1
|
Villamañán E, Laorden D, Granda P, Sobrino C, De Andrés S, Carpio C, Domínguez-Ortega J, Romero D, Mariscal P, De Las Vecillas L, Quirce S, Álvarez-Sala R, On Behalf Of AsmaGrave-Hulp Study. Current Biologic Therapies for Severe Asthma and Real-World Data: Are Expectations Being Met? J Clin Med 2024; 13:7152. [PMID: 39685611 DOI: 10.3390/jcm13237152] [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: 10/28/2024] [Revised: 11/19/2024] [Accepted: 11/23/2024] [Indexed: 12/18/2024] Open
Abstract
Advances in knowledge about clinical features, physiology, and underlying immunology are leading to targeted therapies and a new era of therapies. Biological treatments for severe asthma have changed the way this disease is managed, especially in patients who do not respond adequately to conventional treatments with corticosteroids and bronchodilators. These treatments block the action of different molecules involved in the immune response and in the inflammation of the airways, bronchoconstriction, bronchial hyperresponsiveness, and excessive mucus production. Currently, there are sufficient real-life data to corroborate the good results obtained in clinical trials by these type of drugs for severe asthma patients. Observational studies reveal their efficacy and safety, reducing exacerbations, leading to fewer emergency room visits and hospitalizations, and improving quality of life with better asthma control and better functional status.
Collapse
Affiliation(s)
- Elena Villamañán
- Department of Pharmacy, Hospital La Paz, IdiPAZ, 28046 Madrid, Spain
| | - Daniel Laorden
- Department of Pneumology, Hospital La Paz, Universidad Autónoma de Madrid, IdiPAZ, and CIBER of Respiratory Diseases, 28046 Madrid, Spain
| | - Paula Granda
- Department of Pharmacy, Hospital La Paz, IdiPAZ, 28046 Madrid, Spain
| | - Carmen Sobrino
- Department of Pharmacy, Hospital La Paz, IdiPAZ, 28046 Madrid, Spain
| | - Susana De Andrés
- Department of Pharmacy, Hospital La Paz, IdiPAZ, 28046 Madrid, Spain
| | - Carlos Carpio
- Department of Pneumology, Hospital La Paz, Universidad Autónoma de Madrid, IdiPAZ, and CIBER of Respiratory Diseases, 28046 Madrid, Spain
| | - Javier Domínguez-Ortega
- Department of Allergy, Hospital La Paz, IdiPAZ, and CIBER of Respiratory Diseases, 28046 Madrid, Spain
| | - David Romero
- Department of Pneumology, Hospital La Paz, Universidad Autónoma de Madrid, IdiPAZ, and CIBER of Respiratory Diseases, 28046 Madrid, Spain
| | - Pablo Mariscal
- Department of Pneumology, Hospital La Paz, Universidad Autónoma de Madrid, IdiPAZ, and CIBER of Respiratory Diseases, 28046 Madrid, Spain
| | - Leticia De Las Vecillas
- Department of Allergy, Hospital La Paz, IdiPAZ, and CIBER of Respiratory Diseases, 28046 Madrid, Spain
| | - Santiago Quirce
- Department of Allergy, Hospital La Paz, IdiPAZ, and CIBER of Respiratory Diseases, 28046 Madrid, Spain
| | - Rodolfo Álvarez-Sala
- Department of Pneumology, Hospital La Paz, Universidad Autónoma de Madrid, IdiPAZ, and CIBER of Respiratory Diseases, 28046 Madrid, Spain
| | | |
Collapse
|
2
|
González-Tuyub YH, González-Iñiguez KD, Lizarazo-Guiza PC, García-García SR. Benralizumab: Effectiveness in Patients with Uncontrolled Severe Eosinophilic Asthma at 6 and 12 Months at a Third-Level Care Hospital. Capacity for ICS-LABA Therapy Reduction. J Asthma Allergy 2024; 17:1141-1149. [PMID: 39540023 PMCID: PMC11559237 DOI: 10.2147/jaa.s472490] [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: 06/18/2024] [Accepted: 10/24/2024] [Indexed: 11/16/2024] Open
Abstract
Background Asthma is a health condition with worldwide relevance, evaluated based on the necessary treatment to control symptoms and exacerbations. Severe asthma is uncontrolled despite high doses of ICS-LABA and treatment for triggering factors. Severe eosinophilic asthma is characterized by an increase in eosinophils in the peripheral circulation, walls, and passages of the respiratory tract. Biologic treatments such as benralizumab have demonstrated effectiveness as aids in decreasing respiratory tract inflammation and improving the management of symptoms in patients living with asthma. Objective To assess the efficacy and safety of benralizumab as an add-on therapy for patients with severe, uncontrolled asthma and elevated blood eosinophil counts. Methods Observational, analytic and ambispective study in 21 patients diagnosed with severe eosinophilic asthma treated with benralizumab, to determine the treatment's effectiveness through the change in estimated respiratory function by spirometry through the forced expiratory volume in one second (FEV1) value, reduction in second controlling treatment, serum eosinophil reduction, change in the Asthma Control Test score and the Asthma Control Questionnaire test at 6 and 16 months of treatment. Results An average difference of 241.43 mL (±461.43) in FEV1 at 6 months was found, as well as an average FeNO reduction of 49.8 ppm and eosinophil reduction of 612.78 cells at 12 months of treatment, additionally, CSI requirements were reduced in 95% of patients. Conclusion Benralizumab improved respiratory function as well as key biomarkers such as eosinophil count, exhaled nitric oxide fraction (FeNO), which reflected in a decreased requirement of inhaled corticosteroids and improved symptom control.
Collapse
Affiliation(s)
- Yair Humberto González-Tuyub
- Clinical Immunology and Allergy Service, ISSSTE Hospital Regional General, Ignacio Zaragoza, Ciudad de México, México
| | | | | | | |
Collapse
|
3
|
Jones AP, Debono M, Walsh J, Smith C, Hunt L, McKevitt FM. Glucocorticoid prescribing in neurology. Pract Neurol 2024; 24:289-295. [PMID: 38553045 DOI: 10.1136/pn-2023-003855] [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: 03/10/2024] [Indexed: 07/18/2024]
Abstract
Glucocorticoids are commonly used for neurological disorders, but they can have significant adverse effects, including adrenal insufficiency, hyperglycaemia, osteoporosis and increased infection risk. Long-term use of corticosteroids requires the prescriber to plan risk mitigation, including monitoring and often coprescribing. This article highlights the potential risks of corticosteroid prescribing and draws together up-to-date guidance with multispecialty input to clarify ways of reducing those risks. We discuss home blood glucose monitoring and consider a steroid safety checklist to promote safer steroid prescribing.
Collapse
Affiliation(s)
- Andrew P Jones
- Neurology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Miguel Debono
- Endocrinology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Jennifer Walsh
- Metabolic Bone Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Cheryl Smith
- Diabetes Department, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Leanne Hunt
- Diabetes Department, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Fiona M McKevitt
- Neurology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| |
Collapse
|
4
|
Al-Ahmad M, Al Zaabi A, Madkour A, Alqaraghuli HA, Al Hayaan H, Mobayed H, Idrees M, Al Busaidi N, Zeineldine S. Expert consensus on oral corticosteroids stewardship for the treatment of severe asthma in the Middle East and Africa. Respir Med 2024; 228:107674. [PMID: 38782138 DOI: 10.1016/j.rmed.2024.107674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 05/17/2024] [Accepted: 05/18/2024] [Indexed: 05/25/2024]
Abstract
In the Middle East and Africa (MEA) region, overuse of oral corticosteroids (OCS) for asthma management, both as burst and maintenance therapy, poses a significant challenge. Gaps in knowledge regarding the need to taper OCS in patients with severe asthma and the use of OCS in comorbid conditions have been noted. OCS stewardship can help attain optimal and effective OCS tapering along with reducing OCS overuse and over-reliance. In this paper, we discuss current practices regarding the use of OCS in asthma, globally and in the MEA region. Expert recommendations for achieving OCS stewardship in the MEA region have also been presented. Regional experts recommend increasing awareness among patients about the consequences of OCS overuse, engaging community pharmacists, and educating primary healthcare professionals about the benefits of prompt appropriate referral. Innovative local referral tools like ReferID can be utilized to refer patients with asthma to specialist care. The experts also endorse a multidisciplinary team approach and accelerating access to newer medicines like biologics to implement OCS stewardship and optimize asthma care in the MEA region.
Collapse
Affiliation(s)
- Mona Al-Ahmad
- Microbiology Department, College of Medicine, Kuwait University, Kuwait.
| | | | | | | | | | | | - Majdy Idrees
- Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | | | | |
Collapse
|
5
|
Plaza Moral V, Alobid I, Álvarez Rodríguez C, Blanco Aparicio M, Ferreira J, García G, Gómez-Outes A, Garín Escrivá N, Gómez Ruiz F, Hidalgo Requena A, Korta Murua J, Molina París J, Pellegrini Belinchón FJ, Plaza Zamora J, Praena Crespo M, Quirce Gancedo S, Sanz Ortega J, Soto Campos JG. GEMA 5.3. Spanish Guideline on the Management of Asthma. OPEN RESPIRATORY ARCHIVES 2023; 5:100277. [PMID: 37886027 PMCID: PMC10598226 DOI: 10.1016/j.opresp.2023.100277] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2023] Open
Abstract
The Spanish Guideline on the Management of Asthma, better known by its acronym in Spanish GEMA, has been available for more than 20 years. Twenty-one scientific societies or related groups both from Spain and internationally have participated in the preparation and development of the updated edition of GEMA, which in fact has been currently positioned as the reference guide on asthma in the Spanish language worldwide. Its objective is to prevent and improve the clinical situation of people with asthma by increasing the knowledge of healthcare professionals involved in their care. Its purpose is to convert scientific evidence into simple and easy-to-follow practical recommendations. Therefore, it is not a monograph that brings together all the scientific knowledge about the disease, but rather a brief document with the essentials, designed to be applied quickly in routine clinical practice. The guidelines are necessarily multidisciplinary, developed to be useful and an indispensable tool for physicians of different specialties, as well as nurses and pharmacists. Probably the most outstanding aspects of the guide are the recommendations to: establish the diagnosis of asthma using a sequential algorithm based on objective diagnostic tests; the follow-up of patients, preferably based on the strategy of achieving and maintaining control of the disease; treatment according to the level of severity of asthma, using six steps from least to greatest need of pharmaceutical drugs, and the treatment algorithm for the indication of biologics in patients with severe uncontrolled asthma based on phenotypes. And now, in addition to that, there is a novelty for easy use and follow-up through a computer application based on the chatbot-type conversational artificial intelligence (ia-GEMA).
