Combination of monoclonal antibodies targeting type 2 inflammation for severe asthma and eosinophilic granulomatosis with polyangiitis

Monoclonal antibodies targeting type 2 inflammation are promising treatments for eosinophilic-associated diseases. There is growing interest in the potential benefits of combining two biologics to treat patients with poorly controlled conditions. We present a case of a 54-year-old female patient affected with a relapsing-refractory ANCA myeloperoxidase positive eosinophilic granulomatosis with polyangiitis (EGPA), presenting with difficult-to-treat asthma and rhino-sinusitis manifestations. She failed several biologics, including omalizumab 300 mg, mepolizumab 100 mg, and benralizumab 30 mg every 8 weeks. A switch to dupilumab led to significant eosinophilia (7.69 × 109/L) as well as systemic symptoms, and a deterioration of asthma control. Therefore, a combination of dupilumab-benralizumab was started, leading to better nasal and ear outcomes, asthma control and decrease in blood eosinophils. During the 12-month treatment, no adverse effects were observed. We conducted an extensive literature search in MEDLINE for original articles published until August 1st, 2023 reporting the combination of anti-type 2 biologics. A total of 51 cases were retrieved from the literature. Omalizumab was the most frequently combined drugs (34 cases). Combination therapy led to reduction of asthma exacerbations and glucocorticoid intake, though was ineffective only for one EGPA patient. Only one patient on omalizumab-mepolizumab therapy reported a mild adverse reaction. Combination biologic therapies for conditions which share pathogenic pathways appears to be both safe and effective. This approach may benefit patients with uncontrolled conditions and counter side effects of biologics, like dupilumab-related hypereosinophilia.

Benralizumab for eosinophilic granulomatosis with polyangiitis: a retrospective, multicentre, cohort study

BACKGROUND

Interleukin-5 (IL-5) inhibitors represent novel therapies for eosinophilic granulomatosis with polyangiitis (EGPA). This study assessed the effectiveness and safety of the IL-5 receptor inhibitor benralizumab in a European cohort of patients with EGPA.

METHODS

This retrospective cohort study included patients with EGPA from 28 European referral centres of the European EGPA Study Group across six countries (Italy, France, UK, Russia, Spain, and Switzerland) who received benralizumab as any line of treatment between Jan 1, 2019, and Sep 30, 2022. We assessed the rates of complete response, defined as no disease activity (Birmingham Vasculitis Activity Score [BVAS] of 0) and a prednisone dose of up to 4 mg/day, in contrast to partial response, defined as a BVAS of 0 and a prednisone dose greater than 4 mg/day. Active disease manifestations, pulmonary function, variation in glucocorticoid dose, and safety outcomes were also assessed over a 12-month follow-up.

FINDINGS

121 patients with relapsing-refractory EGPA treated with benralizumab at the dose approved for eosinophilic asthma were included (64 [53%] women and 57 [47%] men; median age at the time of beginning benralizumab treatment 54·1 years [IQR 44·2-62·2]). Complete response was reported in 15 (12·4%, 95% CI 7·1-19·6) of 121 patients at month 3, 25 (28·7%, 19·5-39·4) of 87 patients at month 6, and 32 (46·4%, 34·3-58·8) of 69 patients at month 12; partial response was observed in an additional 43 (35·5%, 27·0-44·8) patients at month 3, 23 (26·4%, 17·6-37·0) at month 6, and 13 (18·8%, 10·4-30·1) at month 12. BVAS dropped from 3·0 (IQR 2·0-8·0) at baseline to 0·0 (0·0-2·0) at months 3 and 6, and to 0·0 (0·0-1·0) at month 12. The proportion of patients with systemic manifestations, active peripheral neurological disease, ear, nose, and throat involvement, and pulmonary involvement decreased, with an improvement in lung function tests. Six patients relapsed after having a complete response. The oral prednisone (or equivalent) dose decreased from 10·0 mg/day (5·0-12·5) at baseline to 5·0 mg/day (3·6-8·5) at month 3 (p<0·01), to 5·0 mg/day (2·5-6·3) at month 6, and to 2·5 mg/day (0·0-5·0) at month 12 (p<0·0001). 19 (16%) of 121 patients had adverse events and 16 (13%) discontinued benralizumab.

INTERPRETATION

These data suggest that benralizumab could be an effective treatment for EGPA in real-life clinical practice. Further clinical trials are required to confirm the efficacy of benralizumab in patients with a higher baseline disease activity.

FUNDING

None.

