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Chiner E, Murcia M, Boira I, Bernabeu MÁ, Esteban V, Martínez-Moragón E. Real-Life Clinical Outcomes of Benralizumab Treatment in Patients with Uncontrolled Severe Asthma and Coexisting Chronic Rhinosinusitis with Nasal Polyposis. J Clin Med 2024; 13:4247. [PMID: 39064286 PMCID: PMC11278437 DOI: 10.3390/jcm13144247] [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: 07/02/2024] [Revised: 07/15/2024] [Accepted: 07/18/2024] [Indexed: 07/28/2024] Open
Abstract
Background: The objective of this study was to evaluate, the clinical benefit of benralizumab in patients with uncontrolled severe asthma associated with chronic rhinosinusitis with nasal polyposis (CRSwNP). Methods: The study included patients with uncontrolled severe asthma associated with CRSwNP who started therapy with benralizumab. Pulmonary function, eosinophilia, IgE, comorbidity, changes in the Asthma Control Test (ACT), Asthma Control Questionnaire (ACQ), Visual Analogue Scale (VAS), Quality of Life (AQLQ), VAS (obstruction, drip, anosmia, facial pressure), SNOT-22, decrease or withdrawal of steroids and other medication, hospital admissions and emergency visits were analysed. The FEOS scale and EXACTO were employed in the assessment of response. Results: We analyzed 58 patients who completed minimal treatment at 12 months. After treatment with benralizumab, exacerbations were reduced by 82% (p < 0.001), steroid cycles by 84% (p < 0.001), emergencies visit by 83% p < 0.001) and admissions by 76% (p < 0.001), improving all the scales for asthma control, (p < 0.001). In terms of lung function, differences were observed in FVC% (p < 0.001), FEV1% (p < 0.001), and FEV1/FVC% (69.5 ± 10 vs. 74 ± 10, p < 0.001). In relation to CRSwNP, differences were observed in SNOT-22 (54.66 ± 17 vs. 20.24 ± 9, p < 0.001), VAS obstruction (7.91 ± 1 vs. 1.36 ± 1, p < 0. 001), VAS drip (7.76 ± 1 vs. 1.38 ± 1, p < 0.001), VAS anosmia (7.66 ± 1 vs. 1.38 ± 1, p < 0.001) and VAS facial pressure (7.91 ± 1 vs. 1.22 ± 1, p < 0.001). The mean FEOS score after treatment was 73 ± 14. A complete response/super response was achieved in 33 patients (57%), good response in 16 (28%) and partial response in 9 (15%). Conclusions: The administration of benralizumab to patients with uncontrolled severe asthma associated with CRSwNP has been demonstrated to improve nasal symptoms, asthma control and lung function. This resulted in a reduction in the need for oral steroids, maintenance and rescue medication, emergency room visits, and hospital admissions, with 57% of patients achieving the clinical remission criteria.
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Affiliation(s)
- Eusebi Chiner
- Pulmonology Department, University Hospital of Saint John of Alicante, 03550 Alicante, Spain; (E.C.); (M.M.); (V.E.)
| | - María Murcia
- Pulmonology Department, University Hospital of Saint John of Alicante, 03550 Alicante, Spain; (E.C.); (M.M.); (V.E.)
| | - Ignacio Boira
- Pulmonology Department, University Hospital of Saint John of Alicante, 03550 Alicante, Spain; (E.C.); (M.M.); (V.E.)
| | - María Ángeles Bernabeu
- Pharmacy Department, University Hospital of Saint John of Alicante, 03550 Alicante, Spain;
| | - Violeta Esteban
- Pulmonology Department, University Hospital of Saint John of Alicante, 03550 Alicante, Spain; (E.C.); (M.M.); (V.E.)
| | - Eva Martínez-Moragón
- Pulmonology Department, Doctor Peset University Hospital, 46017 Valencia, Spain;
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Domínguez-Ortega J, Mullol J, Álvarez Gutiérrez FJ, Miguel-Blanco C, Castillo JA, Olaguibel JM, Blanco-Aparicio M. The effect of biologics in lung function and quality of life of patients with united airways disease: A systematic review. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. GLOBAL 2024; 3:100174. [PMID: 37915724 PMCID: PMC10616425 DOI: 10.1016/j.jacig.2023.100174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 08/08/2023] [Accepted: 08/16/2023] [Indexed: 11/03/2023]
Abstract
Background Increasing evidence supports the united airway disease concept for the management of upper and lower respiratory tract diseases, particularly in patients with asthma and chronic rhinosinusitis with nasal polyps (CRSwNP). However, evidence for a combined approach in asthma and CRSwNP is scarce. Objective In this systematic review, we focused on the role of biologics in the lung function and quality of life in patients with severe asthma and CRSwNP. Methods We conducted a systematic search of 3 electronic databases using 2 search strategies to identify studies published from January 2010 to March 2022. Quality assessment was performed with the Critical Appraisal Skills Programme. Results Of 1030 studies identified, 48 original studies reporting data of benralizumab (12), dupilumab (14), mepolizumab (10), omalizumab (13), and reslizumab (2) were analyzed. Primary diagnosis was mostly asthma or CRSwNP, with only 15 studies, mainly observational, performed in populations with united airway disease. In total, 18 studies reported data on quality of life (mostly 22-item Sino-Nasal Outcome Test score), 8 on lung function (mostly FEV1), and 22 on both outcomes. Significant FEV1 and 22-item Sino-Nasal Outcome Test score improvements were consistently observed after 24-week treatment, and thereafter, mostly in real-world studies that included variable proportions of patients with asthma/CRSwNP. Conclusions The use of biologics in patients with severe asthma and CRSwNP was overall associated with significant improvements in lung function and quality of life. However, we observed a high heterogeneity of populations and outcome measurements across studies. Notwithstanding the need of larger studies, our results reinforce the joint management of asthma and CRSwNP as united airway disease in clinical practice.
