Biologicals for severe asthma: what we can learn from real-life experiences?

Biologics and severe asthma in children

PURPOSE OF REVIEW

Severe asthma can carry significant morbidity and mortality for patients, and it places a burden on families and the healthcare system. Biologic agents have revolutionized the care of patients with severe asthma in recent years. Evidence surrounding some of these therapies is limited in the pediatric population, but recent studies show that they significantly improve asthma care when used appropriately. In this review, we discuss the biologic therapies currently approved to treat severe asthma in school-age children and adolescents.

RECENT FINDINGS

Randomized controlled trials have been published in support of biologics in children and/or adolescents. These therapies have been shown to reduce the annual rate of severe asthma exacerbations by at least 40-50%, and some up to about 70%. Improvements in asthma control, lung function, oral corticosteroid use, and quality of life have also been demonstrated, although these vary by agent. Furthermore, these therapies have reassuring safety profiles in pediatric patients.

SUMMARY

With three biologic agents approved for children ages 6-11 years and five approved for adolescents ages >12 years, it can be challenging to select one. The therapy should be chosen after careful consideration of the patient's asthma phenotype and biomarkers. Additional pediatric-specific clinical trials would be helpful in developing evidence-based guidelines on biologic therapies in this population.

The new indications for biologicals in type 2 diseases: perspectives

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.

Specific Therapy for T2 Asthma

Asthma is a disease with high incidence and prevalence, and its severe form accounts for approximately 10% of asthmatics. Over the last decade, the increasing knowledge of the mechanisms underlying the disease allowed the development of biological drugs capable of sufficiently controlling symptoms and reducing the use of systemic steroids. The best-known mechanisms are those pertaining to type 2 inflammation, for which drugs were developed and studied. Those biological treatments affect crucial points of bronchial inflammation. Among the mechanisms explored, there were IgE (Omalizumab), interleukin 5 (Mepolizumab and Reslizumab), interleukin 5 receptor alpha (Benralizumab) and interleukin 4/13 receptor (Dupilumab). Under investigation and expected to be soon commercialized is the monoclonal antibody blocking the thymic stromal lymphopoietin (Tezepelumab). Seemingly under study and promising, are anti-interleukin-33 (itepekimab) and anti-suppressor of tumorigenicity-2 (astegolimab). With this study, we want to provide an overview of these drugs, paying particular attention to their mechanism of action, the main endpoints reached in clinical trials, the main results obtained in real life and some unclear points regarding their usage.

Evaluation of Real-Life Investigational Use of Enoximone in Asthma, the Third Step in Drug Repurposing: A Preliminary Report

Background

The population of uncontrolled asthma patients represents a large therapeutic burden. The PDE3-inhibitor enoximone is a strong and quick bronchodilator and is known to successfully treat life-threatening bronchial asthma (status asthmaticus). Translational mice models showed anti-inflammatory effects when PDE3 was targeted.

Methods

Here, we investigated the effectiveness of PDE3-inhibitor enoximone as oral treatment for chronic asthma in a real-life off-label setting. Investigational use of PDE3-inhibitor enoximone: 51 outpatients (age 18-77) with chronic asthma were followed using off-label personalized low doses of the PDE3-inhibitor enoximone. Duration of treatment was 2-8 years.

Results

Four groups could be distinguished as follows: The first group includes patients who use enoximone as an add-on, because it helps them in maintaining a better general wellbeing; they still use their traditional medication (n = 5). The second group consists of patients who use enoximone and were able to phase down their traditional medication without deterioration of their asthma symptoms (n = 11). The third group comprises patients who were able to discontinue their traditional medication and use only enoximone without deterioration of their asthma symptoms (n = 24). The last one has patients who, after having used enoximone for some time, saw their symptoms disappear and now use no medication at all, not even enoximone (n = 11). All patients reported improvement or at least alleviation of their asthma symptoms. All patients reported a better quality of life and greater drug compliance.

Conclusion

The evaluation shows that PDE3-inhibitor enoximone is a viable alternative for or addition to current asthma therapeutics, as both add-on and stand-alone, considerably reducing the use of LABAs/SABAs/ICS, with no or negligible side effects. Additional studies are advisable.

Real-life studies in allergen immunotherapy

PURPOSE OF REVIEW

Real-life (or real-world) studies can provide information that cannot be derived from randomized controlled trials. This approach is currently becoming of relevance for many treatments. In recent years, the real-life method has been applied also to allergen immunotherapy, providing new insights on it. We reviewed herein the available literature on the argument.

RECENT FINDINGS

Several prospective and retrospective studies on allergen immunotherapy in the real-world setting have been published, mostly in the last 5 years. Most of them focused on adverse events, compliance, and the long term/preventive effects, and evidenced an overall favorable profile for different products and different allergens.

SUMMARY

Real life study provided novel information and evidenced those aspects of immunotherapy that worth a more detailed approach, without the strict limitations usually imposed by controlled randomized trials.

Prospects for severe asthma treatment

Biological drugs are approved to treat patients with severe uncontrolled asthma and are directed against mediators of type 2 immunity. These agents are effective in reducing the risk of exacerbation, maintaining asthma symptom control and reducing the need of systemic corticosteroids. Although biological drugs have revolutionized the management of the disease, to date there are no head-to-head studies across the current available molecules and there remains the need of specific biomarkers for the diagnosis, prognosis and response to treatment. Moreover, there is still an urgent need to identify further molecular targets to offer effective treatments for those patients who are not responsive to the currently available biological drugs, by moving upstream in the inflammatory cascade to inhibit multiple inflammatory pathways and/or identify effective nontype 2 immunity mechanisms.

Biologics for the Treatments of Allergic Conditions: Severe Asthma

By selectively targeting specific steps of the immune inflammation cascade, biologic drugs for severe asthma have substantially contributed to increase the standard of care, to reduce drug-related morbidity. and most importantly to ameliorate patients' quality of life. Upcoming molecules are going to provide a chance for severe phenotypes besides Th2 high through the interaction with epithelial and innate immunity. Some practical aspects including optimal treatment duration, the possibility of a dose treatment modulation, the place and relevance of ICS in best responders are still under debate. Long-term safety, especially when interacting with innate immunity needs to be further investigated.