An expert consensus framework for asthma remission as a treatment goal

German Asthma Net: Characterisation of responders to anti-IL-5 and anti-IL-5(R) therapy

INTRODUCTION

Previous studies of anti-IL-5/IL-5(R) therapies in severe asthma found that response was mainly predicted by indicators of good baseline disease control. However, long-term response predictors remain unclear.

METHODS

Responders to anti-IL-5/IL-5(R) therapy in the well-characterised, real-life, international German Asthma Net (GAN) registry were analysed using regression analyses. Response was defined by ≥50% reduction in exacerbations or corticosteroid dose, super-response by a complete stop of both, and remission additionally by controlled asthma (ACT score≥20).

RESULTS

Seventy-seven percent of 347 patients (55% female, 56.6±12.3 years, follow-up 20.3±13 months) were responders and showed improved exacerbation rates, asthma control, and corticosteroid treatment reduction. Response was independently predicted by inhaled corticosteroid dose (odds ratio [OR] 1.5; p = 0.014), exacerbation rate (OR 1.2; p = 0.009), and treatment duration (OR 1.05, p = 0.023). Univariately, blood eosinophil counts notably predicted response (OR 12.4; p = 0.004). Super-response was inversely associated with corticosteroid dependence and depression. Remission was associated with the absence of systemic corticosteroids, better asthma control, and FEV1 in litre.

CONCLUSIONS

These results underscore that long-term anti-IL-5/IL-5(R) therapy reduces exacerbation and corticosteroid burden, especially in patients with severe disease and high type 2 inflammatory burden. Contrastingly, low baseline corticosteroid use and markers of good asthma control predicted remission and super-responder status.

Defining Clinical Remission in Severe Asthma: Expert Opinion From the Gulf Region Using the Modified Delphi Method

The introduction of biologics into the asthma management landscape and the adoption of patient-centricity and outcomes principles drive the need to revise clinical goals and targets while treating asthma patients. This necessitates a deeper understanding of asthma phenotypes, endotypes, pathophysiology, and clinical cutoff points depicting an operational definition of clinical remission in asthma. This publication represents a step in this direction, through systemically gathering and analyzing insights from experts in pulmonology and immunology from the Gulf Countries. A pre-workshop survey, scientific workshop, and two rounds of Delphi surveys constituted the analysis process and resulted in agreed-upon comprehensive criteria defining clinical remission in severe asthma. While constructing the Delphi expert opinion addressing the concept of on treatment remission, the following factors were agreed to be the main defining criteria: The sustained absence of asthma symptoms, the sustained absence of asthma exacerbations, stable lung function, and zero systemic corticosteroids for the treatment of asthma for at least 12 months.

Regional challenges to optimize the management of patients with severe asthma type 2 inflammation: a Delphi consensus in seven countries

Objective:Severe asthma burdens patients and presents clinical management challenges for healthcare professionals. Biologics are crucial interventions for severe type two (T2) patients with high eosinophil counts. We conducted a Delphi consensus in seven developing or typically underrepresented countries to understand expert agreement on managing severe asthma with type two (T2) inflammation.

Methods:The study comprised two online survey rounds and a participant meeting, involving 21 and 20 respiratory experts in the first and second survey, respectively. We developed a 70-statement questionnaire after literature review. Responses were recorded on a Likert scale (0-9) with 75% consensus threshold.

Results:Consensus was reached on 37/60 closed-ended questions, including subtypes, in survey-1 and 20/47 closed-ended questions in survey-2. 95% of participants agreed on biomarker use for biologic treatment selection. 100% agreed timely biologic treatment leads to improvement in patients with severe asthma and an eosinophilic phenotype. 90% agreed to avoid maintenance oral corticosteroids (OCS) and start biologic therapy directly. Experts defined clinical remission on treatment as no exacerbations, no OCS use, Asthma Control Questionnaire (ACQ)-5 score < 1.5, and lung function optimization (forced expiratory volume in one second [FEV1] ≥ 80% of predicted or pre-bronchodilator FEV1 increase ≥ 100 mL from baseline). In survey-1, 81% agreed these outcomes are achievable in practice. All referral statements achieved consensus.

Conclusions:This Delphi study focused on understanding patients with severe asthma and T2 inflammation in developing/underrepresented countries. Appropriately utilizing biomarkers, timely treatment interventions for best outcomes, expert consensus on clinical remission, and referral are crucial for improving patient management.