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Affiliation(s)
- Javier Domínguez-Ortega
- Department of Allergy, La Paz University Hospital, Institute for Health Research (IdiPAZ), CIBER of Respiratory Diseases (CIBERES), Madrid, Spain
| | - Joaquim Mullol
- Rhinology Unit & Smell Clinic, ENT Department, Hospital Clinic, Universitat de Barcelona, IDIBAPS, CIBERES, Barcelona, Spain
| | | | | | | | - Jose María Olaguibel
- Department of Allergy, Hospital Universitario de Navarra, CIBER of Respiratory Diseases (CIBERES), Navarra, Spain
| | - Marina Blanco-Aparicio
- Department of Respiratory Medicine, Complexo Hospitalario Universitario de A Coruña A Coruña Spain
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Guo CL, Liu FF, Wang DY, Liu Z. Type 2 Biomarkers for the Indication and Response to Biologics in CRSwNP. Curr Allergy Asthma Rep 2023; 23:703-713. [PMID: 37987873 DOI: 10.1007/s11882-023-01114-w] [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] [Accepted: 10/27/2023] [Indexed: 11/22/2023]
Abstract
PURPOSE OF REVIEW Three biologics targeting type 2 inflammation have been approved for the treatment of severe and uncontrolled chronic rhinosinusitis with nasal polyps (CRSwNP). Nevertheless, around 40-60% of patients do not respond well to these biological treatments. Selecting appropriate patients is crucial to improve treatment outcome of biologics. This review summarizes the literature data on type 2 biomarkers, with a specific focus on the indication to biologics for severe CRSwNP. RECENT FINDINGS No consensus has been reached on how to define mucosal type 2 inflammation in CRSwNP. Clinical markers (e.g., 22-item Sino-nasal Outcome Test (SNOT-22) score, Lund-Mackay CT score (LMS), ethmoid/maxillary sinus CT score, and CT-radiomics), nasal secretion biomarkers (e.g., eosinophil cationic protein and interleukin-5), blood and nasal cytology eosinophil counts, and nasal swab eosinophil peroxidase activity have been reported to be associated with type 2 inflammation in CRSwNP. The time duration since the last surgery, SNOT-22 score at 1 week of treatment, and baseline serum osteoprotegerin levels might indicate the response to dupilumab. LMS and asthma control test scores were found to have moderate predictive value for acceptable improvement after 24-week treatment of omalizumab. High blood eosinophil levels at baseline were associated with treatment response to mepolizumab and benralizumab. Although several clinical and biological markers might be associated with type 2 inflammation and response to biologics in patients with CRSwNP, their validity requires further investigation. Identifying clinically applicable biomarkers for biologic treatment holds significant promise for advancing personalized approaches to biologics and optimizing treatment outcomes for patients with CRSwNP.
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Affiliation(s)
- Cui-Lian Guo
- Department of Otolaryngology-Head and Neck Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1095 Jiefang Avenue, Wuhan, 430030, People's Republic of China
- Institute of Allergy and Clinical Immunology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
- Hubei Clinical Research Center for Nasal Inflammatory Diseases, Wuhan, People's Republic of China
| | - Fei-Fan Liu
- Department of Otolaryngology-Head and Neck Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1095 Jiefang Avenue, Wuhan, 430030, People's Republic of China
- Institute of Allergy and Clinical Immunology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
- Hubei Clinical Research Center for Nasal Inflammatory Diseases, Wuhan, People's Republic of China
| | - De-Yun Wang
- Department of Otolaryngology, Infectious Diseases Translational Research Program, Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road, Singapore, 119228, Singapore.
| | - Zheng Liu
- Department of Otolaryngology-Head and Neck Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1095 Jiefang Avenue, Wuhan, 430030, People's Republic of China.
- Institute of Allergy and Clinical Immunology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China.
- Hubei Clinical Research Center for Nasal Inflammatory Diseases, Wuhan, People's Republic of China.
