Monoclonal Antibodies for the Management of Severe Asthma

Clinical characteristics and biological treatment responses of patients with late-onset asthma phenotype

Background: The data on subphenotypes and treatment responses to biologicals in late-onset asthma (LOA) is limited. This study aims to compare the clinical characteristics and treatment responses in severe asthma patients receiving biological treatments, categorized into early-onset asthma (EOA) and LOA groups. Methods: Patients treated with omalizumab or mepolizumab for at least six months at a tertiary care adult allergy clinic between December 2015 and December 2023 were included. Patients with persistent respiratory symptoms starting at age ≥40 years were categorized as LOA, while those with onset <40 years were categorized as EOA. Changes in Asthma Control Questionnaire (ACQ-6) scores, forced expiratory volume in one second (FEV1) percentages, and blood eosinophil counts were assessed at baseline and 6 months. The percentage change in FEV1 (liters) at 6 months relative to baseline was measured. Clinical remission rates were evaluated in those completing one year of treatment. Results: Among 87 patients, 38 (43.7%) had LOA and 49 (56.3%) had EOA. Of these, 22 (25.3%) received omalizumab and 65 (74.7%) received mepolizumab, with a mean treatment duration of 24.7 (±19.7) months. LOA patients had higher obesity rates and tobacco consumption compared to EOA patients (p = 0.041 and p = 0.024, respectively). There were no significant differences between LOA and EOA groups in ACQ scores, FEV1 percentage, the percentage change in FEV1 in liters and eosinophil counts (p = 0.531, p = 0.219, p = 0.632, p = 0.700, respectively). Within LOA patients, ACQ scores did not significantly differ between those treated with omalizumab and mepolizumab (p = 0.801). At 6 months, eosinophil counts significantly decreased with mepolizumab but not with omalizumab (p = 0.002). Conclusion: Biological treatment responses were similar between LOA and EOA groups. Omalizumab and mepolizumab showed comparable efficacy, with the exception of eosinophil count changes in LOA patients.

IgE-FcεRI protein-protein interaction as a therapeutic target against allergic asthma: An updated review

In the last decade, research has clarified the binding interactions between immunoglobulin E (IgE) and its high-affinity receptor, the FcεRI alpha chain (FcεRI). The formation of the IgE-FcεRI complex is crucial in the context of atopic allergies, linking allergen recognition to cellular activation and disease manifestation. Consequently, pharmacological strategies that disrupt these interactions are vital for managing atopic conditions. Historically, the complexity of the IgE-FcεRI binding process and challenges in producing functional recombinant derivatives has complicated data interpretation. However, advancements in structural biology, protein engineering, and immunological studies have enhanced our understanding of these protein-protein interactions (PPI), facilitating the development of more effective therapies. The introduction of anti-IgE therapies underscores the significance of the IgE-FcεRI PPI in allergic asthma. IgE, that is present locally and systemically, serves as a sensory mechanism in the adaptive immune response, particularly in mast cells (MCs) and basophils. When bound to FcεRI, IgE enables rapid memory responses to allergens, but dysregulation can lead to severe allergic asthma. Thus, the reactivity of IgE sensors can be finely modulated using various IgE-associated molecules. This review explores the mechanisms underlying IgE-dependent MC activation and its regulation by these molecules, including the latest therapeutic candidates under investigation.

Natural killer T cells in allergic asthma: implications for the development of novel immunotherapeutical strategies

Allergic asthma has emerged as a prevalent allergic disease worldwide, affecting most prominently both young individuals and lower-income populations in developing and developed countries. To devise effective and curative immunotherapy, it is crucial to comprehend the intricate nature of this condition, characterized by an immune response imbalance that favors a proinflammatory profile orchestrated by diverse subsets of immune cells. Although the involvement of Natural Killer T (NKT) cells in asthma pathology is frequently implied, their specific contributions to disease onset and progression remain incompletely understood. Given their remarkable ability to modulate the immune response through the rapid secretion of various cytokines, NKT cells represent a promising target for the development of effective immunotherapy against allergic asthma. This review provides a comprehensive summary of the current understanding of NKT cells in the context of allergic asthma, along with novel therapeutic approaches that leverage the functional response of these cells.