Long-term safety and effectiveness of mepolizumab for patients with bronchial asthma in routine clinical practice in Japan - final report of special drug use investigation

BACKGROUND

Mepolizumab is an anti-interleukin-5 (IL-5) monoclonal antibody that blocks IL-5-driven airway inflammation, including eosinophilia. Mepolizumab is well tolerated and effective in reducing exacerbations in patients with bronchial asthma. However, limited real-world data are available for treatment outcomes of mepolizumab in patients with bronchial asthma in Japan. Therefore, this large-scale study aimed to assess the long-term safety and effectiveness of mepolizumab in patients with bronchial asthma in Japan.

METHODS

In this real-world observational study conducted between January 2017 and September 2023, patients with bronchial asthma who had available data in an electronic data capture system for at least 52 weeks prior to subcutaneous mepolizumab treatment were monitored for 52 weeks from their first dose of mepolizumab. Safety was evaluated based on patient-reported adverse drug reactions (ADRs), and effectiveness was evaluated by frequency of asthma exacerbations, changes in Asthma Control Test (ACT) scores, and peak expiratory flow (PEF).

RESULTS

Overall, 1061 patients were enrolled. ADRs were reported by 4.1 % of patients in the safety population (n = 1027). No new safety concerns were identified. The overall effectiveness was evaluated in 959 patients in the effectiveness population. Post-mepolizumab initiation, asthma exacerbations were reduced from 3.8 to 1.0 per person-year; mean (standard deviation [SD]) ACT scores improved from 15.9 (4.6) to 21.4 (3.9); mean (SD) PEF improved from 304.4 L/min (146.8) to 349.5 L/min (134.7) compared with pre-mepolizumab initiation.

CONCLUSIONS

This analysis of real-world data demonstrates that mepolizumab was well tolerated and effective in patients with bronchial asthma in Japan.

Application of Biologics in the Treatment of Asthma in the Past Two Decades: A Bibliometric Analysis and Beyond

This study aims to demonstrate the bibliometric characteristics of articles on biologics for asthma treatment over the past two decades. There were 3395 articles published in 653 journals from 91 countries/regions from January 1, 2000 to September 30, 2023. The results showed biologics changes the course of asthma has attracted the interest of researchers and asthma remission has recently been proposed by researchers. Therefore, the goal of T2-high asthma management was shifted from controlling to complete remission. There was also growing interest among researchers in alleviating symptoms in T2-low asthma. New biological targets also need to be discovered when patients do not achieve satisfactory therapeutic outcomes with biologic agent, and one of the potential future direction for a treatment breakthrough lies in the combination of two biologics or the utilization of novel biologics that target dual sites. The development of biologics has progressed rapidly and has demonstrated their effectiveness in clinic, however, biologics still face multifaceted challenges and require further research to identify additional targets or enhance efficacy.

Clinical Characteristics of Difficult-To-Treat Allergic Bronchopulmonary Aspergillosis and Its Prediction Score

BACKGROUND AND OBJECTIVE

Administration of oral corticosteroids and/or azole antifungals for 4-6 months remains the standard treatment for allergic bronchopulmonary aspergillosis (ABPA). This study investigated the clinical characteristics of patients with difficult-to-treat ABPA who failed to achieve clinical remission within 6 months.

METHODS

Among the participants of a nationwide survey conducted in Japan in 2020, treatment-naïve patients with ABPA who satisfied Asano's criteria were enrolled in this study. Clinical remission was defined as stable disease without exacerbation for ≥ 6 months under minimal treatment (oral prednisolone: ≤ 5 mg/day and no antifungal medication). A risk prediction score for difficult-to-treat ABPA was developed and validated in an independent cohort comprising patients with ABPA from a prospective registration study in Japan.

RESULTS

In total, 316 treatment-naïve patients with ABPA were enrolled in the study. The median time to minimal treatment status was 4.8 months in the group receiving standard treatment. The clinical remission rate at 6 months after standard treatment was 51%. Age ≤ 50 years at onset of ABPA (p = 0.04), serum A. fumigatus-specific IgE titer of ≥ 20 UA/mL (p = 0.006), positive culture for Aspergillus spp. in the sputum/bronchial lavage fluid (p = 0.05), and presence of high attenuation mucus (HAM; p = 0.10) were associated with difficult-to-treat ABPA. The number of positive indicators indicated the risk of failure of standard treatment to yield clinical remission within 6 months in the derivation (n = 87, p < 0.001) and validation (n = 64, p = 0.009) cohorts.

CONCLUSION

Multiple components, including age at onset, allergic sensitization, airway fungal burden, and HAM, were associated with difficult-to-treat ABPA.

