Biologic Therapy Selection for Severe Asthma: Factors to Consider
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.
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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