Rehabilitation pathway for Covid and post-Covid patients

 

A hospital rehabilitation service has been implemented in the Hospital of Cittadella, ULSS 6 Euganea - Health Trust (District of Padua) to offer hospitalized Covid and post-Covid patients a tailored rehabilitation pathway in the treatment of the different phases of the disease. The SARS-CoV-2 pandemic has determined the admission of a large number of acute patients in Intensive Care Units (ICU), Semi-Intensive Care Units (S-ICU) and non-critic hospital wards. Patients recovering from COVID-19 experience a wide range of impairments requiring the implementation of multidisciplinary rehabilitation care protocols; these include the assessment for anticipated impairments (especially for patients admitted to ICU, older patients, and patients showing indications of impairment); patients who had severe-critical disease usually require a period of inpatient rehabilitation. Between October 2020 and April 2021 at Cittadella Hospital 450 patients (ICU, S-ICU, non-critic hospital wards) were enrolled in the Rehabilitation pathway and followed daily by a team made by physiatrists, physiotherapists and speech therapists. Referral options (hospitalization, community based rehab or discharge with follow up), based on the conditions of the patients, were assessed. The reduction of surgery and orthopedics patients to rehabilitate and the decrease of outpatient rehab services during Covid emergency made it possible to convert Rehabilitation ward (20 beds) to Covid Rehabilitation; according to epidemiological scenarios, patients admitted to Rehabilitation ward were initially SARS-CoV-2 positive with mild, moderate and severe symptoms, then post-Covid SARS-CoV-2 negative discharged from Covid wards. The definition of a tailored rehabilitation pathway in the treatment of the different phases of Covid disease has represented an important professional and organizational challenge for the Hospital. Rehabilitation plays a pivotal role in the management of Covid and post-Covid patients.

Key messages

Patients recovering from COVID-19 experience a wide range of impairments requiring the implementation of multidisciplinary rehabilitation care protocols. The definition of a tailored rehabilitation pathway in the treatment of the different phases of Covid disease has represented an important professional and organizational challenge for the Hospital.

Dyspnea, effort and muscle pain during exercise in lung transplant recipients: an analysis of their association with cardiopulmonary function parameters using machine learning

Background

Despite improvement in lung function, most lung transplant (LTx) recipients show an unexpectedly reduced exercise capacity that could be explained by persisting peripheral muscle dysfunction of multifactorial origin. We analyzed the course of symptoms, including dyspnea, muscle effort and muscle pain and its relation with cardiac and pulmonary function parameters during an incremental exercise testing.

Methods

Twenty-four bilateral LTx recipients were evaluated in an observational cross-sectional study. Recruited patients underwent incremental cardio-pulmonary exercise testing (CPET). Arterial blood gases at rest and peak exercise were measured. Dyspnea, muscle effort and muscle pain were scored according to the Borg modified scale. Potential associations between the severity of symptoms and exercise testing parameters were analyzed using a Forest-Tree Machine Learning approach, which accomplishes for a ratio between number of observations and number of screened variables less than unit.

Results

Dyspnea score was significantly associated with maximum power output (WR, watts), and minute ventilation (VE, L/min) at peak exercise. In a controlled subgroup analysis, dyspnea score was a limiting symptom only in LTx recipients who reached the higher levels of WR (≥ 101 watts) and V_E (≥ 53 L/min). Muscle effort score was significantly associated with breathing reserve as percent of maximal voluntary ventilation (BR%MVV). The lower the BR%MVV at peak exercise (< 32) the higher the muscle effort perception. Muscle pain score was significantly associated with VO₂ peak, arterial [HCO₃⁻] at rest, and V_E/VCO₂ slope. In a subgroup analysis, muscle pain was the limiting symptom in LTx recipients with a lower VO₂ peak (< 15 mL/Kg/min) and a higher V_E/VCO₂ slope (≥ 32).

Conclusions

The majority of our LTx recipients reported peripheral limitation as the prevalent reason for exercise termination. Muscle pain at peak exercise was strictly associated with basal and exercise-induced metabolic altered pathways. The onset of dyspnea (breathing effort) was associated with the intensity of ventilatory response to meet metabolic demands for increasing WR. Our study suggests that only an accurate assessment of symptoms combined with cardio-pulmonary parameters allows a correct interpretation of exercise limitation and a tailored exercise prescription. The role and mechanisms of muscle pain during exercise in LTx recipients requires further investigations.

Relevance of TH2 Markers in the Assessment and Therapeutic Management of Severe Allergic Asthma: A Real-Life Perspective

BACKGROUND

Although blood eosinophils are currently recognized as the main clinical marker of TH2-type inflammation, their relevance in identifying asthma severity remains a matter of debate.

METHODS

Our retrospective real-life study on severe asthmatics included in the NEONet Italian database aimed to investigate the relevance of blood eosinophil count and fractional exhaled nitric oxide (FeNO) in the clinical assessment of severe asthma and their role as potential predictors of responsiveness to anti-IgE therapy. The cut-off values chosen were 300 eosinophils/mm3 and FeNO of 30 ppm.

