unit, Arcispedale Santa Maria Nuova, Azienda USL di Reggio Emilia IRCCS, Reggio Emilia, Italy
| | - Nicola Facciolongo
- Pneumology Unit, Arcispedale Santa Maria Nuova, Azienda USL di Reggio Emilia IRCCS, Reggio Emilia, Italy
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Detoraki A, Tremante E, Poto R, Morelli E, Quaremba G, Granata F, Romano A, Mormile I, Rossi FW, de Paulis A, Spadaro G. Real-life evidence of low-dose mepolizumab efficacy in EGPA: a case series. Respir Res 2021; 22:185. [PMID: 34162391 PMCID: PMC8220666 DOI: 10.1186/s12931-021-01775-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 06/09/2021] [Indexed: 12/26/2022] Open
Abstract
Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare, small vessel, necrotizing vasculitis. The disease is mainly characterized by hypereosinophilia and asthma with frequent sinonasal involvement, although multiple organs can be affected, including the heart, lungs, skin, gastrointestinal tract, kidneys, and nervous system. IL-5 production is pathogenetically central for the development of the disease by promoting proliferation, transvascular migration and functional activation of eosinophils. The degree of blood and tissue eosinophilia appears to be associated with disease pathogenesis and eosinophil depletion represents a promising treatment approach for EGPA. We prospectively evaluated the efficacy and safety of a low dose (100 mg q4w), 12-month course of mepolizumab, an anti-IL-5 monoclonal antibody, in eight patients with severe asthma and active EGPA. Patients were recruited by the tertiary care center of Clinical Immunology and Allergy, University of Naples Federico II. The following outcomes were assessed before (T0), and after 6 (T6) and 12 months (T12) of mepolizumab treatment: Birmingham Vasculitis Activity Score (BVAS), prednisone intake, Sino-Nasal Outcome Test (SNOT-22), Total Endoscopic Polyp Score (TENPS), Asthma Control Test (ACT), Forced Expiratory Volume one second (FEV1)%, blood eosinophilia. BVAS score significantly decreased showing a sharp reduction in disease activity score. Clinical improvements in terms of sinonasal scores and asthma symptoms were observed, in parallel with a drastic drop in eosinophil blood count. Prednisone intake was significantly reduced. In two patients, asthma exacerbations led to discontinuation in mepolizumab therapy after 6 and 12 months despite BVAS reduction. Mepolizumab treatment was well tolerated, and no severe adverse drug effects were registered. In conclusion, our 12-month real-life study suggests that mepolizumab may be beneficial and safe in active EGPA patients by improving disease activity score, sinonasal and asthma outcomes while reducing the burden of prednisone intake.
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Affiliation(s)
- Aikaterini Detoraki
- Department of Internal Medicine, Clinical Immunology, Clinical Pathology and Infectious Diseases, Azienda Ospedaliera Universitaria Federico II, Naples, Italy.
| | | | - Remo Poto
- Post Graduate Program in Clinical Immunology and Allergy, University of Naples Federico II, Naples, Italy
| | - Emanuela Morelli
- Post Graduate Program in Clinical Immunology and Allergy, University of Naples Federico II, Naples, Italy
| | - Giuseppe Quaremba
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Francescopaolo Granata
- Department of Internal Medicine, Clinical Immunology, Clinical Pathology and Infectious Diseases, Azienda Ospedaliera Universitaria Federico II, Naples, Italy
| | - Antonio Romano
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, Maxilofacial Surgery Unit, University of Naples Federico II, Naples, Italy
| | - Ilaria Mormile
- Department of Translational Medical Sciences, University of Naples Ferderico II, Naples, Italy
| | - Francesca Wanda Rossi
- Department of Translational Medical Sciences, University of Naples Ferderico II, Naples, Italy
| | - Amato de Paulis
- Department of Translational Medical Sciences, University of Naples Ferderico II, Naples, Italy
| | - Giuseppe Spadaro
- Department of Translational Medical Sciences, University of Naples Ferderico II, Naples, Italy.,Allergy and Clinical Immunology Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, Naples, Italy
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17
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Caminati M, Giollo A, Senna G, Lunardi C. Biologics for Eosinophilic Granulomatosis With Polyangiitis-One Size Does Not Fit All: Comment on the Article by Canzian et al. Arthritis Rheumatol 2021; 73:1346-1347. [PMID: 33605091 DOI: 10.1002/art.41695] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Accepted: 02/04/2021] [Indexed: 11/09/2022]
Affiliation(s)
- Marco Caminati
- University of Verona and Verona University Hospital, Verona, Italy
| | | | - Gianenrico Senna
- University of Verona and Verona University Hospital, Verona, Italy
| | - Claudio Lunardi
- University of Verona and Verona University Hospital, Verona, Italy
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