Collapse
Affiliation(s)
| | - Isam Alobid
- Otorrinolaringología, Hospital Clinic de Barcelona, España
| | | | | | - Jorge Ferreira
- Hospital de São Sebastião – CHEDV, Santa Maria da Feira, Portugal
| | | | - Antonio Gómez-Outes
- Farmacología clínica, Agencia Española de Medicamentos y Productos Sanitarios (AEMPS), Madrid, España
| | - Noé Garín Escrivá
- Farmacia Hospitalaria, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | | | | | - Javier Korta Murua
- Neumología Pediátrica, Hospital Universitario Donostia, Donostia-San, Sebastián, España
| | - Jesús Molina París
- Medicina de familia, semFYC, Centro de Salud Francia, Fuenlabrada, Dirección Asistencial Oeste, Madrid, España
| | | | - Javier Plaza Zamora
- Farmacia comunitaria, Farmacia Dr, Javier Plaza Zamora, Mazarrón, Murcia, España
| | | | | | - José Sanz Ortega
- Alergología Pediátrica, Hospital Católico Universitario Casa de Salud, Valencia, España
| | | |
Collapse
|
6
|
Padilla-Galo A, Moya Carmona I, Ausín P, Carazo Fernández L, García-Moguel I, Velasco-Garrido JL, Andújar-Espinosa R, Casas-Maldonado F, Martínez-Moragón E, Martínez Rivera C, Vera Solsona E, Sánchez-Toril López F, Trisán Alonso A, Blanco Aparicio M, Valverde-Monge M, Valencia Azcona B, Palop Cervera M, Nuevo J, Sánchez Tena J, Resler G, Luzón E, Levy Naon A. Achieving clinical outcomes with benralizumab in severe eosinophilic asthma patients in a real-world setting: orbe II study. Respir Res 2023; 24:235. [PMID: 37770889 PMCID: PMC10540395 DOI: 10.1186/s12931-023-02539-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 09/15/2023] [Indexed: 09/30/2023] Open
Abstract
BACKGROUND The ORBE II study aimed to describe the characteristics and clinical outcomes of adult patients with severe eosinophilic asthma (SEA) treated with benralizumab in a real-world setting in Spain. METHODS ORBE II (NCT04648839) was an observational, retrospective cohort study in adult SEA patients who had been prescribed benralizumab. Demographic and clinical data of 204 SEA patients were collected 12 months prior to benralizumab initiation (baseline) and at follow-up. Exacerbation rate, asthma symptoms, maintenance oral corticosteroid (OCS) use and lung function were evaluated, among other variables. RESULTS A total of 204 SEA patients were evaluated. Mean (standard deviation, SD) age of the study population was 56.4 (12.4) years, 62.3% were women and mean (SD) duration of asthma was 15.1 (12.7) years. Median (Q1-Q3) follow-up duration was 19.5 (14.2-24.2) months. At baseline, 72.6% of the overall population (OP) presented blood eosinophil counts ≥ 300 cells/µL; 36.8% had comorbid chronic rhinosinusitis with nasal polyps (CRSwNP); 84.8% reported at least one severe exacerbation, and 29.1% were OCS-dependent. At 1 year of follow-up, patients receiving benralizumab treatment had a 85.6% mean reduction in exacerbations from baseline, and 81.4% of patients achieved zero exacerbations. We also found a clinically relevant mean (SD) increase in pre-bronchodilator (BD) FEV1 of 331 (413) mL, with 66.7% of patients achieving a pre-BD FEV1 increase ≥ 100 mL, and 46.3% of patients achieving a pre-BD FEV1 ≥ 80% of predicted. Regarding symptom control, 73.8% of the OP obtained an ACT score ≥ 20 points. After 1 year of follow-up, mean reduction in the daily OCS dose was 70.5%, and complete OCS withdrawal was achieved by 52.8% of the OCS-dependent patients. Almost half (43.7%) of the OP on benralizumab met all four criteria for clinical remission. Patients with concomitant CRSwNP obtained similar or enhanced outcomes. CONCLUSIONS These data support the real-world benefits of benralizumab in SEA patients, and particularly in those with concomitant CRSwNP. TRIAL REGISTRATION NCT04648839.
Collapse
Affiliation(s)
| | | | - Pilar Ausín
- H. del Mar, Universidad Pompeu Fabra University (UPF), Barcelona, Spain
| | | | - Ismael García-Moguel
- H. U. 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (Imas12), Madrid, Spain
| | | | | | | | | | | | | | | | | | | | | | | | | | - Javier Nuevo
- Medical Department, AstraZeneca Farmacéutica S.A, Madrid, Spain
| | | | - Gustavo Resler
- Medical Department, AstraZeneca Farmacéutica S.A, Madrid, Spain
| | - Elisa Luzón
- Medical Department, AstraZeneca Farmacéutica S.A, Madrid, Spain
| | | |
Collapse
|
7
|
Ramsahai JM, Simpson JL, Cook A, Gibson PG, McDonald V, Grainge C, Heaney LG, Wark PA. Randomised controlled trial for the titration of oral corticosteroids using markers of inflammation in severe asthma. Thorax 2023; 78:868-874. [PMID: 36948587 DOI: 10.1136/thorax-2021-217865] [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: 07/01/2021] [Accepted: 12/24/2022] [Indexed: 03/24/2023]
Abstract
INTRODUCTION Biomarkers are used to select biologic therapies for patients with severe asthma, but not to regularly adjust therapy, especially oral corticosteroids (OCS). OBJECTIVE Our goal was to test the efficacy of an algorithm to guide the titration of OCS using blood eosinophil count and fraction of exhaled nitric oxide (FeNO) levels. DESIGN, PARTICIPANTS, INTERVENTIONS AND SETTING This proof-of-concept prospective randomised controlled trial assigned adult participants with severe uncontrolled asthma (n=32) to biomarker-based management (BBM) where OCS dose was adjusted based on a composite biomarker score comprised of blood eosinophil count and FeNO, or a standard best practice (SBP) arm. The study was conducted at the Hunter Medical Research Institute, Newcastle, Australia. Participants were recruited from the local Severe Asthma Clinic and were blinded to their study allocation. MAIN OUTCOME The coprimary outcomes were number of severe exacerbations and time to first severe exacerbation assessed over 12 months. RESULTS There was a longer median time to first severe exacerbation with BBM, although not significant (295 vs 123 days, Adj. HR: 0.714; 95% CI: 0.25 to 2.06; p=0.533). The relative risk of a severe exacerbation in BBM (n=17) vs SBP (n=15) was 0.88 (Adj.; 95% CI: 0.47 to 1.62; p=0.675) with a mean exacerbation rate per year of 1.2 and 2.0, respectively. There was a significant reduction in the proportion of patients requiring an emergency department (ED) visit using BBM (OR 0.09, 95% CI: 0.01 to 0.91; p=0.041). There was no difference in the cumulative OCS dose used between the two groups. CONCLUSION A treatment algorithm to adjust OCS using blood eosinophil count and FeNO is feasible in a clinical setting and resulted in a reduced odds of an ED visit. This warrants further study to optimise the use of OCS in the future. TRIAL REGISTRATION NUMBER This trial was registered with the Australia and New Zealand Clinical Trials Registry (ACTRN12616001015437).
Collapse
Affiliation(s)
- J Michael Ramsahai
- Hunter Medical Research Institute, Centre of Excellence in Severe Asthma and Priority Research Centre for Healthy Lungs, University of Newcastle, Newcastle, New South Wales, Australia
- Division of Respiratory Medicine, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jodie L Simpson
- Hunter Medical Research Institute, Centre of Excellence in Severe Asthma and Priority Research Centre for Healthy Lungs, University of Newcastle, Newcastle, New South Wales, Australia
| | - Alistair Cook
- Hunter Medical Research Institute, Centre of Excellence in Severe Asthma and Priority Research Centre for Healthy Lungs, University of Newcastle, Newcastle, New South Wales, Australia
| | - Peter G Gibson
- Hunter Medical Research Institute, Centre of Excellence in Severe Asthma and Priority Research Centre for Healthy Lungs, University of Newcastle, Newcastle, New South Wales, Australia
| | - Vanessa McDonald
- Hunter Medical Research Institute, Centre of Excellence in Severe Asthma and Priority Research Centre for Healthy Lungs, University of Newcastle, Newcastle, New South Wales, Australia
| | - Christopher Grainge
- Hunter Medical Research Institute, Centre of Excellence in Severe Asthma and Priority Research Centre for Healthy Lungs, University of Newcastle, Newcastle, New South Wales, Australia
| | - Liam G Heaney
- Centre of Infection and Immunity, Queens University Belfast, Belfast, UK
| | - Peter Ab Wark
- Hunter Medical Research Institute, Centre of Excellence in Severe Asthma and Priority Research Centre for Healthy Lungs, University of Newcastle, Newcastle, New South Wales, Australia
| |
Collapse
|
8
|
Fyles F, Nuttall A, Joplin H, Burhan H. Long-Term Real-World Outcomes of Mepolizumab and Benralizumab Among Biologic-Naive Patients With Severe Eosinophilic Asthma: Experience of 3 Years' Therapy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:2715-2723. [PMID: 37245734 DOI: 10.1016/j.jaip.2023.05.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 05/05/2023] [Accepted: 05/16/2023] [Indexed: 05/30/2023]
Abstract
BACKGROUND Biologic therapies such as mepolizumab and benralizumab offer treatment options for severe eosinophilic asthma (SEA), although long-term real-world data on their use are limited. OBJECTIVES To evaluate the impact of benralizumab and mepolizumab treatment among biologic-naive patients with SEA over 36 months and describe the incidence of super-response at 12 and 36 months, identifying potential predictive factors. METHODS We conducted a retrospective, single-center study of patients with SEA who were given mepolizumab or benralizumab from May 2017 to December 2019, and who completed 36 months of therapy. Baseline demographics, comorbidities, and medication use were described. Data on clinical outcomes, including maintenance oral corticosteroid (OCS) use, annual exacerbation rate (AER), mini Asthma Quality of Life Questionnaire, Asthma Control Questionnaire (ACQ-6), and eosinophil count were collected at baseline and at 12 and 36 months. Super-response was evaluated at 12 and 36 months. RESULTS A total of 81 patients were included. Maintenance OCS use significantly improved from baseline (5.3 mg/d) to 12 months (2.4 mg/d, P < .0001) and 36 months (0.6 mg/d; P < .0001). Annual exacerbation rate decreased from baseline (5.8) to 12 months (0.9; P < .0001) and 36 months (1.2; P < .0001). Mini Asthma Quality of Life Questionnaire, ACQ-6, and eosinophil count significantly improved from baseline to 12 and 36 months. Twenty-nine patients demonstrated super-response at 12 months. Compared with those without a super-response, these patients had better baseline AER (4.7 vs 6.5; P = .009), mini Asthma Quality of Life Questionnaire (3.41 vs 2.54; P = .002), and ACQ-6 (3.38 vs 4.06; P = .03) scores. Most maintained a super-response up to 36 months. CONCLUSIONS Mepolizumab and benralizumab are associated with significant improvements in OCS use, AER, and asthma control in real-world cohorts for up to 36 months, providing insight into long-term use for SEA.
Collapse
Affiliation(s)
- Fred Fyles
- Liverpool University Hospitals National Health Service Foundation Trust, Liverpool, United Kingdom.
| | - Amy Nuttall
- Liverpool University Hospitals National Health Service Foundation Trust, Liverpool, United Kingdom
| | - Hannah Joplin
- Liverpool University Hospitals National Health Service Foundation Trust, Liverpool, United Kingdom
| | - Hassan Burhan
- Liverpool University Hospitals National Health Service Foundation Trust, Liverpool, United Kingdom; Liverpool School of Tropical Medicine, Liverpool, United Kingdom; University of Liverpool, Liverpool, United Kingdom
| |
Collapse
|
9
|
Patel NJ, Fu X, Zhang Y, Stone JH. Baseline Glucocorticoid-Related Toxicity Scores in Giant Cell Arteritis: A Post Hoc Analysis of the GiACTA Trial. ACR Open Rheumatol 2023; 5:51-58. [PMID: 36604825 PMCID: PMC9837393 DOI: 10.1002/acr2.11520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 11/23/2022] [Accepted: 12/09/2022] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVE Giant cell arteritis (GCA) requires treatment with high-dose, long-term glucocorticoids (GCs). A score assessing and quantifying patients' baseline GC-related toxicity may be important to risk stratification and therapeutic decision-making in patients initiating immunosuppression. METHODS We analyzed patients with GCA enrolled in the Tocilizumab in Giant Cell Arteritis (GiACTA) trial. Baseline GC-related toxicity scores for 12 domains were derived from the Glucocorticoid Toxicity Index using baseline medications, medical history, vital signs, and laboratory values. The 12 domains examined were body mass index, glucose tolerance, blood pressure, lipid metabolism, bone and/or tendon, GC myopathy, skin toxicity, neuropsychiatric effects, infection, ocular toxicity, gastrointestinal injury, and adrenal function. Potential scores ranged from 0 to 538. We compared differences between those with newly diagnosed versus relapsing disease at baseline. RESULTS A total of 250 patients were included (75% female, mean age 69 years). The mean ± SD baseline GC-related toxicity score among all patients was 111.3 ± 53.2. The domains that contributed most to the overall scores were blood pressure (24.0% of the overall score), followed by glucose tolerance (22.6%) and neuropsychiatric effects (15.9%). Baseline GC-related toxicity scores were higher in patients with relapsing disease compared with those with newly diagnosed disease (mean of 122.5 vs. 98.9; P < 0.001). The body mass index and neuropsychiatric domain scores were significantly higher in patients with relapsing disease. CONCLUSION This approach to the assessment of baseline GC-related toxicity distinguished patients with relapsing GCA from those with newly diagnosed disease. Baseline GC-related toxicity scores may be useful in therapeutic decision-making for patients beginning immunosuppressive treatment.