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Cergan R, Berghi ON, Dumitru M, Vrinceanu D, Manole F, Serboiu CS. Biologics for Chronic Rhinosinusitis-A Modern Option for Therapy. Life (Basel) 2023; 13:2165. [PMID: 38004305 PMCID: PMC10672088 DOI: 10.3390/life13112165] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 11/02/2023] [Accepted: 11/03/2023] [Indexed: 11/26/2023] Open
Abstract
Chronic rhinosinusitis (CRS) is an important ENT pathology which affects about 5-12% of the general population. The treatment of CRS can be pharmacological (nasal sprays, douches, systemic antibiotics and steroids), surgical (endoscopic sinus surgery) or immunological according to established algorithms. CRS was divided for many years into CRS with nasal polyps (CRSwNP) and CRS without nasal polyps (CRSsNP). New ways of classifying CRS by endotypes (presence of neutrophilia, eosinophilia, fibrosis, glandular hypertrophy and epithelial dysmorphisms) appeared after the most recent understandings of the pathophysiology of the disease. Other classifications divide CRS into primary and secondary forms, localized/diffuse types and anatomical presentation. A new type of treatment has been administered in the last years, biologics. For the moment, biologics are indicated just in the cases of the patients who have undergone ESS or have contraindications for surgery and have bilateral polyps and meet a minimum of three of the following criteria: the necessity for systemic therapies with oral or parenteral corticosteroids or contraindications to systemic steroids, significant loss of smell or impaired QoL score, comorbid asthma and type 2 inflammation. This article aims to present the most relevant studies which used the three types of biologics (anti-IgE, anti-IL5 and anti-IL4/IL3) and wishes to increase the awareness of this new type of treatment that can be used in some CRS cases.
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Affiliation(s)
- Romica Cergan
- Anatomy Department, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania;
| | - Ovidiu Nicolae Berghi
- Saint Mary Laboratories and Clinics, Carol Davila University of Medicine and Pharmacy, 011013 Bucharest, Romania;
| | - Mihai Dumitru
- ENT Department, Carol Davila University of Medicine and Pharmacy, 050472 Bucharest, Romania
| | - Daniela Vrinceanu
- ENT Department, Carol Davila University of Medicine and Pharmacy, 050472 Bucharest, Romania
| | - Felicia Manole
- ENT Department, Faculty of Medicine, University of Oradea, 410073 Oradea, Romania;
| | - Crenguta Sorina Serboiu
- Cellular Biology and Histology Department, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania;
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Talwar D, Yadav M, Maturu N, Sharma R, Meshram P, Das S. An early Indian experience with benralizumab - A compendium on severe asthma cases: a case series. F1000Res 2023; 12:1225. [PMID: 38434642 PMCID: PMC10904938 DOI: 10.12688/f1000research.132704.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/30/2023] [Indexed: 03/05/2024] Open
Abstract
Background: Severe eosinophilic asthma (SEA), one of the phenotypes of asthma that is characterized by elevated blood eosinophil counts, is a common cause of uncontrolled asthma. Patients with SEA often experience severe persistent symptoms and have frequent exacerbations despite optimal inhaler therapy. They also have poor lung function and quality of life (QoL). Benralizumab (Fasenra), a monoclonal antibody, has been approved for managing cases of SEA. This series of six cases, the first of its kind from India, aims to add to the real-world evidence of benralizumab in India. Methods: Benralizumab 30 mg (once in four weeks for the first three doses followed by a dose every eight weeks for two years) was administered in six patients with symptoms of cough, breathlessness on exertion, and wheezing, diagnosed with SEA. The following were the endpoints assessed: (i) overlap between high immunoglobulin E (IgE) and eosinophilic asthma; (ii) reduction of exacerbations; (iii) withdrawal of oral corticosteroids; and (iv) improvement in lung function and QoL. Results: In all cases, management with benralizumab resulted in optimal clinical and functional improvement, a decline in systemic steroid use, and improved QoL. Conclusions: The cases presented here are the first of their kind in the Indian asthmatic population with all SEA patients demonstrating significant improvement in symptoms with the use of benralizumab.
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Affiliation(s)
- Deepak Talwar
- Pulmonology and Sleep Medicine, Metro Hospitals and Heart Institute, Noida, Uttar Pradesh, 201301, India
| | - Manoj Yadav
- Pulmonology, Kailash Hospital, Centre for Respiratory Disease, Vadodara, Gujrat, 390007, India
| | - Nagarjuna Maturu
- Pulmonology, Yashodha Hospital, Hyderabad, Telangana, 500036, India
| | - Rahul Sharma
- Pulmonology, Yatharth Superspeciality Hospital, Noida, Uttar Pradesh, 201304, India
| | - Priti Meshram
- Pulmonology Medicine, GGMC and JJ Hospital, Mumbai, Maharashtra, 400008, India
| | - Soumya Das
- Pulmonology, B.P Poddar Hospital and Medical Research Centre, Kolkata, West Bengal, 700053, India
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Heredero-Jung DH, Elena-Pérez S, García-Sánchez A, Estravís M, Isidoro-García M, Sanz C, Dávila I. Interleukin 5 Receptor Subunit Alpha Expression as a Potential Biomarker in Patients with Nasal Polyposis. Biomedicines 2023; 11:1966. [PMID: 37509606 PMCID: PMC10377376 DOI: 10.3390/biomedicines11071966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 07/06/2023] [Accepted: 07/10/2023] [Indexed: 07/30/2023] Open
Abstract
Chronic Rhinosinusitis with Nasal Polyposis (CRSwNP) affects the quality of life of patients suffering from it. The search for a suitable biomarker has been conducted over the last decades. Interleukin 5 receptor subunit alpha (IL-5Rα) involves the activation, maintenance, and survival of eosinophils, which are highly tied to chronic inflammatory processes of the airways, like asthma or CRSwNP. In this study, we evaluate the utility of IL5RA as a genetic biomarker in CRSwNP. IL5RA mRNA expression level was analyzed in different groups of patients by performing qPCR assays. A significant increase in IL5RA expression was observed in CRSwNP patients, especially those with asthma and atopy. We found differences in expression levels when comparing groups with or without polyposis or asthma, as well as some atypical cases related to eosinophil levels. That opens a path to future studies to further characterize groups of patients with common features in the context of pharmacogenetics and in an era towards developing a more precise personalized treatment with IL-5Rα as a therapeutic target for CRSwNP.
