Asthma endotype, clinical biomarkers, and patient-specific factors should all be considered when selecting a biologic treatment for patients with severe asthma, according to a new review published in the journal Annals of Allergy, Asthma & Immunology.

For patients with asthma, biologic treatment can be considered when frequent exacerbations and symptoms occur despite treatment with high-dose inhaled corticosteroids, inhaled combination therapy, or oral corticosteroids. The authors write that once severe asthma is diagnosed, clinicians should determine asthma endotype (Type2-high or Type2-low) to help choose the best therapy for the patient. Several biologic therapies have been approved for the treatment of Type2-high asthma and treatment can be tailored based on clinical biomarkers such as blood or sputum eosinophils, fractional exhaled nitric oxide (FeNO), and IgE levels.

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In their review, the authors make the following recommendations regarding biologic treatment choices for patients with severe asthma based on available evidence:

  • Omalizumab, a recombinant humanized anti-IgE antibody, may be considered first-line treatment for patients with allergic, non-eosinophilic asthma.
  • Interleukin (IL)-5 antagonist therapy (benralizumab, mepolizumab, reslizumab) should be considered first-line for patients with eosinophilic, non-allergic asthma. Factors such as patient insurance, weight, comorbidities, mechanism of action, and ease of administration should be considered when choosing among these 3 FDA-approved treatments.
  • IL-5 antagonist or anti-IgE therapy may work well for patients with both allergic and eosinophilic disease.
  • There are currently no FDA-approved biologic treatments for severe asthma of non-Th-2 endotype; macrolides, bronchial thermoplasty, and imatinib may be considered for these patients.

The authors conclude that “despite the rapid evolution of knowledge in biologics in asthma, there still remains a significant amount that needs to be understood regarding the pathophysiology of asthma to develop new targeted therapies, and the indications for use, safety, and efficacy of currently available therapies.”

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