Collapse
|
10
|
Angeletti G, Mazzolini M, Rocca A. Two years follow-up of relapsing eosinophilic pneumonia with concomitant severe asthma successfully treated with benralizumab: A case report and brief review of the literature. Respir Med Case Rep 2022; 41:101795. [PMID: 36579077 PMCID: PMC9791164 DOI: 10.1016/j.rmcr.2022.101795] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 12/12/2022] [Indexed: 12/15/2022] Open
Abstract
Relapsing eosinophilic pneumonia and severe eosinophilic asthma are rare and disabling diseases, which share common inflammatory backgrounds and often require long-term systemic steroid therapy. Benralizumab is a humanized antibody targeting IL-5 receptor that reduces corticosteroid dependence and flares up in severe eosinophilic asthma on long term. In this case report, successful treatment of eosinophilic pneumonia and severe eosinophilic asthma with benralizumab is described after a 2-year follow up, showing the promising results of this therapy for eosinophilic pneumonia management.
Collapse
|
11
|
Bleecker ER, Al-Ahmad M, Bjermer L, Caminati M, Canonica GW, Kaplan A, Papadopoulos NG, Roche N, Ryan D, Tohda Y, Yáñez A, Price D. Systemic corticosteroids in asthma: A call to action from World Allergy Organization and Respiratory Effectiveness Group. World Allergy Organ J 2022; 15:100726. [PMID: 36582404 PMCID: PMC9761384 DOI: 10.1016/j.waojou.2022.100726] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 11/11/2022] [Accepted: 11/18/2022] [Indexed: 12/14/2022] Open
Abstract
Systemic corticosteroids (SCS) are a highly effective treatment for acute exacerbations and long-term symptom control in asthma. Long-term SCS use is highly prevalent across all asthma severities, occurring in over 20% of patients with severe or uncontrolled disease globally. It is now well known that exposure to both long-term and repeated acute courses of SCS is associated with a high risk of serious adverse effects (AEs), such as osteoporosis, and metabolic and cardiovascular complications, especially when prescribed onto a background of other corticosteroids. The aim of this call-to-action article, endorsed by the World Allergy Organization and the Respiratory Effectiveness Group, is to review the accumulating evidence on the burden of SCS on patients with asthma and provide an overview of potential strategies for implementing SCS Stewardship. Primary prevention of exacerbations and improvement of asthma control is a key first step in achieving SCS Stewardship, by optimizing maintenance asthma medications and addressing modifiable risk factors, such as adherence and inhaler technique. Other key elements of SCS Stewardship include increasing appropriate specialist referrals for multidisciplinary review, assessment of biomarkers, and consideration of oral corticosteroid-sparing add-on therapies (eg, biologics). In cases where SCS use is deemed clinically justified, it should be tapered to the lowest possible dose. In addition, patients receiving long-term SCS or frequent acute courses should be closely monitored for emergence of SCS-related AEs. Because of the extensive data available on the costly and burdensome AEs associated with SCS use, as well as the range of treatment options now available, there is a need for healthcare providers (HCPs) to carefully evaluate whether the benefits of SCS outweigh the potential harms, to adopt SCS-sparing and Stewardship strategies, and to consider alternative therapies where possible. Development of a structured and collaborative SCS Stewardship approach is urgently required to protect patients from the potential harm of SCS use.
Collapse
Affiliation(s)
- Eugene R. Bleecker
- Division of Genetics, Genomics and Precision Medicine, Department of Medicine, University of Arizona, Tucson, AZ, USA
| | - Mona Al-Ahmad
- Microbiology Department, College of Medicine, Kuwait University, Kuwait City, Kuwait
| | - Leif Bjermer
- Department of Respiratory Medicine and Allergology, University Hospital, Lund, Sweden
| | - Marco Caminati
- Department of Medicine, University of Verona, Verona, Italy
| | - Giorgio Walter Canonica
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
- Personalized Medicine, Asthma and Allergy, Humanitas Clinical and Research Center, IRCCS, Rozzano, Italy
| | - Alan Kaplan
- Family Physician Airways Group of Canada, Stouffville, ON, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Nikolaos G. Papadopoulos
- Division of Infection, Immunity & Respiratory Medicine, Royal Manchester Children's Hospital, University of Manchester, Manchester, UK
- Allergy Department, 2nd Pediatric Clinic, Athens General Children's Hospital ‘P&A Kyriakou’, University of Athens, Athens, Greece
| | - Nicolas Roche
- Department of Respiratory Medicine, APHP. Centre Université Paris Cité, Cochin Hospital (AP-HP) and Institute (UMR1016), Paris, France
| | - Dermot Ryan
- Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Yuji Tohda
- Kindai University Hospital, Osaka, Japan
| | - Anahí Yáñez
- Center for Research on Allergies and Respiratory Diseases (InAER), Buenos Aires, Argentina
| | - David Price
- Observational and Pragmatic Research Institute, Singapore
- Centre of Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
- Corresponding author. Professor David B Price, Observational and Pragmatic Research Institute, 22 Sin Ming Lane, #06 Midview City, Singapore 573969
| |
Collapse
|
12
|
Menzies-Gow A, Gurnell M, Heaney LG, Corren J, Bel EH, Maspero J, Harrison T, Jackson DJ, Price D, Lugogo N, Kreindler J, Burden A, de Giorgio-Miller A, Faison S, Padilla K, Martin UJ, Garcia Gil E. Adrenal function recovery after durable oral corticosteroid sparing with benralizumab in the PONENTE study. Eur Respir J 2022; 60:2103226. [PMID: 35896216 PMCID: PMC9791910 DOI: 10.1183/13993003.03226-2021] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 07/04/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Oral corticosteroid (OCS) dependence among patients with severe eosinophilic asthma can cause adverse outcomes, including adrenal insufficiency. PONENTE's OCS reduction phase showed that, following benralizumab initiation, 91.5% of patients eliminated corticosteroids or achieved a final dosage ≤5 mg·day-1 (median (range) 0.0 (0.0-40.0) mg). METHODS The maintenance phase assessed the durability of corticosteroid reduction and further adrenal function recovery. For ∼6 months, patients continued benralizumab 30 mg every 8 weeks without corticosteroids or with the final dosage achieved during the reduction phase. Investigators could prescribe corticosteroids for asthma exacerbations or increase daily dosages for asthma control deteriorations. Outcomes included changes in daily OCS dosage, Asthma Control Questionnaire (ACQ)-6 and St George's Respiratory Questionnaire (SGRQ), as well as adrenal status, asthma exacerbations and adverse events. RESULTS 598 patients entered PONENTE; 563 (94.1%) completed the reduction phase and entered the maintenance phase. From the end of reduction to the end of maintenance, the median (range) OCS dosage was unchanged (0.0 (0.0-40.0) mg), 3.2% (n=18/563) of patients experienced daily dosage increases, the mean ACQ-6 score decreased from 1.26 to 1.18 and 84.5% (n=476/563) of patients were exacerbation free. The mean SGRQ improvement (-19.65 points) from baseline to the end of maintenance indicated substantial quality-of-life improvements. Of patients entering the maintenance phase with adrenal insufficiency, 32.4% (n=104/321) demonstrated an improvement in adrenal function. Adverse events were consistent with previous reports. CONCLUSIONS Most patients successfully maintained maximal OCS reduction while achieving improved asthma control with few exacerbations and maintaining or recovering adrenal function.
Collapse
Affiliation(s)
- Andrew Menzies-Gow
- Department of Respiratory Medicine, Royal Brompton and Harefield Hospitals, London, UK
| | - Mark Gurnell
- Wellcome-MRC Institute of Metabolic Science, University of Cambridge and NIHR Cambridge Biomedical Research Centre, Cambridge Biomedical Campus, Cambridge, UK
| | - Liam G Heaney
- Wellcome-Wolfson Centre for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Jonathan Corren
- David Geffen School of Medicine at UCLA and Allergy Medical Clinic Inc., Los Angeles, CA, USA
| | - Elisabeth H Bel
- Department of Respiratory Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Timothy Harrison
- Nottingham Respiratory NIHR BRC, University of Nottingham, Nottingham, UK
- BioPharmaceuticals R&D Digital, AstraZeneca, Cambridge, UK
| | - David J Jackson
- Guy's Severe Asthma Centre, Guy's and St Thomas' NHS Trust, London, UK
- Asthma UK Centre, School of Immunology and Microbial Sciences, King's College London, London, UK
| | - David Price
- Observational and Pragmatic Research Institute, Singapore, Singapore
- Centre of Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Njira Lugogo
- Division of Pulmonary and Critical Care Medicine, University of Michigan Medical Center, Ann Arbor, MI, USA
| | - James Kreindler
- Global Medical Respiratory, BioPharmaceuticals Medical, AstraZeneca, Wilmington, DE, USA
| | - Annie Burden
- BioPharmaceuticals R&D, Late Respiratory and Immunology, Biometrics, AstraZeneca, Cambridge, UK
| | | | - Sarai Faison
- Late Respiratory and Immunology, BioPharmaceuticals R&D, AstraZeneca, Durham, NC, USA
| | - Kelly Padilla
- Late Respiratory and Immunology, BioPharmaceuticals R&D, AstraZeneca, Durham, NC, USA
| | - Ubaldo J Martin
- Late Stage Development, Respiratory and Immunology Therapeutic Area, AstraZeneca, Gaithersburg, MD, USA
| | - Esther Garcia Gil
- Global Medical Respiratory, BioPharmaceuticals Medical, AstraZeneca, Barcelona, Spain
| |
Collapse
|
13
|
Domínguez-Ortega J, Delgado Romero J, Muñoz Gall X, Marco A, Blanco-Aparicio M. Uso de glucocorticoides sistémicos para el tratamiento del asma grave: Consenso multidisciplinar español. OPEN RESPIRATORY ARCHIVES 2022. [PMID: 37496970 PMCID: PMC10369533 DOI: 10.1016/j.opresp.2022.100202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
Abstract
Background and aim Since their effectiveness was initially demonstrated, oral corticosteroids (OCS) have been routinely used to treat asthma. We now know that their usage is linked to the development of side effects such osteoporosis and adrenal insufficiency. This is an observational study based on Delphi methodology. The questionnaire was divided into 4 sections: OCS generalities, maintenance treatment, short-term treatment, and adverse events. Materials and methods Two rounds of a 68-item questionnaire were completed by a panel of 48 allergists and pneumologists. Results Definitions were agreed upon, as was the proper use of OCS in the treatment of severe asthma. The experts agreed that the use of OCS should be minimized as much as possible and that in the event of maintenance treatments, a slow and progressive tapering strategy should be used. They also emphasized the importance of standardizing the technique for measuring the amount of SCG delivered in both cases. Conclusions This consensus document attempts to bring together scientifically supported suggestions from specialists in the management of asthma to reduce the use of OCS in Spain.