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Affiliation(s)
- David Hansoe Heredero-Jung
- Department of Clinical Biochemistry, University Hospital of Salamanca, 37007 Salamanca, Spain
- Allergic Disease Research Group IIMD-01, Institute for Biomedical Research of Salamanca (IBSAL), 37007 Salamanca, Spain
| | - Sandra Elena-Pérez
- Department of Clinical Biochemistry, University Hospital of Salamanca, 37007 Salamanca, Spain
- Allergic Disease Research Group IIMD-01, Institute for Biomedical Research of Salamanca (IBSAL), 37007 Salamanca, Spain
| | - Asunción García-Sánchez
- Allergic Disease Research Group IIMD-01, Institute for Biomedical Research of Salamanca (IBSAL), 37007 Salamanca, Spain
- Department of Biomedical Sciences and Diagnostics, University of Salamanca, 37007 Salamanca, Spain
- Results-Oriented Cooperative Research Networks in Health (RICORS), Carlos III Health Institute, 28029 Madrid, Spain
| | - Miguel Estravís
- Allergic Disease Research Group IIMD-01, Institute for Biomedical Research of Salamanca (IBSAL), 37007 Salamanca, Spain
- Results-Oriented Cooperative Research Networks in Health (RICORS), Carlos III Health Institute, 28029 Madrid, Spain
| | - María Isidoro-García
- Department of Clinical Biochemistry, University Hospital of Salamanca, 37007 Salamanca, Spain
- Allergic Disease Research Group IIMD-01, Institute for Biomedical Research of Salamanca (IBSAL), 37007 Salamanca, Spain
- Results-Oriented Cooperative Research Networks in Health (RICORS), Carlos III Health Institute, 28029 Madrid, Spain
- Department of Medicine, University of Salamanca, 37007 Salamanca, Spain
| | - Catalina Sanz
- Allergic Disease Research Group IIMD-01, Institute for Biomedical Research of Salamanca (IBSAL), 37007 Salamanca, Spain
- Department of Biomedical Sciences and Diagnostics, University of Salamanca, 37007 Salamanca, Spain
- Department of Microbiology and Genetics, University of Salamanca, 37007 Salamanca, Spain
| | - Ignacio Dávila
- Allergic Disease Research Group IIMD-01, Institute for Biomedical Research of Salamanca (IBSAL), 37007 Salamanca, Spain
- Department of Biomedical Sciences and Diagnostics, University of Salamanca, 37007 Salamanca, Spain
- Results-Oriented Cooperative Research Networks in Health (RICORS), Carlos III Health Institute, 28029 Madrid, Spain
- Department of Allergy, University Hospital of Salamanca, 37007 Salamanca, Spain
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Ryder CY, Zacharek MA, Welch CM. Improvement of Suspected Eosinophilic Otitis Media with Targeted Biologic Therapy. Otol Neurotol 2023; 44:462-468. [PMID: 37026811 PMCID: PMC10175161 DOI: 10.1097/mao.0000000000003850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023]
Abstract
OBJECTIVE To compare the responses of suspected eosinophilic otitis media to treatment with or without a targeted biologic therapy against interleukin-4 (IL-4), IL-5, or IL-13 signaling. STUDY DESIGN Retrospective review. SETTING Tertiary referral center. PATIENTS Subjects with type 2 chronic rhinosinusitis with nasal polyposis (CRSwNP), asthma, and otitis media who underwent treatment between 2005 and 2021. INTERVENTION Treatment with targeted biologic therapy. MAIN OUTCOME MEASURES Pre- and posttreatment nasal endoscopy, ear examination, and audiologic evaluation. RESULTS Four hundred seventy-seven subjects with type 2 CRSwNP were treated between 2005 and 2021. Sixty-two had otitis media with pre- and posttreatment evaluation. Retrospective chart review assessed pre- and posttreatment exam findings, nasal endoscopy, audiometry, and tympanometry. Nineteen subjects received a biologic therapy, whereas 43 did not. Exam, endoscopy, and tympanometry were graded for severity and compared pre- and posttreatment. Subjective ear exam and tympanometry were significantly improved with biologic therapy (control = 0.05, biologic = 0.84, p = 9.3 × 10 -5 ; control = -0.1, biologic = 0.62, p = 0.0002). Conductive hearing loss as assessed by air-bone gaps did not change between groups (control = 1.2 dB better, biologic = 1.2 dB worse, p = 0.32). Nasal endoscopy findings improved with biologic therapy relative to the control group, although not statistically significant (control = 1.04, biologic = 1.36, p = 0.22). CONCLUSIONS Biologic therapies targeting interleukin-4 (IL-4), IL-5, and IL-13 signaling are potential new treatments for eosinophilic otitis media. This is the largest study demonstrating improvement in subjects with suspected eosinophilic otitis media in response to biologic therapy, and immune modulation represents a novel treatment strategy for this challenging condition. PROFESSIONAL PRACTICE GAP AND EDUCATIONAL NEED Current treatment strategies for otologic symptoms in eosinophilic disease are not tremendously effective or durable, resulting in a need for improved treatment options. LEARNING OBJECTIVE To determine if targeted biologic therapy, often used for eosinophilic asthma and type 2 chronic rhinosinusitis with nasal polyposis, improves coexistent suspected eosinophilic otitis media. DESIRED RESULT Treatment of suspected eosinophilic otitis media with targeted biologic therapy will result in improvement of otologic symptoms with a durable response compared with current treatment options. LEVEL OF EVIDENCE Level IV. INDICATE IRB OR IACUC Exempt. HUM00182703.