Mast Cells as a Double Edged Sword in Immunity: Disorders of Mast Cell Activation and Therapeutic Management. Second of Two Parts

Mast cells (MCs) bear many receptors that allow them to respond to a variety of exogenous and endogenous stimuli. However, MC function is dual since they can initiate pathological events or protect the host against infectious challenges. The role of MCs in disease will be analyzed in a broad sense, describing cellular and molecular mechanisms related to their involvement in auto-inflammatory diseases, asthma, autoimmune diseases and cancer. On the other hand, their protective role in the course of bacterial, fungal and parasitic infections will also be illustrated. As far as treatment of MC-derived diseases is concerned, allergen immunotherapy as well as other attempts to reduce MC-activation will be outlined according to the recent data. Finally, in agreement with current literature and our own data polyphenols have been demonstrated to attenuate type I allergic reactions and contact dermatitis in response to nickel. The use of polyphenols in these diseases will be discussed also in view of MC involvement.

Pharmacotherapeutic management of asthma in the elderly patient

INTRODUCTION

Asthma is a heterogeneous syndrome with variable phenotypes. Reversible airway obstruction and airway hyper-responsiveness often with an atopic or eosinophilic component is common in the elderly asthmatic. Asthma chronic obstructive pulmonary disease overlap syndrome (ACOS), a combination of atopy-mediated airway hyper-responsiveness and a history of smoking or other environmental noxious exposures, can lead to some fixed airway obstruction and is also common in elderly patients. Little specific data exist for the treating the elderly asthmatic, thus requiring the clinician to extrapolate from general adult data and asthma treatment guidelines.

AREAS COVERED

A stepwise approach to pharmacotherapy of the elderly patient with asthma and ACOS is offered and the literature supporting the use of each class of drugs reviewed.

EXPERT OPINION

Inhaled, long-acting bronchodilators in combination with inhaled corticosteroids represent the backbone of treatment for the elderly patient with asthma or ACOS . Beyond these medications used as direct bronchodilators and topical anti-inflammatory agents, a stepwise approach to escalation of therapy includes multiple options such as oral leukotriene receptor antagonist or 5-lipoxygense inhibitor therapy, oral phosphodiesterase inhibitors, systemic corticosteroids, oral macrolide antibiotics and if evidence of eosinophilic/atopic component disease exists then modifying monoclonal antibody therapies.

A Phase 2 Randomized Controlled Multisite Study Using Omalizumab-facilitated Rapid Desensitization to Test Continued vs Discontinued Dosing in Multifood Allergic Individuals

BACKGROUND

As there is limited data on the sustainability of desensitization of multifood-oral immunotherapy (multifood-OIT), we conducted a multisite multifood-OIT study to compare the efficacy of successful desensitization with sustained dosing vs discontinued dosing after multifood-OIT.

METHODS

We enrolled 70 participants, aged 5-22 years with multiple food allergies confirmed by double-blind placebo-controlled food challenges (DBPCFCs). In the open-label phase of the study, all participants received omalizumab (weeks 1-16) and multi-OIT (2-5 allergens; weeks 8-30) and eligible participants (on maintenance dose of each allergen by weeks 28-29) were randomized 1:1:1 to 1 g, 300 mg, or 0 mg arms (blinded, weeks 30-36) and then tested by food challenge at week 36. Success was defined as passing 2 g food challenge to at least 2 foods in week 36.

FINDINGS

Most participants were able to reach a dose of 2 g or higher of each of 2, 3, 4, and 5 food allergens (as applicable to the participant's food allergens in OIT) in week 36 food challenges. Using an intent-to-treat analysis, we did not find evidence that a 300 mg dose was effectively different than a 1 g dose in maintaining desensitization, and both together were more effective than OIT discontinuation (0 mg dose) (85% vs 55%, P = 0.03). Fifty-five percent of the intent-to-treat participants and 69% of per protocol participants randomized to the 0 mg arm showed no objective reactivity after 6 weeks of discontinuation. Cross-desensitization was found between cashew/pistachio and walnut/pecan when only one of the foods was part of OIT. No statistically significant safety differences were found between the three arms.