Collapse
|
14
|
Mansur AH, Gonem S, Brown T, Burhan H, Chaudhuri R, Dodd JW, Pantin T, Gore R, Jackson D, Menzies-Gow A, Patel M, Pavord I, Pfeffer P, Siddiqui S, Busby J, Heaney LG. Biologic therapy practices in severe asthma; outcomes from the UK Severe Asthma Registry and survey of specialist opinion. Clin Exp Allergy 2022; 53:173-185. [PMID: 36057784 DOI: 10.1111/cea.14222] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 07/05/2022] [Accepted: 08/15/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND several biological treatments have become available for management of severe asthma. There is a significant overlap in the indication of these treatments with lack of consensus on the first-line biologic choice and switching practice in event of treatment failure. AIMS to evaluate outcomes of biologic treatments through analysis of the UK Severe Asthma Registry (UKSAR), and survey of the UK severe asthma specialists' opinion. METHODS patients registered in the UKSAR database and treated with biologics for severe asthma in the period between January 2014 and August 2021, were studied to explore biologic treatments practice. This was complemented by survey of opinion of severe asthma specialists. RESULTS a total of 2,490 patients from 10 severe asthma centres were included in the study (mean age 51.3 years, 61.1% female, mean BMI 30.9kg/m2 ). Biologics use included mepolizumab 1,115 (44.8%), benralizumab 925 (37.1%), omalizumab 432 (17.3%), dupilumab 13 (0.5%), and reslizumab 5 (0.2%). Patients on omalizumab were younger and had earlier age of onset asthma than those prescribed mepolizumab or benralizumab. Patients prescribed mepolizumab and benralizumab had similar clinical characteristics. Those on benralizumab were more likely to continue treatment at approximately one year follow up (93.9%), than those on mepolizumab (80%), or omalizumab (69.6%). The first choice biologic differed between centres and changed over the study time period. Experts' opinion also diverged in terms of biologic initiation choice and switching practice. CONCLUSION We observed significant variation and divergence in the prescribing practices of biologics in severe asthma that necessitates further research and standardisation.
Collapse
Affiliation(s)
- Adel H Mansur
- Birmingham Regional Severe Asthma Service, Heartlands Hospital, University Hospitals Birmingham and University of Birmingham, UK
| | - Sherif Gonem
- Department of Respiratory Medicine, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Thomas Brown
- Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Hassan Burhan
- Dr Hassan Burhan, Liverpool University Hospitals NHS Foundation Trust and University of Liverpool
| | - Rekha Chaudhuri
- Gartnavel General Hospital, Glasgow and University of Glasgow, UK
| | - James W Dodd
- North Bristol Complex Airways Service, Southmead Hospital, North Bristol NHS Trust & Academic Respiratory Unit, Translational Health Sciences, Bristol Medical School, University of Britsol, UK
| | - Thomas Pantin
- Severe Asthma Service, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Robin Gore
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - David Jackson
- Guy's Severe Asthma Centre, Guy's & St Thomas' NHS Trust; School of Immunology & Microbial Sciences, King's College London
| | | | - Mitesh Patel
- Mitesh Patel, Derriford Hospital, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Ian Pavord
- Oxford Respiratory NIHR BRC, Nuffield Department of Medicine, Infection and Inflammation, University of Oxford, UK
| | - Paul Pfeffer
- Department of Respiratory Medicine, Barts Health NHS Trust, London, UK; and Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Salman Siddiqui
- College of Life Sciences, Department of Respiratory Medicine, University of Leicester. Leicester NIHR Biomedical Research Centre (Respiratory theme), Glenfield Hospital, Leicester, UK
| | - John Busby
- Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queens University Belfast, Belfast, UK
| | - Liam G Heaney
- Wellcome-Wolfson Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, Northern Ireland
| |
Collapse
|
15
|
Abstract
BACKGROUND This is the second update of previously published reviews in the Cochrane Library (2015, first update 2017). Interleukin-5 (IL-5) is the main cytokine involved in the proliferation, maturation, activation and survival of eosinophils, which cause airway inflammation and are a classic feature of asthma. Studies of monoclonal antibodies targeting IL-5 or its receptor (IL-5R) suggest they reduce asthma exacerbations, improve health-related quality of life (HRQoL) and lung function in appropriately selected patients, justifying their inclusion in the latest guidelines. OBJECTIVES To compare the effects of therapies targeting IL-5 signalling (anti-IL-5 or anti-IL-5Rα) with placebo on exacerbations, health-related quality-of-life (HRQoL) measures and lung function in adults and children with chronic asthma, and specifically in those with eosinophilic asthma refractory to existing treatments. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, and two trials registers, manufacturers' websites, and reference lists of included studies. The most recent search was 7 February 2022. SELECTION CRITERIA We included randomised controlled trials comparing mepolizumab, reslizumab and benralizumab versus placebo in adults and children with asthma. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and analysed outcomes using a random-effects model. We used standard methods expected by Cochrane. MAIN RESULTS Seventeen studies on about 7600 participants met the inclusion criteria. Six used mepolizumab, five used reslizumab, and six used benralizumab. One study using benralizumab was terminated early due to sponsor decision and contributed no data. The studies were predominantly on people with severe eosinophilic asthma, which was similarly but variably defined. One was in children aged 6 to 17 years; nine others included children over 12 years but did not report results by age group separately. We deemed the overall risk of bias to be low, with all studies contributing data of robust methodology. We considered the certainty of the evidence for all comparisons to be high overall using the GRADE scheme, except for intravenous (IV) mepolizumab and subcutaneous (SC) reslizumab because these are not currently licensed delivery routes. The anti-IL-5 treatments assessed reduced rates of 'clinically significant' asthma exacerbation (defined by treatment with systemic corticosteroids for three days or more) by approximately half in participants with severe eosinophilic asthma on standard care (at least medium-dose inhaled corticosteroids (ICS)) with poorly controlled disease (either two or more exacerbations in the preceding year or Asthma Control Questionnaire (ACQ) score of 1.5 or more), except for reslizumab SC. The rate ratios for these effects were 0.45 (95% confidence interval (CI) 0.36 to 0.55; high-certainty evidence) for mepolizumab SC, 0.53 (95% CI 0.44 to 0.64; moderate-certainty evidence) for mepolizumab IV, 0.43 (95% CI 0.33 to 0.55; high-certainty evidence) for reslizumab IV, and 0.59 (95% CI 0.52 to 0.66; high-certainty evidence) for benralizumab SC. Non-eosinophilic participants treated with benralizumab also showed a significant reduction in exacerbation rates, an effect not seen with reslizumab IV, albeit in only one study. No data were available for non-eosinophilic participants treated with mepolizumab. There were improvements in validated HRQoL scores with all anti-IL-5 agents in severe eosinophilic asthma. This met the minimum clinically important difference (MCID) for the broader St. George's Respiratory Questionnaire (SGRQ; 4-point change) for benralizumab only, but the improvement in the ACQ and Asthma Quality of Life Questionnaire (AQLQ), which focus on asthma symptoms, fell short of the MCID (0.5 point change for both ACQ and AQLQ) for all of the interventions. The evidence for an improvement in HRQoL scores in non-eosinophilic participants treated with benralizumab and reslizumab was weak, but the tests for subgroup difference were negative. All anti-IL-5 treatments produced small improvements in mean pre-bronchodilator forced expiratory flow in one second (FEV1) of between 0.08 L and 0.15 L in eosinophilic participants, which may not be sufficient to be detected by patients. There were no excess serious adverse events with any anti-IL-5 treatment; in fact, there was a reduction in such events with benralizumab, likely arising from fewer asthma-related hospital admissions. There was no difference compared to placebo in adverse events leading to discontinuation with mepolizumab or reslizumab, but significantly more discontinued benralizumab than placebo, although the absolute numbers were small (42/2026 (2.1%) benralizumab versus 11/1227 (0.9%) placebo). The implications for efficacy or adverse events are unclear. AUTHORS' CONCLUSIONS Overall this analysis supports the use of anti-IL-5 treatments as an adjunct to standard care in people with severe eosinophilic asthma and poor symptom control. These treatments roughly halve the rate of asthma exacerbations in this population. There is limited evidence for improved HRQoL scores and lung function, which may not meet clinically detectable levels. The studies did not report safety concerns for mepolizumab or reslizumab, or any excess serious adverse events with benralizumab, although there remains a question over adverse events significant enough to prompt discontinuation. Further research is needed on biomarkers for assessing treatment response, optimal duration and long-term effects of treatment, risk of relapse on withdrawal, non-eosinophilic patients, children (particularly under 12 years), comparing anti-IL-5 treatments to each other and, in patients meeting relevant eligibility criteria, to other biological (monoclonal antibody) therapies. For benralizumab, future studies should closely monitor rates of adverse events prompting discontinuation.
Collapse
Affiliation(s)
| | - Amanda Wilson
- School of Nursing and Midwifery, University of Technology Sydney, Sydney, Australia
| | - Stephen Milan
- Health Innovation Campus and Centre for Health Futures, Lancaster University, Lancaster, UK
| | | | - Freda Yang
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Colin Ve Powell
- Department of Emergency Medicine, Sidra Medciine, Doha, Qatar
| |
Collapse
|
16
|
Abstract
Severe asthma is a heterogeneous syndrome with several clinical variants and often represents a complex disease requiring a specialized and multidisciplinary approach, as well as the use of multiple drugs. The prevalence of severe asthma varies from one country to another, and it is estimated that 50% of these patients present a poor control of their disease. For the best management of the patient, it is necessary a correct diagnosis, an adequate follow-up and undoubtedly to offer the best available treatment, including biologic treatments with monoclonal antibodies. With this objective, this consensus process was born, which began in its first version in 2018, whose goal is to offer the patient the best possible management of their disease in order to minimize their symptomatology. For this 2020 consensus update, a literature review was conducted by the authors. Subsequently, through a two-round interactive Delphi process, a broad panel of asthma experts from SEPAR and the regional pulmonology societies proposed the recommendations and conclusions contained in this document.
Collapse
|
17
|
Lehtimäki L, Arvidsson M, Erdemli B, Nan C, Nguyen TM, Samant A, Telg G. Regional variation in intensity of inhaled asthma medication and oral corticosteroid use in Denmark, Finland, and Sweden. Eur Clin Respir J 2022; 9:2066815. [PMID: 35529252 PMCID: PMC9067971 DOI: 10.1080/20018525.2022.2066815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Oral corticosteroids (OCS) are often prescribed to patients with asthma that remains uncontrolled with maintenance therapy. We performed a real-world analysis to describe the geographic distributions of patients with asthma and OCS dispensed in Nordic countries. This observational, retrospective study examined patient-level data from nationally prescribed drug registries from January to December 2018 for individuals aged ≥12 years in Denmark, Finland, and Sweden. Using an algorithm based on asthma treatment combinations defined by the Global Initiative for Asthma (GINA), we identified patients with asthma, those on GINA Step 4–5 treatments, and those being dispensed ≥2 courses of OCS and determined volumes of OCS dispensed to these patients over the 1-year analysis period. Data were plotted geographically within each country using colour-coded heat maps. The overall asthma prevalence rates were 7.4% in Denmark, 11.6% in Finland, and 8.1% in Sweden. In Denmark, Finland, and Sweden, respectively, the frequencies of patients on GINA Step 4–5 treatments were 19%, 15%, and 16%; among whom 10%, 23%, and 5% received ≥2 courses of OCS. The rates of patients on GINA Step 4–5 treatments who were dispensed OCS in each country were 23%, 30%, and 46%, of which 22%, 17%, and 10% were dispensed doses averaging ≥5 mg/day over the year. Heat maps revealed considerable heterogeneity in geographic densities of patients with asthma and OCS claims within each country. Taken together, these results demonstrate regional variations in estimated asthma severity, control, and OCS dispensed within and between countries. Patterns of medication use suggest that a high proportion of patients in Denmark, Finland, and Sweden are on GINA Step 4–5 treatments, many of whom are dispensed OCS; this poses a considerable corticosteroid burden to these patients. Geographic differences in medication use within and between Nordic countries may reflect variations in population characteristics and/or treatment approaches.