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Affiliation(s)
| | - Mark A. Zacharek
- Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Christopher M. Welch
- Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, Ann Arbor, Michigan, USA
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Pianigiani T, Alderighi L, Meocci M, Messina M, Perea B, Luzzi S, Bergantini L, D’Alessandro M, Refini RM, Bargagli E, Cameli P. Exploring the Interaction between Fractional Exhaled Nitric Oxide and Biologic Treatment in Severe Asthma: A Systematic Review. Antioxidants (Basel) 2023; 12:antiox12020400. [PMID: 36829959 PMCID: PMC9952501 DOI: 10.3390/antiox12020400] [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: 12/25/2022] [Revised: 02/02/2023] [Accepted: 02/03/2023] [Indexed: 02/10/2023] Open
Abstract
BACKGROUND Fractional exhaled nitric oxide (FeNO) is a biomarker of airway inflammation associated with airway hyper-responsiveness and type-2 inflammation. Its role in the management of severe asthmatic patients undergoing biologic treatment, as well as FeNO dynamics during biologic treatment, is largely unexplored. PURPOSE The aim was to evaluate published data contributing to the following areas: (1) FeNO as a predictive biomarker of response to biologic treatment; (2) the influence of biologic treatment in FeNO values; (3) FeNO as a biomarker for the prediction of exacerbations in patients treated with biologics. METHODS The systematic search was conducted on the Medline database through the Pubmed search engine, including all studies from 2009 to the present. RESULTS Higher baseline values of FeNO are associated with better clinical control in patients treated with omalizumab, dupilumab, and tezepelumab. FeNO dynamics during biologic treatment highlights a clear reduction in FeNO values in patients treated with anti-IL4/13 and anti-IL13, as well as in patients treated with tezepelumab. During the treatment, FeNO may help to predict clinical worsening and to differentiate eosinophilic from non-eosinophilic exacerbations. CONCLUSIONS Higher baseline FeNO levels appear to be associated with a greater benefit in terms of clinical control and reduction of exacerbation rate, while FeNO dynamics during biologic treatment remains a largely unexplored issue since few studies have investigated it as a primary outcome. FeNO remains detectable during biologic treatment, but its potential utility as a biomarker of clinical control is still unclear and represents an interesting research area to be developed.
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Biological Therapy of Severe Asthma and Nasal Polyps. J Pers Med 2022; 12:jpm12060976. [PMID: 35743760 PMCID: PMC9225008 DOI: 10.3390/jpm12060976] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 06/13/2022] [Accepted: 06/14/2022] [Indexed: 01/03/2023] Open
Abstract
Chronic rhinosinusitis is a common disease worldwide and can be categorized into chronic rhinosinusitis with nasal polyps and chronic rhinosinusitis without nasal polyps. Chronic rhinosinusitis with nasal polyps is common in patients with asthma and, particularly, severe asthma. Severe asthma is effectively treated with biologics and the coexistence of severe asthma with chronic rhinosinusitis with nasal polyps presents a phenotype that is more likely to respond to such treatment. In this review, we focus on the link between asthma and nasal polyps, and we review the treatment effect of various monoclonal antibodies in patients with severe asthma and nasal polyps as well as in patients with nasal polyps without asthma or with mild-to-moderate asthma. With the enhancement of our armamentarium with new monoclonal antibodies the right choice of biologic becomes an important target and one that is difficult to achieve due to the lack of comparative head-to-head studies.
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Mullol J, Azar A, Buchheit KM, Hopkins C, Bernstein JA. Chronic Rhinosinusitis With Nasal Polyps: Quality of Life in the Biologics Era. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:1434-1453.e9. [PMID: 35306180 DOI: 10.1016/j.jaip.2022.03.002] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 03/04/2022] [Accepted: 03/08/2022] [Indexed: 06/14/2023]
Abstract
Chronic rhinosinusitis (CRS) affects up to 12% of the general population and is traditionally divided into two main phenotypic subsets, based on the presence of nasal polyps (CRSwNP) or their absence. It is well-established that many patients with CRSwNP report poor quality of life (QoL), which is further compromised by comorbidities (eg, asthma, bronchiectasis, aspirin-exacerbated respiratory disease). Chronic rhinosinusitis CRS with nasal polyps is managed with a combination of medical therapy and surgical interventions, and biologics are emerging as a promising new treatment option for patients with inadequate response to the standard of care. A range of patient-reported outcome measures have been used to assess QoL for patients with CRSwNP in clinical trials, including disease-specific questionnaires (eg, Sino-Nasal Outcome Test-22) and generic ones (eg, Short Form-36). Significantly impaired QoL has been identified as a criterion for the indication to use biologics in patients with CRSwNP. This review summarizes clinical evidence (2010-2021) on QoL outcomes with currently available treatments for CRSwNP and assesses the improvement in QoL after biologic treatments, especially for patients with comorbidities reported in interventional studies (randomized controlled trials and real-world experience).