Patient response and remission in respiratory disease: Special focus on severe asthma and chronic obstructive pulmonary disease

Over the past decades, monoclonal antibodies have been playing a pivotal role in the treatment of chronic inflammatory airway diseases. Currently, ample data are available on the efficacy and safety of biologics in asthma from randomized controlled trials and open-label trials; conversely, limited data are available on the use of biologics in chronic obstructive pulmonary disease. In this context, once the fundamental role of inhaled corticosteroid/long-acting β2-agonist/long-acting muscarinic antagonist therapy is established, clinical response and disease remission, based on clinical and functional response parameters such as oral corticosteroid need, annual exacerbation rates, and lung function, are the key factors driving the clinical and therapeutic management. This narrative review has summarized the literature data from randomized controlled trials and real-life experience on currently available biologics in asthma and chronic obstructive pulmonary disease. The role of inhaled corticosteroid, long-acting β2-agonist, and long-acting muscarinic antagonist therapy has been further investigated with a particular focus on drug-free concept.

Recent evidence for stepping down severe asthma therapies

PURPOSE OF REVIEW

Biologics have proven safe and effective for severe asthma. Their introduction has offered hope for patients and prescribers with a growing list of novel medications and indications. While 'step-up' indications for biologic initiation are well described in guidelines, 'step-down' strategy remains poorly understood and thus guidance is limited. In this opinion article we aim to focus on recent practice changing evidence for stepping-down severe asthma management, tools for the assessment of biologic efficacy, propose a framework for the step-down of biologic and nonbiologic therapies and suggest topics of interest for future research.

RECENT FINDINGS

Clinical tools have been developed to aid in assessing biologic response. Some patients experience marked improvement and may enter a period of clinical remission or even complete remission. Following positive response, add-on therapy may safely be approached for taper or withdrawal.

SUMMARY

There is limited consensus but growing evidence for stepping-down therapies in patients who achieve clinical response and/or remission after biologic initiation. Further structured guidance would benefit clinicians who face clinical uncertainty when deciding to step-down therapy in patients with well controlled asthma.

Clinical remission of mild-to-moderate asthma: Rates, contributing factors, and stability

Background

Although clinical remission (CR) of severe asthma has been extensively investigated, CR of mild-to-moderate asthma remains unexplored.

Objective

This study aimed to determine CR rates, contributing factors, and stability in patients with mild-to-moderate asthma.

Methods

We retrospectively analyzed 263 patients with asthma. Three-component CR was defined as no exacerbation, no daily oral corticosteroid receipt, and an Asthma Control Test score equivalent to that of the well control; 4-component CR included these parameters plus forced expiratory volume in 1 second of ≥80% predicted. CR during the 1 year and stability of CR over 10 years were retrospectively analyzed in patients with mild-to-moderate and severe asthma.

Results

The CR rates were significantly higher (4-component, 73.2%; 3-component, 81.0%) in patients with mild-to-moderate asthma compared with the CR rate in patients with severe asthma (4-component, 33.9%; and 3-component, 30.6%). A lower smoking index contributed to 3- and 4-component CR. Lower body mass index contributed to 3-component remission, and later onset and shorter asthma duration contributed to 4-component remission. In patients experiencing 4-component remission 10 years before, 80.3% maintained disease in remission; 89.1% of patients experiencing 3-component remission maintained disease in remission. In patients with disease that did not maintain 4-component CR after 10 years, predicted forced expiratory volume decreased, but no differences in inhaled corticosteroid and long-acting β-agonists/long-acting muscarinic antagonists receipt were detected between 10 years ago and the present. The current muscarinic antagonist receipt remained low, at 16.7%.

Conclusion

CR, including normalized forced expiratory volume, is obtainable and sustainable in most Japanese patients with mild-to-moderate asthma. Assessing CR in these patients may help avoid undertreatment and reduce future risks.

Head-To-Head Comparison of Biologic Efficacy in Asthma: What Have We Learned?

We performed an in-depth appraisal of indirect head-to-head comparisons of biologics approved for asthma, including anti-IL5/5Rα (mepolizumab, benralizumab), anti-IL4Rα (dupilumab), anti-TSLP (tezepelumab) and anti-IgE (omalizumab), which was neither a systematic review nor a meta-analysis. A crude evaluation of 95% CI's for rate ratios which excluded unity revealed greater overall reductions in annualised exacerbations with dupilumab versus either mepolizumab or benralizumab and also with tezepelumab versus benralizumab. Furthermore in patients with eosinophils ≥ 300/μL exacerbation rates were lower for tezepelumab, dupilumab and mepolizumab versus benralizumab; and with eosinophils< 150/μL for tezepelumab versus dupilumab. For lung function, no overall differences in FEV1 response were observed between drugs where there was considerable heterogeneity of overlapping 95% CI's. Dupilumab was superior to benralizumab for oscillometry-derived peripheral lung resistance and compliance, as well as for attenuation of mannitol airway hyperresponsiveness. There were no differences in asthma control or quality of life scores where the effect sizes were small, along with wide overlaps in 95% CI's. There is an unmet need for prospective pragmatic randomised controlled trials to directly compare biologics, especially to assess clinical remission in both type 2 high and low asthma patients. Real-life studies might also evaluate complete remission with different biologics to include outcomes such as inhaled corticosteroid sparing, small airways dysfunction using oscillometry, abolition of airway hyperresponsiveness and to assess mucus plugging and remodelling as wall thickening with imaging.