RESULTS

We evaluated 132 adult patients. No significant differences were observed between the groups (high and low baseline eosinophil counts) in terms of demographic data, total IgE, lung function, patient-reported outcomes, or nasal comorbidities. The Asthma Control Test score and Asthma Quality of Life Questionnaire scores were poorer in patients with FeNO ≥30 ppb than in patients with FeNO <30 ppb. In the high FeNO subgroup, more frequent hospital admissions and a higher number of working days lost in the previous year were registered. A combined score including both eosinophils and FeNO did not improve the accuracy of the individual parameters. In the high-eosinophil subgroup, the proportion of responders to omalizumab was greater and increased at each follow-up time point.

CONCLUSIONS

Our findings show that blood eosinophil count is not an unequivocal marker of asthma severity, whereas a higher FeNO level is associated with more frequent hospital admissions and more working days lost. Blood eosinophils seem to act as a predictor of response to omalizumab.

Spontaneous pneumomediastinum complicating severe acute asthma exacerbation in adult patients

Objectives: The real incidence of pneumomediastinum (PNM) in adult patients with severe acute asthma exacerbation continues to be unknown. The current study aims to investigate the occurrence of PNM in an adult population of patients presenting a severe asthma attack and to evaluate the risk factors associated to its development. Methods: The 45 consecutive subjects who were admitted to our Division between January 1, 2015 and December 31, 2016 for severe acute asthma exacerbation underwent a diagnostic protocol including a standard chest X-ray and continuous monitoring of arterial oxygen saturation (SaO₂) during the first 24 hours following admission. The patients showing persistence or deterioration of oxyhemoglobin desaturation were prescribed a chest Computed Tomographic (CT) scan. Results: Five out of the 45 patients (11.1%) with severe acute asthma exacerbation were diagnosed with PNM, in one case on the basis of an X-ray image and in four on the basis of a chest CT scan. Data analysis showed that the PNM patients were younger [21 (17-21) vs 49.5 (20-73) yrs; p < 0.001] and more likely to show sensitization to Alternaria (2/5 vs 0/40; p = 0.0101) with respect to their non-PNM counterparts. The duration of hospital stay was similar in the two groups [8 (4-12) vs 7 (3-15) days; p = 0.6939]. Conclusions: PNM is a common clinical entity in young adults with severe acute asthma exacerbation, particularly in those with unsatisfactory response to initial medical therapy. Although generally benign, patients with suspected PNM should be closely monitored because of the risk of developing severe hypoxemia.

Randomized clinical trial of psychological support and sleep adjuvant measures for postoperative sleep disturbance in patients undergoing oesophagectomy

BACKGROUND

Major surgery such as oesophagectomy requires a postoperative stay in intensive care. Painful stimuli lead to sleep disturbance and impairment in quality of life. The aim of this study was to evaluate the effect of psychological counselling and sleep adjuvant measures on postoperative quality of sleep and quality of life.

METHODS

This RCT was performed between January 2013 and October 2015. Patients undergoing oesophagectomy for cancer were randomized into one of four groups receiving: psychological counselling plus sleep adjuvant measures during the ICU stay; psychological counselling alone; sleep adjuvant measures alone during the ICU stay; or standard care. The primary endpoint was impairment in quality of life measured using the European Organisation for Research and Treatment of Cancer C30-QL2 questionnaire between admission for surgery and discharge from hospital. The secondary endpoint was impairment in quality of sleep assessed by means of the Pittsburgh Sleep Quality Index between admission for surgery and hospital discharge.

RESULTS

The local ethics committee approved the early termination of the study because of relevant changes in the ICU setting. Some 87 patients were randomized and 74 patients were evaluated in the analysis. Psychological counselling reduced the impairment in quality of life (odds ratio 0·23, 95 per cent c.i. 0·09 to 0·61) and in quality of sleep (odds ratio 0·27, 0·10 to 0·73).

CONCLUSION

Perioperative psychological support reduces impairment in quality of life and quality of sleep after oesophagectomy. Registration number: NCT01738620 (http://www.clinicaltrials.gov).

Fatal asthma; is it still an epidemic?

BACKGROUND

Asthma mortality has declined since the 1980s. Nevertheless the World Health Organization (WHO) identified asthma as responsible for 225.000 deaths worldwide in 2005, and 430.000 fatal cases are expected by 2030. Some unexpected and concentrated fatal asthma events all occurred between 2013 and 2015 in Veneto, a North Eastern region of Italy, which prompted a more in-depth investigation of characteristics and risk factors.

METHODS

A web search including key words related to fatal asthma in Italy between 2013 and 2015 has been performed. Concerning the cases that occurred in Veneto, subjects' clinical records have been evaluated and details about concomitant weather conditions, pollutants and pollen count have been collected.