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Affiliation(s)
- Joaquim Mullol
- Clinical and Experimental Respiratory Immunoallergy, Hospital Clinic Barcelona, Instituto de Investigaciones Biomédicas August Pi i Sunyer, Universidad de Barcelona, Centro Investigación Biomédica En Red Enfermedades Respiratorias, Barcelona, Spain.
| | - Antoine Azar
- Division of Allergy and Clinical Immunology, Johns Hopkins School of Medicine, Baltimore, Md
| | - Kathleen M Buchheit
- AERD Center, Allergy and Immunology, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Claire Hopkins
- Guy's and St Thomas NHS Foundation Trust, London, United Kingdom
| | - Jonathan A Bernstein
- Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
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11
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Canonica GW, Bourdin A, Peters AT, Desrosiers M, Bachert C, Weidinger S, Simpson EL, Daizadeh N, Chen Z, Kamat S, Khan AH, Chao J, Graham NMH, Laws E, Rossi AB, Ardeleanu M, Mannent LP, Amin N, Ortiz B, Deniz Y, Djandji M, Rowe PJ. Dupilumab Demonstrates Rapid Onset of Response Across Three Type 2 Inflammatory Diseases. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:1515-1526. [PMID: 35259535 DOI: 10.1016/j.jaip.2022.02.026] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 02/03/2022] [Accepted: 02/04/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Type 2 inflammatory diseases often coexist in patients. Dupilumab targets type 2 inflammation and has demonstrated treatment benefits in patients with atopic dermatitis (AD), asthma, and chronic rhinosinusitis with nasal polyps (CRSwNP) with an acceptable safety profile. OBJECTIVE This post hoc analysis across five phase 3 studies in patients with moderate to severe AD or asthma, or severe CRSwNP, evaluated time of onset and duration of the treatment response. METHODS Patients received subcutaneous dupilumab 200/300 mg or placebo. Assessments included the Eczema Area and Severity Index, Peak Pruritus Numerical Rating Scale, and Dermatology Life Quality Index in AD; pre-bronchodilator FEV1, daily morning peak expiratory flow, and symptom scores in asthma; and University of Pennsylvania Smell Identification Test, daily nasal congestion, and loss of smell scores in CRSwNP. RESULTS At week 2 after the initiation of dupilumab versus placebo, 67.8% versus 36.5% of AD patients achieved a clinically meaningful benefit (Eczema Area and Severity Index: 50% or greater improvement; Peak Pruritus Numerical Rating Scale: 3 point or greater improvement; or Dermatology Life Quality Index: 4 point or greater improvement) (P < .001). Moreover, 61.6% versus 39.9% of asthma patients achieved improvements in pre-bronchodilator FEV1 of 100 mL or greater and 48.8% versus 26.3% achieved 200 mL or greater improvement (both P < .001); 33.2% versus 5.6% of CRSwNP patients regained a sense of smell (P < .001). Treatment effects further improved or were sustained to the end of treatment. CONCLUSIONS Clinically meaningful responses were achieved rapidly after the first dupilumab dose in AD, asthma, or CRSwNP and were sustained throughout treatment (see Video in this article's Online Repository at www.jaci-inpractice.org).
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Affiliation(s)
- G Walter Canonica
- Personalized Medicine, Asthma and Allergy, Humanitas University and Research Hospital IRCCS, Milan, Italy.
| | - Arnaud Bourdin
- Department of Respiratory Diseases, University of Montpellier, Montpellier, France
| | - Anju T Peters
- Allergy-Immunology Division and the Sinus and Allergy Center, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Martin Desrosiers
- Centre de recherche du Centre hospitalier de l'Université de Montréal, Montreal, Québec, Canada
| | - Claus Bachert
- Upper Airways Research Laboratory, Department of Otorhinolaryngology, Ghent University, Ghent, Belgium; CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - Stephan Weidinger
- Department of Dermatology and Allergy, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Schleswig-Holstein, Germany
| | - Eric L Simpson
- Department of Dermatology, Oregon Health and Science University, Portland, Ore
| | | | - Zhen Chen
- Regeneron Pharmaceuticals, Inc, Tarrytown, NY
| | | | | | | | | | | | | | | | | | - Nikhil Amin
- Regeneron Pharmaceuticals, Inc, Tarrytown, NY
| | | | - Yamo Deniz
- Regeneron Pharmaceuticals, Inc, Tarrytown, NY
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12
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Pavord ID, Bel EH, Bourdin A, Chan R, Han JK, Keene ON, Liu MC, Martin N, Papi A, Roufosse F, Steinfeld J, Wechsler ME, Yancey SW. From DREAM to REALITI-A and beyond: Mepolizumab for the treatment of eosinophil-driven diseases. Allergy 2022; 77:778-797. [PMID: 34402066 PMCID: PMC9293125 DOI: 10.1111/all.15056] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 08/13/2021] [Indexed: 12/11/2022]
Abstract
Effective treatment of inflammatory diseases is often challenging owing to their heterogeneous pathophysiology. Understanding of the underlying disease mechanisms is improving and it is now clear that eosinophils play a complex pathophysiological role in a broad range of type 2 inflammatory diseases. Standard of care for these conditions often still includes oral corticosteroids (OCS) and/or cytotoxic immune therapies, which are associated with debilitating side effects. Selective, biological eosinophil‐reducing agents provide treatment options that improve clinical symptoms associated with eosinophilic inflammation and reduce OCS use. Mepolizumab is a humanized monoclonal antibody that binds to and neutralizes interleukin‐5, the major cytokine involved in eosinophil proliferation, activation, and survival. Mepolizumab is approved for the treatment of severe eosinophilic asthma, eosinophilic granulomatosis with polyangiitis and hypereosinophilic syndrome. Additionally, the efficacy of add‐on mepolizumab has been observed in patients with severe chronic rhinosinusitis with nasal polyposis and chronic obstructive pulmonary disease with an eosinophilic phenotype. Here, we review the development, approval, and real‐world effectiveness of mepolizumab for the treatment of patients with severe eosinophilic asthma, from the DREAM to REALITI‐A studies, and describe how knowledge from this journey extended to the use of mepolizumab and other biologics across a broad spectrum of eosinophilic diseases.