Collapse
Affiliation(s)
- Lauri Lehtimäki
- Faculty of Medicine and Health Technology, Tampere University; Allergy Centre, Tampere University Hospital, Tampere, Finland
| | - Monica Arvidsson
- Respiratory Medicine and Allergy, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Bora Erdemli
- Department of Statistics, ZS Associates, Zurich, Switzerland
| | - Cassandra Nan
- Department of Epidemiology, AstraZeneca, Mölndal, Sweden
| | | | | | - Gunilla Telg
- Medical Department, AstraZeneca Nordic, Södertälje, Sweden
| |
Collapse
|
18
|
Reducing Tolerance for SABA and OCS towards the Extreme Ends of Asthma Severity. J Pers Med 2022; 12:jpm12030504. [PMID: 35330503 PMCID: PMC8949541 DOI: 10.3390/jpm12030504] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 03/08/2022] [Accepted: 03/16/2022] [Indexed: 02/04/2023] Open
Abstract
Asthma is a heterogeneous chronic inflammatory airway disease that imposes a great burden on public health worldwide. In the past two years, fundamental changes have been addressed in the Global Initiative for Asthma (GINA) recommendations focusing mainly on the management of mild and severe asthma. The use of as-needed treatment containing inhaled corticosteroids plus fast-acting bronchodilators (either short or long-acting formoterol) in mild asthma has dominated the field, and both randomized and real-world studies favor such an approach and associate it with fewer exacerbations and good asthma control. At the same time, the effort to diminish the use of oral steroids (OCS) as maintenance treatment in severe asthma was substantially accomplished with the initiation of treatment with biologics. Still, these options are available at the moment only for severe asthmatics with a T2-high endotype, and relevant studies on biologics have yielded, as a primary outcome, the reduction or even cessation of OCS. Accordingly, OCS should be considered as a temporary option, mainly for the treatment of asthma exacerbations, and as a maintenance treatment only for a minority of patients with severe asthma, after ensuring good inhaler technique, modification of all possible contributory factors and comorbidities, and optimized pharmacotherapy using all other add-on treatments including biologics in the armamentarium of anti-asthma medication.
Collapse
|
19
|
Korn S, Howarth P, Smith SG, Price RG, Yancey SW, Prazma CM, Bel EH. Development of methodology for assessing steroid-tapering in clinical trials for biologics in asthma. Respir Res 2022; 23:45. [PMID: 35246123 PMCID: PMC8896284 DOI: 10.1186/s12931-022-01959-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 02/14/2022] [Indexed: 11/10/2022] Open
Abstract
Background Long-term use of oral corticosteroids (OCS) is associated with a risk of adverse events and comorbidities. As such, a goal in assessing the efficacy of biologics in severe asthma is often to monitor reduction in OCS usage. Importantly, however, OCS dose reductions must be conducted without loss of disease control.
Main body Herein, we describe the development of OCS-sparing study methodologies for biologic therapies in patients with asthma. In particular, we focus on four randomized, placebo-controlled, parallel-group studies of varying sizes (key single-center study [n = 20], SIRIUS [n = 135], ZONDA [n = 220], VENTURE [n = 210]) and one open-label study (PONENTE [n = 598]), which assessed the effect of asthma biologics (mepolizumab, benralizumab or dupilumab) on OCS use using predefined OCS-tapering schedules. In particular, we discuss the evolution of study design elements in these studies, including patient eligibility criteria, the use of tailored OCS dose reduction schedules, monitoring of outcomes, the use of biomarkers and use of repetitive assessments of adrenal function during OCS tapering. Conclusion Taken together, these developments have improved OCS-sparing asthma studies in recent years and the lessons learned may help with optimization of further OCS-sparing studies, and potentially clinical practice in the future. Supplementary Information The online version contains supplementary material available at 10.1186/s12931-022-01959-1.
Collapse
Affiliation(s)
- Stephanie Korn
- Pulmonary Department, Universitätsmedizin Mainz, Mainz, Langenbeckstr, Germany. .,Clinical Research Centre Respiratory Disease, IKF Pneumologie GmbH & Co. KG, Haifa-Allee 24, 55128, Mainz, Germany. .,Thoraxklinik Heidelberg, Röntgenstr. 1, 69126, Heidelberg, Germany.
| | - Peter Howarth
- Global Medical Franchise, GSK House, Brentford, Middlesex, UK
| | - Steven G Smith
- Respiratory Therapeutic Area, GSK, Research Triangle Park, NC, USA
| | | | - Steven W Yancey
- Respiratory Therapeutic Area, GSK, Research Triangle Park, NC, USA
| | | | - Elisabeth H Bel
- Department of Respiratory Medicine, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, The Netherlands
| |
Collapse
|
20
|
Salter B, Lacy P, Mukherjee M. Biologics in Asthma: A Molecular Perspective to Precision Medicine. Front Pharmacol 2022; 12:793409. [PMID: 35126131 PMCID: PMC8807637 DOI: 10.3389/fphar.2021.793409] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 12/10/2021] [Indexed: 12/11/2022] Open
Abstract
Recent developments in therapeutic strategies have provided alternatives to corticosteroids as the cornerstone treatment for managing airway inflammation in asthma. The past two decades have witnessed a tremendous boost in the development of anti-cytokine monoclonal antibody (mAb) therapies for the management of severe asthma. Novel biologics that target eosinophilic inflammation (or type 2, T2 inflammation) have been the most successful at treating asthma symptoms, though there are a few in the drug development pipeline for treating non-eosinophilic or T2-low asthma. There has been significant improvement in clinical outcomes for asthmatics treated with currently available monoclonal antibodies (mAbs), including anti-immunoglobulin (Ig) E, anti-interleukin (IL)-4 receptor α subunit, anti-IL-5, anti-IL-5Rα, anti-IL-6, anti-IL-33, and anti-thymic stromal lymphopoietin (TSLP). Despite these initiatives in precision medicine for asthma therapy, a significant disease burden remains, as evident from modest reduction of exacerbation rates, i.e., approximately 40-60%. There are numerous studies that highlight predictors of good responses to these biologics, but few have focused on those who fail to respond adequately despite targeted treatment. Phenotyping asthmatics based on blood eosinophils is proving to be inadequate for choosing the right drug for the right patient. It is therefore pertinent to understand the underlying immunology, and perhaps, carry out immune endotyping of patients before prescribing appropriate drugs. This review summarizes the immunology of asthma, the cytokines or receptors currently targeted, the possible mechanisms of sub-optimal responses, and the importance of determining the immune make-up of individual patients prior to prescribing mAb therapy, in the age of precision medicine for asthma.
Collapse
Affiliation(s)
- Brittany Salter
- Division of Respirology, Department of Medicine, McMaster University, Hamilton, ON, Canada
- Firestone Institute for Respiratory Health, St. Joseph’s Healthcare, Hamilton, ON, Canada
| | - Paige Lacy
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Manali Mukherjee
- Division of Respirology, Department of Medicine, McMaster University, Hamilton, ON, Canada
- Firestone Institute for Respiratory Health, St. Joseph’s Healthcare, Hamilton, ON, Canada
| |
Collapse
|
21
|
Casale TB, Burnette A, Bourdin A, Howarth P, Hahn B, Stach-Klysh A, Khurana S. Oral corticosteroid-sparing effects of mepolizumab in severe eosinophilic asthma: evidence from randomized controlled trials and real-world studies. Ther Adv Respir Dis 2022; 16:17534666221107313. [PMID: 35972211 PMCID: PMC9386863 DOI: 10.1177/17534666221107313] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 05/30/2022] [Indexed: 11/16/2022] Open
Abstract
Oral corticosteroids (OCS) have long been a mainstay of treatment for asthma exacerbations and chronic severe asthma. However, it is increasingly recognized that both long-term and short-term OCS use are directly associated with a wide range of serious adverse effects, and as such OCS-sparing treatment alternatives are now widely recommended for patients with severe asthma. While several international guidelines recommend these treatments, guidance on OCS tapering, and which patients are most likely to tolerate OCS reduction and/or discontinuation, is still lacking. Several biologics have demonstrated efficacy in patients with OCS-dependent asthma. One OCS-sparing treatment is the anti-interleukin-5 monoclonal antibody mepolizumab, which is approved for the treatment of severe eosinophilic asthma. In addition to improved exacerbation rates, asthma control, quality of life, and lung function among patients with severe eosinophilic asthma, mepolizumab also has an OCS-sparing effect, which has been demonstrated in randomized controlled trials and real-world studies. Both physicians and patients express concerns about the adverse effects of OCS, and additional data from the randomized, controlled SIRIUS trial (NCT01691508) highlight the high level of concern among patients regarding OCS-related burden. In this article, we discuss current guidance on OCS-sparing strategies for patients with severe asthma, provide a summary of the available evidence of the OCS-sparing effect of mepolizumab, and highlight patient and physician perspectives on the use of OCS and OCS-sparing treatments in severe asthma.
Collapse
Affiliation(s)
- Thomas B. Casale
- Division of Allergy and Immunology, University of South Florida, Tampa, FL, USA
| | - Autumn Burnette
- Division of Allergy and Immunology, Howard University Hospital, Washington, DC, USA
| | - Arnaud Bourdin
- Department of Respiratory Diseases, PhyMedExp, INSERM, CNRS, CHU de Montpellier, Université de Montpellier, Montpellier, France
| | | | - Beth Hahn
- US Medical Affairs, GlaxoSmithKline, Research Triangle Park, NC, USA
| | - Alexandra Stach-Klysh
- US Medical Affairs, GlaxoSmithKline, 5 Moore Drive, Research Triangle Park, NC 27709-3398, USA
| | - Sandhya Khurana
- Mary Parkes Center for Asthma, Division of Pulmonary and Critical Care Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| |
Collapse
|
22
|
Menzella F, Ghidoni G, Fontana M, Capobelli S, Livrieri F, Castagnetti C, Facciolongo N. The role of systemic corticosteroids in severe asthma and new evidence in their management and tapering. Expert Rev Clin Immunol 2021; 17:1283-1299. [PMID: 34761712 DOI: 10.1080/1744666x.2021.2004123] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Based on the latest literature evidence, between 30% and 60% of adults with severe refractory asthma (SRA) are systemic corticosteroid (SCS) dependent. There are numerous therapeutic options in asthma, which are often not effective in severe forms. In these cases, SCS should be considered, but it is increasingly recognized that their regular use is often associated with significant and potentially serious adverse events. AREAS COVERED The aim of this article is to provide an update about the recent and significant literature on SCS and to establish their role in the management of SRA. We summarized the most important and recent evidence and we provided useful indications for clinicians. EXPERT OPINION There is now strong evidence supporting the increased risk of comorbidities and complications with long-term SCS therapies, regardless of the dose. New evidence on SCS tapering and withdrawal will allow to define protocols to address SCS management with greater safety and effectiveness, after starting efficient steroid-sparing strategies. In the next 5years, it will be necessary to implement corrective actions to address these unmet needs, to reduce the inappropriate use of SCS by maximizing the application of more innovative and effective therapies.