RESULTS

Twenty-three cases of asthma deaths were found in Italy; 16 of them (69%) occurred in the Veneto Region. A prevalence of male and young age was observed. Most of patients were atopic, died in the night-time hours and during the weekends. The possible risk factors identified were the sensitization to alternaria, previous near fatal asthma attacks and the incorrect treatment of the disease. Weather condition did not appear to be related to the fatal exacerbations, whereas among the pollutants only ozone was detected over the accepted limits. Smoking habits, possible drug abuse and concomitant complementary therapies might be regarded as further risk factors.

DISCUSSION

Although not free from potential biases, our web search and further investigations highlight an increasing asthma mortality trend, similarly to what other observatories report. The analysis of available clinical data suggests that the lack of treatment more than a severe asthma phenotype characterizes the fatal events.

CONCLUSIONS

Asthma mortality still represents a critical issue in the management of the disease, particularly in youngsters. Once more the inadequate treatment and the lack of adherence seem to be not only related to the uncontrolled asthma but also to asthma mortality.

Omalizumab management beyond clinical trials: the added value of a network model

BACKGROUND

Omalizumab is effective and safe in severe allergic asthma. Few data are available about its impact on lung function and on asthma comorbidities, long-term follow-up of treated patients, adherence, non-responders profile, and optimal treatment duration.

OBJECTIVE

We aimed at evaluating omalizumab-related clinical outcomes and unmet needs in a real-life setting.

METHODS

We created a collaborative network (NEONet - North East Omalizumab Network) involving 9 Allergy and Respiratory referral centres for severe asthma placed in the North-East of Italy. Patients' data were entered into a common study database shared by all the participating physicians. A preliminary retrospective analysis was performed.

RESULTS

Patients come from a common well-defined geographical and environmental district providing a homogeneous population sample. A moderate but statistically significant improvement of the FEV1, and an increasing proportion of exacerbations-free patients were observed since the treatment start. These findings were independent of the baseline severity of bronchial obstruction. A positive impact of omalizumab on rhinitis in patients with both asthma and rhinitis was detected. Moreover the efficacy of omalizumab on asthma seemed not to be affected by the baseline severity of rhinitis.

CONCLUSION

Our retrospective analysis represents a preliminary report from the NEONet activity. It confirmed omalizumab efficacy and provided some new insights about its impact on lung function and on comorbid rhinitis. The network approach, under a prospective view, allows creating a large uniform database, by means of a standardized shared tool for data collecting, and joining a multidisciplinary expertise.

Noninvasive positive pressure ventilation in the management of acute respiratory failure due to osteogenesis imperfecta

The development of acute respiratory failure (ARF) secondary to respiratory tract infection is a common event in patients affected with osteogenesis imperfecta type III. Noninvasive positive pressure ventilation (NPPV) is increasingly administered to treat severe ARF of various origin. The use of NPPV in two patients with severe ARF secondary to osteogenesis imperfecta type III is presented.

Prevention of extubation failure in high-risk patients with neuromuscular disease

BACKGROUND

A substantial proportion of patients with neuromuscular disease (NMD) who undergo positive pressure ventilation via endotracheal intubation for acute respiratory failure fail to pass spontaneous breathing trials and should be considered at high risk for extubation failure. In our study, we prospectively investigated the efficacy of early application of noninvasive ventilation (NIV) combined with assisted coughing as an intervention aimed at preventing extubation failure in patients with NMD.

METHODS

This study is a prospective analysis of the short-term outcomes of 10 patients with NMD who were treated by NIV and assisted coughing immediately after extubation and comparison with the outcomes of a population of 10 historical control patients who received standard medical therapy (SMT) alone. The participants were composed of 10 patients with NMD who were submitted to NIV and assisted coughing after extubation (group A) and 10 historical control patients who were administered SMT (group B), who were admitted to a 4-bed respiratory intensive care unit (RICU) in a university hospital. Need for reintubation despite treatment was evaluated. Mortality during RICU stay, need for tracheostomy, and length of stay in the RICU were also compared.

RESULTS

Significantly fewer patients who received the treatment protocol required reintubation and tracheostomy compared with those who received SMT (reintubation, 3 vs 10; tracheostomy, 3 vs 9; P = .002 and .01, respectively). Mortality did not differ significantly between the 2 groups. Patients in group A remained for a shorter time in the RICU compared with group B (7.8 ± 3.9 vs 23.8 ± 15.8 days; P = .006).

CONCLUSIONS

Preventive application of NIV combined with assisted coughing after extubation provides a clinically important advantage to patients with NMD by averting the need for reintubation or tracheostomy and shortening their stay in the RICU; its use should be included in the routine approach to patients with NMD at high risk for postextubation respiratory failure.