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Affiliation(s)
- Ian D. Pavord
- Nuffield Department of Medicine and Oxford Respiratory NIHR BRC University of Oxford Oxford UK
| | - Elisabeth H. Bel
- Department of Respiratory Medicine Amsterdam UMC University of Amsterdam Amsterdam The Netherlands
| | - Arnaud Bourdin
- INSERM 12 F‐CRIN Clinical Research Initiative In Severe Asthma: a Lever for Innovation & Science (CRISALIS) France
- Service de Pneumologie and INSERM CNRS CHU Montpellier Université de Montpellier Montpellier France
| | | | - Joseph K. Han
- Department of Otolaryngology, Head & Neck Surgery Eastern Virginia Medical School Norfolk Virginia USA
| | | | - Mark C. Liu
- Divisions of Allergy and Clinical Immunology, Pulmonary and Critical Care Medicine Johns Hopkins Asthma and Allergy Center Baltimore MD USA
| | - Neil Martin
- Global Medical Affairs GSK Brentford UK
- Institute for Lung Health University of Leicester Leicester UK
| | - Alberto Papi
- Research Center on Asthma and COPD University of Ferrara Ferrara Italy
| | - Florence Roufosse
- Department of Internal Medicine Hôpital Erasme Université Libre de Bruxelles Brussels Belgium
| | | | - Michael E. Wechsler
- Department of Medicine National Jewish Health Cohen Family Asthma Institute Denver CO USA
| | - Steven W. Yancey
- Respiratory Therapeutic Area Unit GSK Research Triangle Park NC USA
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13
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Xu X, Reitsma S, Wang DY, Fokkens WJ. Highlights in the advances of chronic rhinosinusitis. Allergy 2021; 76:3349-3358. [PMID: 33948955 DOI: 10.1111/all.14892] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 04/15/2021] [Accepted: 04/26/2021] [Indexed: 12/27/2022]
Abstract
Chronic rhinosinusitis (CRS) is a complex upper airway inflammatory disease with a broad spectrum of clinical variants. As our understanding of the disease pathophysiology evolves, so too does our philosophy towards the approach and management of CRS. Endotyping is gaining favour over phenotype-based classifications, owing to its potential in prognosticating disease severity and delivering precision treatment. Endotyping is especially useful in challenging CRS with nasal polyposis cases, for whom novel treatment options such as biologicals are now available. The latest European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS2020) reflects these changes with updated rhinosinusitis classifications and new integrated care pathways. With the coronavirus disease 2019 (COVID-19) pandemic, physicians and rhinologists have to balance the responsibility of managing their patients' upper airway while adequately protecting themselves from droplet and aerosol transmission. This review summarises the key updates from EPOS2020, endotype-based classification and biomarkers. The role of biologicals in CRS and the lessons we can draw from their use in severe asthma will be examined. Finally, the principles of CRS management during COVID-19 will also be discussed.
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Affiliation(s)
- Xinni Xu
- Department of Otolaryngology ‐ Head & Neck Surgery National University Hospital Singapore Singapore
| | - Sietze Reitsma
- Department of Otorhinolaryngology Amsterdam University Medical Centers, location AMC Amsterdam The Netherlands
| | - De Yun Wang
- Department of Otolaryngology, Yong Loo Lin School of Medicine National University of Singapore Singapore Singapore
| | - Wytske J. Fokkens
- Department of Otorhinolaryngology Amsterdam University Medical Centers, location AMC Amsterdam The Netherlands
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14
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C Morse J, Miller C, Senior B. Management of Chronic Rhinosinusitis with Nasal Polyposis in the Era of Biologics. J Asthma Allergy 2021; 14:873-882. [PMID: 34285514 PMCID: PMC8285230 DOI: 10.2147/jaa.s258438] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 06/30/2021] [Indexed: 12/20/2022] Open
Abstract
Purpose of Review Chronic rhinosinusitis with nasal polyposis (CRSwNP) is a phenotypic designation of the broader condition of chronic rhinosinusitis. The advent of targeted biologics has shown promise in targeting different aspects of the inflammatory pathway, yet there remains a lack of consensus on the correct timing and use of these medications. This review seeks to provide a concise update of the available literature on the pathophysiology of CRSwNP, the evolution and cost utility of biologics as it pertains to management of patients with CRSwNP, and evidence for each available biologic and its use in CRSwNP. Recent Findings There are two biologics with FDA approval for use in CRSwNP: dupilumab and omalizumab. Recent clinical trials of other biologic therapies targeting type 2 inflammatory pathways have also demonstrated efficacy both in symptom scores and nasal polyp reduction. However, studies have questioned the cost utility of these medications compared to other interventions. Furthermore, timing of use with respect to other interventions including surgery remains challenging.
