Moving toward consensus on diagnosis and management of severe asthma in adults

Omalizumab Effectiveness in Severe Allergic Asthma with Multiple Allergic Comorbidities: A Post-Hoc Analysis of the STELLAIR Study

Background

Immunoglobulin (Ig) E-mediated pathophysiological mechanisms are common in allergic diseases including severe allergic asthma (SAA). The anti-IgE monoclonal antibody omalizumab may be particularly beneficial for patients with SAA and multiple allergic comorbidities (AC) including perennial/seasonal rhinitis, conjunctivitis, atopic dermatitis (AD), and food allergy.

Methods

We conducted a post-hoc analysis of the patients from the STELLAIR study (n=872, 149 minors and 723 adults). The patients were classified based on the presence of multiple AC (≥3 AC or <3 AC) or AD as assessed by questionnaire. Response to omalizumab was assessed after 4-6 months (T_4-6) and after 12 months (T₁₂). Asthma response at T_4-6 was based on global evaluation of treatment effectiveness, reduction of ≥40% in annual exacerbation rate, and a combination of both. Asthma response at T₁₂ was based on change in yearly exacerbation and hospitalization rates. AC improvement at T₁₂ was based on patient perception.

Results

Patients with ≥3 AC demonstrated a higher combined response to omalizumab (74.7% vs 58.3%) at T_4-6 and had reduced yearly exacerbation and hospitalization rates (88.9% vs 77.4% and -94.0% vs -70.5%, respectively). Patients with ≥3 AC were more likely to show an improvement in their AC (85.3% vs 51.9%) at T₁₂. Results were similar in minors and adults. The presence of AD was associated with greater omalizumab effectiveness at T_4-6 and a greater AC improvement at T₁₂. Improvement of AD and food allergies at T₁₂ were 73.2% and 38.7%, respectively, in the population overall.

Conclusion

This post-hoc analysis of the STELLAIR study shows that omalizumab is beneficial for all SAA patients and especially for patients with multiple AC or AD. In patients with ≥3 AC, omalizumab also improved AC outcomes.

Bronchiectasis and asthma: a dangerous liaison?

PURPOSE OF REVIEW

To explore the latest insight of the literature on the asthma/bronchiectasis phenotype providing an updated overview about epidemiological, clinical and biological evidence linking these two conditions.

RECENT FINDINGS

An increasing body of literature has shown that the association of asthma and bronchiectasis is a frequent phenomenon leading to a more severe disease with frequent exacerbations. The mechanisms by which the two diseases are linked are still not well established but they share several clinical and immunological features and many comorbidities.

SUMMARY

The early identification of bronchiectasis through high-definition computer tomography in patients with severe asthma is crucial in order to provide an adequate treatment for both diseases and therefore to better control symptoms, exacerbations and infections.

Primary care of asthma: new options for severe eosinophilic asthma

Objective: Asthma is a common heterogeneous disease characterized by airway inflammation and bronchoconstriction. Current treatment guidelines provide recommendations for categorizing disease severity, asthma control and management. This paper reviews asthma assessment in primary care and describes the pathophysiology, clinical characteristics and new targeted treatments available for patients with severe eosinophilic asthma. Methods: A non-systematic PubMed literature search was conducted and articles, primarily from the last 5 years, were selected based on relevance to primary care practice, asthma pathophysiology and biologic therapies. Results: Despite optimal therapy including high-dose inhaled corticosteroids (ICS), long-acting β2-agonists and tiotropium, ∼4-10% of all patients with severe asthma continue to have poor asthma control. These patients have impaired quality of life, frequent exacerbations and are exposed to the side effects of repeated courses of oral steroids. Approximately 50% of patients with severe uncontrolled asthma have eosinophilic asthma, with increased airway expression of type 2 cytokines IL-4, IL-5 and IL-13. Eosinophilic asthma is identified in primary care by having eosinophils ≥150-300 cells/μL on a complete blood count with differential. Conclusions: A new class of agents is available for patients with moderate to severe eosinophilic asthma. Four biologic therapies - mepolizumab, reslizumab, benralizumab and dupilumab - that interfere with the regulation and activity of eosinophils have been approved by the FDA for patients with moderate to severe asthma with an eosinophilic phenotype. Primary care physicians should be familiar with these medications to explain part of the rationale for referral to specialist care and manage patient expectations for treatment.

IgE-Mediated Multimorbidities in Allergic Asthma and the Potential for Omalizumab Therapy

Allergic asthma often coexists with different pathological conditions, called multimorbidities, that are mostly of allergic nature and share a common underlying inflammatory pathophysiological mechanism. Multimorbidities of allergic asthma may influence asthma control, its severity, and patients' response to treatment, and contribute to the overall socioeconomic burden of the disease. Immunoglobulin E (IgE) is known to play a central role in the pathogenesis of various allergic diseases, including asthma. Thus, IgE-mediated immunologic pathways present an attractive target for intervention in asthma and multimorbidities. In this review, we discuss the most frequently reported IgE-mediated multimorbidities in allergic asthma, including allergic rhinitis, rhinoconjunctivitis, atopic dermatitis, vernal keratoconjunctivitis, chronic rhinosinusitis with nasal polyps, food allergies, and allergic bronchopulmonary aspergillosis. Omalizumab is a recombinant humanized monoclonal antibody against IgE and has been in use to treat allergic asthma for more than a decade. We comprehensively review the clinical evidence for omalizumab in the treatment of the aforementioned multimorbidities in allergic asthma.

Moving toward consensus on diagnosis and management of severe asthma in children

Children with severe asthma continue to experience symptoms despite long-term treatment with high doses of corticosteroids. Moreover, the heterogeneous nature of asthma and the presence of several phenotypes have limited our ability to develop an optimized management strategy for these patients. Adequate management of severe asthma in children necessitates a detailed understanding of what makes asthma difficult to control, knowledge of the causal factors, review of diagnosis for accurate identification of pediatric patients with severe asthma and a precise definition of the phenotypes to be able to better target the therapy. Advancement in all these aspects is likely to improve childhood asthma treatment in the future. Although our understanding of severe pediatric asthma has grown in recent years, there remains a lack of consensus and clarity around critical aspects of this condition. This review attempts to present a harmonized view on the definition of severe asthma in the pediatric age group, identification of phenotypes and diagnosis, the inflammatory cascade, pharmacological and non-pharmacological treatment strategies, considerations for follow-up and referral to specialists, and disease prevention strategies.