Collapse
Affiliation(s)
- Francesco Menzella
- Department of Medical Specialties, Pulmonology Unit, Arcispedale Santa Maria Nuova, Azienda USL Di Reggio Emilia - IRCCS, Reggio Emilia, Italy
| | - Giulia Ghidoni
- University Hospital of Modena, 208968,Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University of Modena Reggio Emilia, Modena, Italy
| | - Matteo Fontana
- Department of Medical Specialties, Pulmonology Unit, Arcispedale Santa Maria Nuova, Azienda USL Di Reggio Emilia - IRCCS, Reggio Emilia, Italy
| | - Silvia Capobelli
- Department of Medical Specialties, Pulmonology Unit, Arcispedale Santa Maria Nuova, Azienda USL Di Reggio Emilia - IRCCS, Reggio Emilia, Italy
| | - Francesco Livrieri
- Department of Medical Specialties, Pulmonology Unit, Arcispedale Santa Maria Nuova, Azienda USL Di Reggio Emilia - IRCCS, Reggio Emilia, Italy
| | - Claudia Castagnetti
- Department of Medical Specialties, Pulmonology Unit, Arcispedale Santa Maria Nuova, Azienda USL Di Reggio Emilia - IRCCS, Reggio Emilia, Italy
| | - Nicola Facciolongo
- Department of Medical Specialties, Pulmonology Unit, Arcispedale Santa Maria Nuova, Azienda USL Di Reggio Emilia - IRCCS, Reggio Emilia, Italy
| |
Collapse
|
23
|
Watchorn D, Menzies-Gow A. Oral corticosteroid stewardship for asthma: Time to move from theory to routine clinical practice. Respirology 2021; 26:1094-1095. [PMID: 34668272 DOI: 10.1111/resp.14171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 10/07/2021] [Indexed: 11/29/2022]
Affiliation(s)
- David Watchorn
- Department of Respiratory Medicine, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Andrew Menzies-Gow
- Department of Respiratory Medicine, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, London, UK
| |
Collapse
|
24
|
The Benefit of Benralizumab Monoclonal Antibody Treatment for Severe Eosinophilic Asthma in a Case Series (Pulmonology Clinic Târgu Mureș, Romania). JOURNAL OF INTERDISCIPLINARY MEDICINE 2021. [DOI: 10.2478/jim-2021-0030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Abstract
Background: Monoclonal antibody therapy is currently an additional treatment option to reduce exacerbations and improve symptom control in patients with severe eosinophilic asthma (SEA) that is uncontrolled despite treatment with high-dose inhaled corticosteroids and long-acting beta-2 agonists. Benralizumab, a monoclonal antibody that binds to the interleukin-5 receptor (IL-5), significantly reduces symptoms and annual exacerbations, as well as the use of systemic corticosteroids in patients with SEA. However, few studies are available on the effectiveness of this biological treatment in real life. The aim of this case series was to evaluate the efficacy of benralizumab by analyzing changes in clinical parameters and blood eosinophils in patients with SEA.
Methods: We analyzed four patients with SEA who started treatment with benralizumab. The history of symptoms and exacerbations, eosinophil counts, data regarding the oral corticosteroid dose, need for rescue treatment, spirometry measurements and asthma control questionnaires (ACT) regarding the level of asthma control were recorded. A positive response to treatment was defined by a significant reduction in eosinophil counts, increased ACT scores, and lower rates of exacerbations.
Results and conclusions: Benralizumab monoclonal antibody was effective in all four patients. This was shown by a reduction in exacerbation rates, symptom severity, and lower dose of oral corticosteroids and rescue medication. This novel treatment was well tolerated by the analyzed patients, thus indicating that benralizumab is an attractive choice for patients due to eosinophilic count reduction as well as the less frequent dosing schedule. However, further studies are required, on larger populations.
Collapse
|
25
|
Menzies-Gow A, Gurnell M, Heaney LG, Corren J, Bel EH, Maspero J, Harrison T, Jackson DJ, Price D, Lugogo N, Kreindler J, Burden A, de Giorgio-Miller A, Padilla K, Martin UJ, Garcia Gil E. Oral corticosteroid elimination via a personalised reduction algorithm in adults with severe, eosinophilic asthma treated with benralizumab (PONENTE): a multicentre, open-label, single-arm study. THE LANCET RESPIRATORY MEDICINE 2021; 10:47-58. [PMID: 34619104 DOI: 10.1016/s2213-2600(21)00352-0] [Citation(s) in RCA: 79] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 07/08/2021] [Accepted: 07/20/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND No consensus exists on how to reduce oral corticosteroids after the initiation of biologics in severe asthma. The PONENTE trial evaluated the effectiveness and safety of a rapid, individualised steroid-reduction algorithm, including adrenal insufficiency monitoring, after benralizumab initiation. METHODS This multicentre, open-label, single-arm study was done at 138 clinical asthma treatment centres across 17 countries. We enrolled adult patients (age ≥18 years) with severe, eosinophilic asthma (blood eosinophil count ≥150 cells per μL at enrolment or ≥300 cells per μL in the previous year) requiring maintenance oral corticosteroids for at least 3 months preceding enrolment. Patients received benralizumab 30 mg (subcutaneous injection) every 4 weeks for three doses, then every 8 weeks thereafter. The oral corticosteroid reduction phase began at week 4 with daily oral corticosteroid dosages reduced by 1-5 mg every 1-4 weeks depending on the starting dosage, asthma control, and adrenal function status. Adrenal function was assessed with an early morning serum cortisol measurement, followed by adrenocorticotropic hormone stimulation when required, once patients achieved a daily oral corticosteroid dosage of 5 mg/day for 4 weeks. Repeat cortisol measurements were taken for patients with evidence of adrenal insufficiency at first testing. Asthma control was assessed with the Asthma Control Questionnaire-6 (ACQ-6) weekly throughout the induction and oral corticosteroid reduction phases. The primary endpoints were the percentage of patients eliminating daily oral corticosteroids, sustained for at least 4 weeks, and the percentage achieving elimination or a daily prednisone or prednisolone dosage of 5 mg or less, for at least 4 weeks, if the reason for no further reduction was adrenal insufficiency. Safety and efficacy analyses included all patients who received at least one dose of benralizumab and were descriptive. We present results after the oral corticosteroid reduction phase; a maintenance phase is ongoing. The trial is registered with ClinicalTrials.gov, NCT03557307. FINDINGS Between April 1, 2018, and Sept 5, 2020, of 705 patients assessed for eligibility, 598 were recruited and all received at least one dose of benralizumab. Overall, 376 (62·88%, 95% CI 58·86-66·76) of 598 patients eliminated oral corticosteroids and 490 (81·94%, 78·62-84·94) of 598 eliminated use or achieved a dosage of 5 mg or less if the reason for stopping the reduction was adrenal insufficiency. Subgroup analysis showed that dosage reductions were achieved irrespective of baseline eosinophil count, baseline oral corticosteroid dosage, or oral corticosteroid treatment duration. Adrenal insufficiency was detected in 321 (60%) of 533 patients at first assessment and in 205 (38%) of 533 patients 2-3 months later. The safety profile was consistent with previous experience. Most patients (448 [75%] of 598) had no asthma exacerbations during the oral corticosteroid reduction phase with an annualised exacerbation rate of 0·63. Of 598 patients, 38 (6%) experienced a total of 46 exacerbations resulting in emergency department or urgent care visits or hospitalisations. INTERPRETATION Despite a high prevalence of adrenal insufficiency, most patients with eosinophilic asthma treated with benralizumab achieved elimination of oral corticosteroids or maximal possible reduction using a personalised dosage-reduction algorithm. FUNDING AstraZeneca.
Collapse
Affiliation(s)
| | - Mark Gurnell
- Wellcome-MRC Institute of Metabolic Science, University of Cambridge and NIHR Cambridge Biomedical Research Centre, Cambridge, UK
| | - Liam G Heaney
- Wellcome-Wolfson Centre for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Jonathan Corren
- David Geffen School of Medicine at UCLA, Los Angeles, CA, USA; Allergy Medical Clinic, Los Angeles, CA, USA
| | - Elisabeth H Bel
- Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Timothy Harrison
- Respiratory Research Unit, Nottingham NIHR Biomedical Research Centre, University of Nottingham, UK; BioPharmaceuticals R&D Digital, AstraZeneca, Cambridge, UK
| | - David J Jackson
- Guy's Severe Asthma Centre, Guy's and St Thomas' NHS Trust, London, UK; Asthma UK Centre, School of Immunology and Microbial Sciences, King's College London, London, UK
| | - David Price
- Observational and Pragmatic Research Institute, Singapore; Centre of Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Njira Lugogo
- University of Michigan Medical Center, Ann Arbor, MI, USA
| | - James Kreindler
- Global Medical Respiratory, BioPharmaceuticals Medical, AstraZeneca, Wilmington, DE; USA
| | - Annie Burden
- Late Respiratory and Immunology and Biometrics, BioPharmaceuticals R&D, AstraZeneca, Cambridge, UK
| | | | - Kelly Padilla
- Late Respiratory and Immunology, BioPharmaceuticals R&D, AstraZeneca, Durham, NC, USA
| | - Ubaldo J Martin
- Late Respiratory and Immunology, AstraZeneca, Gaithersburg, MD, USA
| | - Esther Garcia Gil
- Global Medical Respiratory, BioPharmaceuticals Medical, AstraZeneca, Barcelona, Spain
| |
Collapse
|
26
|
Blakey J, Chung LP, McDonald VM, Ruane L, Gornall J, Barton C, Bosnic-Anticevich S, Harrington J, Hew M, Holland AE, Hopkins T, Jayaram L, Reddel H, Upham JW, Gibson PG, Bardin P. Oral corticosteroids stewardship for asthma in adults and adolescents: A position paper from the Thoracic Society of Australia and New Zealand. Respirology 2021; 26:1112-1130. [PMID: 34587348 PMCID: PMC9291960 DOI: 10.1111/resp.14147] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Revised: 08/04/2021] [Accepted: 08/31/2021] [Indexed: 12/13/2022]
Abstract
Oral corticosteroids (OCS) are frequently used for asthma treatment. This medication is highly effective for both acute and chronic diseases, but evidence indicates that indiscriminate OCS use is common, posing a risk of serious side effects and irreversible harm. There is now an urgent need to introduce OCS stewardship approaches, akin to successful initiatives that optimized appropriate antibiotic usage. The aim of this TSANZ (Thoracic Society of Australia and New Zealand) position paper is to review current knowledge pertaining to OCS use in asthma and then delineate principles of OCS stewardship. Recent evidence indicates overuse and over-reliance on OCS for asthma and that doses >1000 mg prednisolone-equivalent cumulatively are likely to have serious side effects and adverse outcomes. Patient perspectives emphasize the detrimental impacts of OCS-related side effects such as weight gain, insomnia, mood disturbances and skin changes. Improvements in asthma control and prevention of exacerbations can be achieved by improved inhaler technique, adherence to therapy, asthma education, smoking cessation, multidisciplinary review, optimized medications and other strategies. Recently, add-on therapies including novel biological agents and macrolide antibiotics have demonstrated reductions in OCS requirements. Harm reduction may also be achieved through identification and mitigation of predictable adverse effects. OCS stewardship should entail greater awareness of appropriate indications for OCS prescription, risk-benefits of OCS medications, side effects, effective add-on therapies and multidisciplinary review. If implemented, OCS stewardship can ensure that clinicians and patients with asthma are aware that OCS should not be used lightly, while providing reassurance that asthma can be controlled in most people without frequent use of OCS.