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Affiliation(s)
- Justin C Morse
- University of North Carolina Department of Otolaryngology-Head and Neck Surgery, University of North Carolina Medical Center, Chapel Hill, NC, 27599, USA
| | - Craig Miller
- University of North Carolina Department of Otolaryngology-Head and Neck Surgery, University of North Carolina Medical Center, Chapel Hill, NC, 27599, USA
| | - Brent Senior
- University of North Carolina Department of Otolaryngology-Head and Neck Surgery, University of North Carolina Medical Center, Chapel Hill, NC, 27599, USA
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Padilla-Galo A, García-Ruiz AJ, Levy Abitbol RC, Olveira C, Rivas-Ruiz F, García-Agua Soler N, Pérez Morales M, Valencia Azcona B, Tortajada-Goitia B, Moya-Carmona I, Levy-Naon A. Real-life cost-effectiveness of benralizumab in patients with severe asthma. Respir Res 2021; 22:163. [PMID: 34044819 PMCID: PMC8155800 DOI: 10.1186/s12931-021-01758-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 05/19/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Availability of clinically effective and cost-effective treatments for severe asthma would be beneficial to patients and national healthcare systems. The aim of this study was to evaluate clinical outcomes and healthcare expenditure after incorporating benralizumab into the standard treatment of refractory eosinophilic asthma. METHODS This was a cross-sectional multicentre study of consecutive patients with refractory eosinophilic asthma who received treatment with benralizumab during at least 12 months. Patient follow-up was performed in specialised severe asthma units. The main effectiveness parameters measured were: the avoidance of one asthma exacerbation, a 3-point increase in the asthma control test (ACT) score, and the difference in utility scores (health-related quality of life) between a 1-year baseline treatment and 1-year benralizumab treatment. The health economic evaluation included direct costs and incremental cost-effectiveness ratios (ICERs). RESULTS After 1 year of treatment with benralizumab, patients with refractory eosinophilic asthma showed an improvement in all the effectiveness parameters analysed: improvement of asthma control and lung function, and decrease in the number of exacerbations, oral corticosteroid (both as corticosteroid courses and maintenance therapy), and inhaled corticosteroid use. The total annual cost per patient for the baseline and benralizumab treatment periods were €11,544 and €14,043, respectively, reflecting an increase in costs due to the price of the biological agent but a decrease in costs for the remaining parameters. The ICER was €602 per avoided exacerbation and €983.86 for every 3-point increase in the ACT score. CONCLUSIONS All the pharmacoeconomic parameters analysed show that treatment with benralizumab is a cost-effective option as an add-on therapy in patients with refractory eosinophilic asthma.
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Affiliation(s)
- A. Padilla-Galo
- Pneumology Unit, 4th Floor, Agencia Sanitaria Costa del Sol, Carretera Nacional 340, Km 187, 29603 Marbella, Málaga, Spain
| | - A. J. García-Ruiz
- Chair of Health Economics and Rational Use of Medicines, Department of Pharmacology and Clinical Therapeutics, Faculty of Medicine, University of Málaga, Málaga, Spain
| | | | - C. Olveira
- Pneumology Department, IBIMA (Institute for Biomedical Research of Málaga), Regional University Hospital of Málaga, Avenida Carlos Haya, 29010 Málaga, Spain
- University of Málaga, Málaga, Spain
| | - F. Rivas-Ruiz
- Research Unit, Red de Investigación en Servicios de Salud en Enfermedades Crónicas, REDISSEC (Spanish Healthcare Network for Chronic Diseases), Agencia Sanitaria Costa del Sol, Carretera Nacional 340, Km 187, 29603 Marbella, Málaga, Spain
| | - N. García-Agua Soler
- Chair of Health Economics and Rational Use of Medicines, Department of Pharmacology and Clinical Therapeutics, Faculty of Medicine, University of Málaga, Málaga, Spain
| | - M. Pérez Morales
- Pneumology Unit, 4th Floor, Agencia Sanitaria Costa del Sol, Carretera Nacional 340, Km 187, 29603 Marbella, Málaga, Spain
| | - B. Valencia Azcona
- Pneumology Unit, 4th Floor, Agencia Sanitaria Costa del Sol, Carretera Nacional 340, Km 187, 29603 Marbella, Málaga, Spain
| | - B. Tortajada-Goitia
- Pharmacy and Nutrition Service, Agencia Sanitaria Costa del Sol, Carretera Nacional 340, Km 187, 29603 Marbella, Málaga, Spain
| | - I. Moya-Carmona
- Pharmacy and Nutrition Service, Hospital Universitario Virgen de La Victoria, Campus de Teatinos s/n, 29010 Málaga, Spain
| | - A. Levy-Naon
- Pneumology Department, Hospital Universitario Virgen de La Victoria, Campus de Teatinos s/n, 29010 Málaga, Spain
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