INTERPRETATION

These results suggest that sustained desensitization after omalizumab-facilitated multi-OIT best occurs through continued maintenance OIT dosing of either 300 mg or 1 g of each food allergen as opposed to discontinuation of multi-OIT.

FUNDING

Sean N. Parker Center for Allergy and Asthma Research at Stanford University, Jeff and MacKenzie Bezos, NIAID AADCRC U19AI104209.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov number, NCT02626611.

Late-onset asthma: current perspectives

Because the pathophysiology of asthma has diverse characteristics, to manage the disease effectively, it is important for clinicians to distinguish among the clinical phenotypes. Among them, adult-onset asthma, that is, late-onset asthma (LOA), is increasing because of the aging of the population. The phenotype of LOA is largely divided into two types according to the presence or absence of eosinophilic inflammation, T-helper (Th)2- and non-Th2-associated LOA. Especially in Th2 LOA related to rhinosinusitis, as pulmonary function at onset is poor and asthma exacerbations occur frequently, it is important to detect this phenotype in the early phase by using a biomarker of Th2-type inflammation such as fractional exhaled nitric oxide (FENO). As non-Th2-LOA is often resistant to corticosteroids, this phenotype often requires another treatment strategy such as macrolide, diet, or smoking cessation. We often struggle with the management of LOA patients due to a lack of evidence; therefore, the elucidation of the mechanism of LOA contributes to increased efficiency of diagnosis and treatment of LOA. Age-related immune system and structural changes are thought to be associated with the pathophysiology of LOA. In the former case, changes in inflammatory cell function such as variations in the innate immune response and acquisition of autoimmunity or upregulation of oxidative stress are thought to be involved in the mechanism. Meanwhile, the latter can also become triggers or exacerbating factors of LOA via enhancement of airway hyperresponsiveness, decline in lung function, increased air trapping, and reduction in chest wall compliance. Therefore, appropriate individualized management in LOA may be possible through precisely assessing the pathophysiology based on age-related functional changes, including the immune and structural system.

Severe asthma: anti-IgE or anti-IL-5?

Severe asthma is a discrete clinical entity characterised by recurrent exacerbations, reduced quality of life and poor asthma control as ordinary treatment regimens remain inadequate. Difficulty in managing severe asthma derives partly from the multiple existing phenotypes and our inability to recognise them. Though the exact pathogenetic pathway of severe allergic asthma remains unclear, it is known that numerous inflammatory cells and cytokines are involved, and eosinophils represent a key inflammatory cell mediator. Anti-IgE (omalizumab) and anti-IL-5 (mepolizumab) antibodies are biological agents that interfere in different steps of the Th2 inflammatory cascade and are licensed in severe asthma. Both exhibit a favourable clinical outcome as they reduce exacerbation rate and improve asthma control and quality of life, while mepolizumab also induces an oral steroid sparing effect. Nevertheless, it is still questionable which agent is more suitable in the management of severe allergic asthma since no comparable studies have been conducted. Omalizumab's established effectiveness in clinical practice over a long period is complemented by a beneficial effect on airway remodelling process mediated mainly through its impact on eosinophils and other parameters strongly related to eosinophilic inflammation. However, it is possible that mepolizumab through nearly depleting eosinophils could have a similar effect on airway remodelling. Moreover, to date, markers indicative of the patient population responding to each treatment are unavailable although baseline eosinophils and exacerbation rate in the previous year demonstrate a predictive value regarding anti-IL-5 therapy effectiveness. On the other hand, a better therapeutic response for omalizumab has been observed when low forced expiratory volume in 1 sec, high-dose inhaled corticosteroids and increased IgE concentrations are present. Consequently, conclusions are not yet safe to be drawn based on existing knowledge, and additional research is necessary to unravel the remaining issues for the severe asthmatic population.