Collapse
Affiliation(s)
- John Blakey
- Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia.,Medical School, Curtin University, Perth, Western Australia, Australia
| | - Li Ping Chung
- Department of Respiratory Medicine, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Vanessa M McDonald
- Priority Research Centre for Healthy Lungs, College of Health Medicine and Wellbeing, The University of Newcastle, New Lambton Heights, New South Wales, Australia
| | - Laurence Ruane
- Monash Lung and Sleep, Monash University and Medical Centre, Melbourne, Victoria, Australia
| | - John Gornall
- Centre of Excellence in Severe Asthma, The University of Newcastle, New Lambton Heights, New South Wales, Australia
| | - Chris Barton
- Department of General Practice, Monash University, Melbourne, Victoria, Australia
| | - Sinthia Bosnic-Anticevich
- Sydney Pharmacy School, The University of Sydney AND Quality Use of Respiratory Medicines Group, The Woolcock Institute of Medical Research, Sydney, New South Wales, Australia
| | - John Harrington
- John Hunter Hospital, New Lambton Heights, New South Wales, Australia
| | - Mark Hew
- Allergy, Asthma & Clinical Immunology, Alfred Health, Melbourne, Victoria, Australia
| | - Anne E Holland
- Physiotherapy Department, Alfred Health, Melbourne, Victoria, Australia.,Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Trudy Hopkins
- South Eastern Sydney Health Department, Sydney, New South Wales, Australia
| | - Lata Jayaram
- Department of Respiratory Medicine, Western Health and University of Melbourne, Melbourne, Victoria, Australia
| | - Helen Reddel
- The Woolcock Institute of Medical Research and The University of Sydney, Sydney, New South Wales, Australia
| | - John W Upham
- The University of Queensland, Diamantina Institute AND Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Peter G Gibson
- Priority Research Centre for Healthy Lungs, College of Health Medicine and Wellbeing, The University of Newcastle, New Lambton Heights, New South Wales, Australia.,John Hunter Hospital, New Lambton Heights, New South Wales, Australia
| | - Philip Bardin
- Monash Lung Sleep Allergy & Immunology, Monash University and Medical Centre, Melbourne, Victoria, Australia
| |
Collapse
|
27
|
de Freitas Nakata KC, Marques LD, de Oliveira HC, Magalhães GCB, de Oliveira RG, Botelho C. Anti-interleukin-5 in the Management of Eosinophilic Asthma: A Review of Effectiveness, Safety, and Budgetary Impact From the Perspective of the Brazilian Health System. Value Health Reg Issues 2021; 26:169-181. [PMID: 34547665 DOI: 10.1016/j.vhri.2021.06.010] [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: 10/22/2020] [Revised: 03/30/2021] [Accepted: 06/12/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To evaluate the efficacy and safety of anti-interleukin-5 class therapy agents in the treatment of eosinophilic asthma and the financial impact of these drugs on the Brazilian and Mato Grosso public health systems. METHODS The literature review in important databases was guided by a structured research question including patient or population, intervention, comparator, outcome and type of study. The retrieved studies went through a screening, selection, data extraction, and methodological quality assessment process. A model with two scenarios, one with mepolizumab and the other with benralizumab, was created for budget impact analysis. RESULTS Evidence indicated that anti-interleukins-5 have an acceptable safety profile and can reduce exacerbation rates by up to 50% in the population with eosinophilic asthma; however, they showed no significant difference in quality of life. The adoption of these drugs in the Brazilian health system can impact the budget from R$ 40,379,731.50 to R$ 140,301,211.34 depending on the drug incorporated, considering a time horizon of 5 years. From the perspective of the state of Mato Grosso, the budget impact may reach, in the fifth year, an amount of R$ 1,301,210.58 and R$ 2,050.687.62 for the scenarios with mepolizumab and benralizumab, respectively. CONCLUSION Anti-interleukins-5 are promising treatments for eosinophilic asthma because they minimise exacerbations and are well tolerated and safe. The financial impact is large, implying that technology costs may be a barrier to accessing this treatment class.
Collapse
Affiliation(s)
| | - Luisa Daige Marques
- Núcleo de Avaliação de Tecnologias em Saúde - NATS/SES/MT, Cuiabá-MT, Brasil
| | - Helder Cássio de Oliveira
- Núcleo de Avaliação de Tecnologias em Saúde - NATS/SES/MT, Cuiabá-MT, Brasil; Coordenador do NATS-HUJM - Hospital Universitário Júlio Muller, Cuiabá-MT, Brasil
| | - Graciane Catarina Batista Magalhães
- Núcleo de Avaliação de Tecnologias em Saúde - NATS/SES/MT, Cuiabá-MT, Brasil; Centro Estadual de Referência em Média e Alta Complexidade - Cermac/SES MT, Cuiabá-MT, Brasil
| | - Ruberlei Godinho de Oliveira
- Hospital Universitário Júlio Muller - Programa de Pós-Graduação Mestrado em Ciências Aplicadas a Atenção Hospitalar, Cuiabá-MT, Brasil
| | - Clóvis Botelho
- Universidade Federal de Mato Grosso - UFMT/Universidade de Várzea Grande-MT, Cuiabá-MT, Brasil
| |
Collapse
|
28
|
Gurnell M, Heaney LG, Price D, Menzies‐Gow A. Long-term corticosteroid use, adrenal insufficiency and the need for steroid-sparing treatment in adult severe asthma. J Intern Med 2021; 290:240-256. [PMID: 33598993 PMCID: PMC8360169 DOI: 10.1111/joim.13273] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 01/04/2021] [Accepted: 01/20/2021] [Indexed: 12/24/2022]
Abstract
Secondary adrenal insufficiency (AI) occurs as the result of any process that disrupts normal hypothalamic and/or anterior pituitary function and causes a decrease in the secretion of steroid hormones from the adrenal cortex. The most common cause of secondary AI is exogenous corticosteroid therapy administered at supraphysiologic dosages for ≥ 1 month. AI caused by oral corticosteroids (OCS) is not well-recognized or commonly diagnosed but is often associated with reduced well-being and can be life-threatening in the event of an adrenal crisis. Corticosteroid use is common in respiratory diseases, and asthma is a representative condition that illustrates the potential challenges and opportunities related to corticosteroid-sparing therapies. For individuals with severe asthma (approximately 5%-10% of all cases), reduction or elimination of maintenance OCS without loss of control can now be accomplished with biologic therapies targeting inflammatory mediators. However, the optimal strategy to ensure early identification and treatment of AI and safe OCS withdrawal in routine clinical practice remains to be defined. Many studies with biologics have involved short evaluation periods and small sample sizes; in addition, cautious approaches to OCS tapering in studies with a placebo arm, coupled with inconsistent monitoring for AI, have contributed to the lack of clarity. If the goal is to greatly reduce and, where possible, eliminate long-term OCS use in severe asthma through the increasing adoption of biologic treatments, there is an urgent need for clinical trials that address both the speed of OCS withdrawal and how to monitor for AI.
Collapse
Affiliation(s)
- M. Gurnell
- From theMetabolic Research LaboratoriesWellcome–MRC Institute of Metabolic ScienceUniversity of CambridgeNIHR Cambridge Biomedical Research CentreAddenbrooke’s HospitalCambridgeUK
| | - L. G. Heaney
- Centre for Experimental MedicineQueens University BelfastBelfastUK
| | - D. Price
- Observational and Pragmatic Research Institute Pte LtdSingaporeSingapore
- Division of Applied Health SciencesCentre of Academic Primary CareUniversity of AberdeenAberdeenUK
| | | |
Collapse
|
29
|
Abstract
PURPOSE OF REVIEW Severe asthma remains a debilitating disease and a challenge for the clinicians. Novel therapies have been introduced and have greatly improved asthma control and more are under development or in clinical studies. These include anti-IL5/IL5R, anti-IL4/IL4R, anti IL13, anti- thymic stromal lymphopoietin (TSLP) and more, and severe asthma is currently managed in personalized medicine approach. However, there is still an unmet need to discover new, clinically available biomarkers and targeted therapies for a large group of severe asthma patients, particularly those with T2-low asthma. In this review, we briefly present the phenotypes and endotypes of severe asthma, the omics technologies in asthma as well as current and future treatments for both T2-high and T2-low asthma. RECENT FINDINGS In this review, we are going to present the effectiveness and safety of anti-IL5 therapies, the clinical trials for dupilumab and tezepelumab and the most significant molecules and biological agents used in trials as possible treatments forT2-low asthma. SUMMARY Novel anti-IL5 agents have changed the management of T2-high asthma resulting in improved disease control, QoL and lung function and importantly, fewer exacerbations. Nevertheless, there is still the need to find new treatments, particularly for T2-low asthma, which remains a challenge.
Collapse
|
30
|
Sood V, Rogers L, Khurana S. How I Do It: Managing Corticosteroid-Related Comorbidities in Severe Asthma. Chest 2021; 160:1614-1623. [PMID: 34019864 DOI: 10.1016/j.chest.2021.05.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 05/05/2021] [Accepted: 05/11/2021] [Indexed: 10/21/2022] Open
Abstract
Oral corticosteroid (OCS) use in severe asthma remains all too common despite advances in asthma treatment. Use of OCS is associated with significant toxicity that can have a lasting adverse impact on a patient's overall health. Monoclonal antibodies have been developed that reduce both the rate of occurrence of OCS-treated exacerbations and the OCS requirements in patients with oral corticosteroid-dependent asthma. This article describes strategies to prevent and best manage endocrine complications associated with OCS use and provides guidance on OCS dose management after the introduction of steroid-sparing therapies. (1) We identify OCS-dependent patients and assess for comorbidities including bone health, glycemic control, and adrenal function; (2) we begin attempts at OCS dose optimization before or soon after introducing a steroid-sparing biologic therapy; (3) we taper OCS, using explicit criteria for asthma control; (4) we assess hypothalamic-pituitary-adrenal axis integrity once a physiologic dose of OCS is achieved to guide further the rate of OCS taper; and (5) we manage corticosteroid-related comorbidities as detailed in this article.
Collapse
Affiliation(s)
- Vidushi Sood
- Division of Endocrinology, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Linda Rogers
- Division of Pulmonary, Critical Care and Sleep, Mount Sinai-National Jewish Respiratory Institute and Icahn School of Medicine at Mount Sinai, New York, NY
| | - Sandhya Khurana
- Division of Pulmonary and Critical Care Medicine, Mary Parkes Center for Asthma, University of Rochester School of Medicine and Dentistry, Rochester, NY.
| |
Collapse
|
31
|
Suehs CM, Menzies-Gow A, Price D, Bleecker ER, Canonica GW, Gurnell M, Bourdin A. Expert Consensus on the Tapering of Oral Corticosteroids for the Treatment of Asthma. A Delphi Study. Am J Respir Crit Care Med 2021; 203:871-881. [PMID: 33112646 DOI: 10.1164/rccm.202007-2721oc] [Citation(s) in RCA: 71] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Rationale: There is a need to minimize oral corticosteroid (OCS) use in patients with asthma to prevent their costly and burdensome adverse effects. Current guidelines do not provide recommendations for OCS tapering in patients with asthma.Objectives: To develop expert consensus on OCS tapering among international experts.Methods: A modified Delphi method was used to develop expert consensus statements relating to OCS use, tapering, adverse effects, adrenal insufficiency, and patient-physician shared decision-making. Initial statements proposed by experts were categorized, filtered for repetition, and presented back to experts over three ranking rounds to obtain consensus (≥70% agreement).Measurements and Main Results: One hundred thirty-one international experts participated in the study, and 296 statements were ranked. Numerous recommendations and guidance regarding appropriate OCS use were established. Experts agreed that OCS tapering should be attempted in all patients with asthma receiving maintenance OCS therapy, with personalization of tapering rhythm and speed. The importance of recognizing individual adverse effects was also established; however, a unified approach to the assessment of adrenal insufficiency was not reached. Shared decision-making was considered an important goal during the tapering process.Conclusions: In this Delphi study, expert consensus statements were generated on OCS use, tapering, adverse-effect screening, and shared decision-making, which may be used to inform clinical practice. Areas of nonconsensus were identified, highlighting uncertainty among the experts around some aspects of OCS use in asthma, such as adrenal insufficiency, which underscores the need for further research in these domains.
Collapse
Affiliation(s)
| | - Andrew Menzies-Gow
- PhyMedExp, Université de Montpellier, Institut National de la Santé et de la Recherche Médicale, Centre National de la Recherche Scientifique, Centre Hospitalier Universitaire Montpellier, Montpellier, France
| | - David Price
- Royal Brompton and Harefield National Health Service Foundation Trust, London, United Kingdom.,Observational and Pragmatic Research Institute, Singapore
| | - Eugene R Bleecker
- Division of Applied Health Sciences, Centre of Academic Primary Care, University of Aberdeen, Aberdeen, United Kingdom
| | | | - Mark Gurnell
- Personalized Medicine, Asthma and Allergy Center, Humanitas University and IRCCS Research Hospital, Milan, Italy; and.,Wellcome Trust-Medical Research Council Institute of Metabolic Science and
| | - Arnaud Bourdin
- Département des Maladies Respiratoires and.,Cambridge National Institute for Health Research Biomedical Research Centre, University of Cambridge and Addenbrooke's Hospital, Cambridge, United Kingdom
| | | |
Collapse
|
32
|
McDowell PJ, Stone JH, Heaney LG. The Role of Quantification of Glucocorticoid-associated Toxicity in Severe Asthma. JOURNAL OF CELLULAR IMMUNOLOGY 2021; 3:31-35. [PMID: 33860282 PMCID: PMC8045989 DOI: 10.33696/immunology.3.074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- P J McDowell
- Centre for Experimental Medicine, School of Medicine, Dentistry, and Biological Sciences; Queen's University Belfast, Northern Ireland, UK
| | - J H Stone
- Division of Rheumatology, Allergy, & Clinical Immunology, Massachusetts General Hospital,Harvard Medical School, USA
| | - L G Heaney
- Centre for Experimental Medicine, School of Medicine, Dentistry, and Biological Sciences; Queen's University Belfast, Northern Ireland, UK
| |
Collapse
|
33
|
Wechsler ME, Colice G, Griffiths JM, Almqvist G, Skärby T, Piechowiak T, Kaur P, Bowen K, Hellqvist Å, Mo M, Garcia Gil E. SOURCE: a phase 3, multicentre, randomized, double-blind, placebo-controlled, parallel group trial to evaluate the efficacy and safety of tezepelumab in reducing oral corticosteroid use in adults with oral corticosteroid dependent asthma. Respir Res 2020; 21:264. [PMID: 33050928 PMCID: PMC7550846 DOI: 10.1186/s12931-020-01503-z] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 09/06/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Many patients with severe asthma continue to experience asthma symptoms and exacerbations despite standard-of-care treatment. A substantial proportion of these patients require long-term treatment with oral corticosteroids (OCS), often at high doses, which are associated with considerable multiorgan adverse effects, including metabolic disorders, osteoporosis and adrenal insufficiency. Tezepelumab is a human monoclonal antibody that blocks the activity of the epithelial cytokine thymic stromal lymphopoietin. In the PATHWAY phase 2b study (NCT02054130), tezepelumab significantly reduced exacerbations by up to 71% in adults with severe, uncontrolled asthma. Several ongoing phase 3 trials (SOURCE, NCT03406078; NAVIGATOR, NCT03347279; DESTINATION, NCT03706079) are assessing the efficacy and safety of tezepelumab in patients with severe, uncontrolled asthma. Here, we describe the design and objectives of SOURCE, a phase 3 OCS-sparing study. METHODS SOURCE is an ongoing phase 3, multicentre, randomized, double-blind, placebo-controlled study to evaluate the effect of tezepelumab 210 mg administered subcutaneously every 4 weeks on OCS dose reduction in adults with OCS-dependent asthma. The study comprises a 2-week screening and enrolment period, followed by an OCS optimization phase of up to 8 weeks and a 48-week treatment period, which consists of a 4-week induction phase, followed by a 36-week OCS reduction phase and an 8-week maintenance phase. The primary objective is to assess the effect of tezepelumab compared with placebo in reducing the prescribed OCS maintenance dose. The key secondary objective is to assess the effect of tezepelumab on asthma exacerbation rates. Other secondary objectives include the proportion of patients with a reduction in OCS dose (100% or 50% reduction or those receiving < 5 mg) and the effect of tezepelumab on lung function and patient-reported outcomes. CONCLUSIONS SOURCE is evaluating the OCS-sparing potential of tezepelumab in patients with OCS-dependent asthma. SOURCE also aims to demonstrate that treatment with tezepelumab in patients with severe asthma is associated with reductions in exacerbation rates and improvements in lung function, asthma control and health-related quality of life, while reducing OCS dose. TRIAL REGISTRATION NCT03406078 ( ClinicalTrials.gov ). Registered 23 January 2018. https://clinicaltrials.gov/ct2/show/NCT03406078.
Collapse
Affiliation(s)
| | - Gene Colice
- Respiratory & Immunology, BioPharmaceuticals R&D, AstraZeneca, Gaithersburg, MD, USA
| | - Janet M Griffiths
- Translational Science and Experimental Medicine, Research and Early Development, Respiratory & Immunology, BioPharmaceuticals R&D, AstraZeneca, Gaithersburg, MD, USA
| | - Gun Almqvist
- Late Respiratory & Immunology, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Tor Skärby
- Late Respiratory & Immunology, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Teresa Piechowiak
- Development Operations, BioPharmaceuticals R&D, AstraZeneca, Mississauga, ON, Canada
| | | | - Karin Bowen
- Biometrics, Late Respiratory & Immunology, BioPharmaceuticals R&D, Gaithersburg, MD, USA
| | - Åsa Hellqvist
- Biometrics, Late Respiratory & Immunology, BioPharmaceuticals R&D, Gothenburg, Sweden
| | - May Mo
- Amgen, Thousand Oaks, CA, USA
| | - Esther Garcia Gil
- Global Medical Respiratory, BioPharmaceuticals R&D, AstraZeneca, Barcelona, Spain
| |
Collapse
|
34
|
Papadopoulos NG, Barnes P, Canonica GW, Gaga M, Heaney L, Menzies-Gow A, Kritikos V, Fitzgerald M. The evolving algorithm of biological selection in severe asthma. Allergy 2020; 75:1555-1563. [PMID: 32124991 DOI: 10.1111/all.14256] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 02/08/2020] [Accepted: 02/26/2020] [Indexed: 12/15/2022]
Abstract
New therapeutic options for severe asthma have recently emerged, mostly in the form of monoclonal antibodies ("biologicals") targeting relevant inflammatory pathways. Currently available agents target different aspects of "Type 2" immunity, and their indications often include overlapping patient groups. We present a round-table discussion that took place during the Annual Meeting of the Respiratory Effectiveness Group (REG), on the reasoning behind the use of different add-on medications for severe asthma, and crucially, on selection strategies. The proposed rational is based on current evidence, including real-life studies, as well as on the appreciation of the relevant complexities. Direct head-to-head comparisons of biologicals are lacking; therefore, algorithms for initial choice and potential switch between agents should be based on understanding the key characteristics of different options and the development of a clear plan with predefined targets and shared decision-making, in a structured way.
Collapse
Affiliation(s)
- Nikolaos G Papadopoulos
- Division of Infection, Immunity & Respiratory Medicine, University of Manchester, Manchester, UK
- Allergy Department, 2nd Pediatric Clinic, National Kapodistrian University of Athens, Athens, Greece
| | - Peter Barnes
- National Heart and Lung Institute, Imperial College, London, UK
| | - Giorgio Walter Canonica
- Personalized Medicine, Asthma and Allergy - Humanitas Clinical and Research Center IRCCS, Rozzano, MI, Italy
| | - Mina Gaga
- 7th Respiratory Medicine Department and Asthma Center, Athens Chest Hospital "Sotiria", Athens, Greece
| | - Liam Heaney
- Centre for Experimental Medicine, Wellcome-Wolfson Institute for Experimental Medicine, Belfast, UK
| | | | - Vicky Kritikos
- Quality Use of Respiratory Medicines Group, Woolcock Institute of Medical Research, University of Sydney, Sydney, NSW, Australia
| | - Mark Fitzgerald
- Centre for Heart and Lung Health, The Lung Centre Vancouver General Hospital, UBC Institute for Heart and Lung Health, Vancouver, BC, Canada
| |
Collapse
|
35
|
Padilla-Galo A, Levy-Abitbol RC, Olveira C, Valencia Azcona B, Pérez Morales M, Rivas-Ruiz F, Tortajada-Goitia B, Moya-Carmona I, Levy-Naon A. Real-life experience with benralizumab during 6 months. BMC Pulm Med 2020; 20:184. [PMID: 32600318 PMCID: PMC7325276 DOI: 10.1186/s12890-020-01220-9] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 06/18/2020] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Benralizumab is a monoclonal antibody that binds to the human interleukin-5 (IL-5) receptor (IL-5R), thereby preventing IL-5 from binding to its receptor and inhibiting differentiation and maturation of eosinophils in the bone marrow. Because of its recent marketing approval, sufficient real-life evidence is lacking to confirm the efficacy and safety data from clinical trials. The purpose of this study was to evaluate the efficacy and safety of benralizumab for the treatment of severe refractory eosinophilic asthma in a real-world cohort of patients. METHODS This was a cross-sectional multicentre study of consecutive patients with severe refractory eosinophilic asthma who received treatment with benralizumab during at least 6 months. Patient follow-up was performed in specialised severe asthma units. RESULTS A total of 42 patients were enrolled and treated with benralizumab. Asthma control, as measured by the asthma control test (ACT), improved in all patients both at 3 months of treatment compared with baseline (13.9 ± 4 vs 20.1 ± 3.7, p < 0.001) and at 6 months of treatment compared with the results obtained at 3 months (20.1 ± 3.7 vs 21 ± 2.7, p = 0.037). Similarly, the number of emergency department visits decreased both at 3 months compared with baseline (1 [IR:0.7] vs 0 [IR:0.75], p < 0.001) and at 6 months compared with the results at 3 months (0 [IR:0.75] vs 0 [IR:0], p = 0.012). Reductions in the number of oral corticosteroid cycles, percentage of corticosteroid-dependent patients, and mean daily dose of oral or inhaled corticosteroid were also evidenced. Finally, mean lung function improvement was 291 mL (p < 0.001), and FEV1% improved both at 3 months compared with baseline (64.4 ± 9.3 vs 73.1 ± 9.1, p < 0.001) and at 6 months compared to 3 months (73.1 ± 9.1 vs 76.1 ± 12, p = 0.002). Side effects were mild and did not lead to treatment discontinuation. CONCLUSIONS This study confirms the efficacy and safety of benralizumab in a real-life setting with improved asthma control and lung function, and a reduced oral and inhaled corticosteroid use as well as fewer emergency department visits. In addition to a rapid initial improvement, it appears that patients continue to improve during the first 6 months of treatment.
Collapse
Affiliation(s)
- A. Padilla-Galo
- Pneumology Unit, 4th floor. Agencia Sanitaria Costa del Sol. Carretera Nacional 340, Km 187, 29603, Marbella, Málaga, Spain
| | | | - C. Olveira
- Pneumology Department, IBIMA (Institute for Biomedical Research of Málaga), Regional University Hospital of Málaga/ University of Málaga, Málaga, Spain
- Avenida Carlos Haya, 29010 Málaga, Spain
| | - B. Valencia Azcona
- Pneumology Unit, 4th floor. Agencia Sanitaria Costa del Sol. Carretera Nacional 340, Km 187, 29603, Marbella, Málaga, Spain
| | - M. Pérez Morales
- Pneumology Unit, 4th floor. Agencia Sanitaria Costa del Sol. Carretera Nacional 340, Km 187, 29603, Marbella, 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
| | - 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
| |
Collapse
|
36
|
Cushen B, Menzies-Gow A. Benralizumab: an updated treatment of eosinophilic asthma. Expert Rev Respir Med 2020; 14:435-444. [PMID: 32133878 DOI: 10.1080/17476348.2020.1739526] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Introduction: An estimated 5-10% of people with asthma have disease which remains uncontrolled despite maximal treatment with inhaled corticosteroids and long-acting beta-agonists. Benralizumab is currently licensed for use in patients with severe asthma who have an eosinophilic phenotype. Benralizumab depletes eosinophils by binding to the anti-IL5 receptor on the surface of eosinophils, mitigating the effect of IL-5 on eosinophil proliferation and survival, and induces natural killer cell-mediated eosinophil apoptosis.Areas covered: The authors review the mechanism of action and pharmacokinetic profile of Benralizumab and summarize the scientific data supporting its clinical efficacy and safety in severe asthma. Further, the authors highlight future studies of Benralizumab in asthma and other diseases.Expert opinion: Benralizumab lowers exacerbation rates, symptom burden, and oral glucocorticoid use, and improves lung function, in patients with severe eosinophilic asthma. Benralizumab is well tolerated and is an attractive choice for patients and physicians due to its eosinophil-depleting mechanism of action and less frequent dosing schedule. More data is needed to guide the selection of biologic therapy in severe asthma patients.
Collapse
Affiliation(s)
- Breda Cushen
- Department of Respiratory Medicine, Royal Brompton Hospital, London, UK
| | | |
Collapse
|