PI3K pathway activation in severe asthma is linked to steroid insensitivity and adverse outcomes

Background

Patients with severe asthma may demonstrate reduced sensitivity to steroid treatment. However, the implications of this reduced responsiveness for clinical outcomes and the underlying mechanisms remain unclear.

Objective

The aim of this study was to investigate whether steroid sensitivity in patients with asthma is related to severity and clinical outcomes and to elucidate the role of inflammatory pathways in reducing steroid sensitivity.

Methods

This observational study of 169 asthma patients, with 161 followed for 1 year, involved isolation of peripheral blood mononuclear cells. These cells were treated with dexamethasone, and the mRNA expression of FKBP5, which is a marker of steroid sensitivity, was measured. To explore the mechanism underlying the reduced steroid sensitivity, cells were exposed to PI3K and MAPK inhibitors in combination with dexamethasone.

Results

A total of 53 patients diagnosed with severe asthma exhibited markedly diminished sensitivity to steroids compared with those with nonsevere asthma. Reduced steroid sensitivity has emerged as a critical risk factor for failure to experience clinical remission and exacerbation. This relationship between reduced steroid sensitivity and disease severity and adverse outcomes was confirmed at the 1-year follow-up. Mechanistic investigations revealed that the degree of recovery from steroid sensitivity after PI3Kδ/γ inhibitor treatment was significantly greater in patients with severe asthma than in those with nonsevere asthma, a finding confirmed at the 1-year follow-up.

Conclusions

Patients with severe asthma demonstrate reduced steroid sensitivity, which results in unfavorable clinical outcomes. Conversely, inhibition of the PI3K pathway significantly improves steroid sensitivity.

Early and Sustained Clinical Benefits of Benralizumab in Severe Eosinophilic Asthma: Findings from the ORBE II Study

Introduction: Benralizumab has demonstrated rapid efficacy in treating severe eosinophilic asthma (SEA). This study aims to characterize early responses to benralizumab, the patient features observed in those with early responses, and the potential patient features that could predict them, and it also evaluates whether these improvements are sustained during a one-year follow-up (FUP) in clinical practice. Methods: This analysis was conducted using the ORBE II study database. ORBE II is an observational, retrospective study that included uncontrolled SEA adult patients treated with benralizumab according to routine clinical practice in Spain. We analysed patients with available data on the asthma control test (ACT) at baseline and within the first 120 days after benralizumab initiation, identifying ACT "Early Super-Responders" (ACT-ESR) as patients with a ≥9 point-improvement in the ACT score or reaching an absolute score of ≥24. Likewise, we assessed patients with available data on the pre-BD FEV1 during the same study periods, defining those with a pre-BD FEV1 increment of ≥230 mL as FEV1-ESR patients. Clinical outcomes were described up to 1 year of FUP. Results: A total of 45 and 65 patients with data for ACT and FEV1, respectively, during the first 120 days of treatment were analysed. Of those, 55.5% and 58.5% of patients were categorized as ACT-ESR and FEV1-ESR, respectively. At baseline, both groups showed high T2 inflammation markers and a high prevalence of comorbidities (chronic rhinosinusitis with nasal polyposis: 56% and 50%; gastro-oesophageal reflux disease: 24% and 40%, respectively). Poor asthma control (ACT < 20) was observed at baseline in 96% of ACT-ESR, while impaired lung function (pre-BD FEV1 < 80%) was present in 71.7% of FEV1-ESR. Oral corticosteroid (OCS) dependency affected 25% and 30% of ACT-ESR and FEV1-ESR, respectively. The early gains observed in ACT-ESR and FEV1-ESR were sustained up to 1 year of FUP, with 90.5% and 66.7% of patients achieving a super-response (zero exacerbations and no OCS use) and 92.0% and 71.1% meeting clinical remission criteria (zero exacerbations, no OCS use, ACT ≥ 20 and pre-BD FEV1 increment of ≥100 mL), respectively. Conclusions: Benralizumab provides early benefits for SEA patients in clinical practice, with more than half achieving early super-responses in both ACT score and lung function. These improvements were sustained over a 1-year FUP, resulting in high rates of clinical remission.

Challenges and Opportunities in Achieving Asthma Remission

Background: Asthma is a chronic inflammatory disorder in millions of individuals across the globe with high morbidity, mortality, and health care costs. Despite advances in asthma treatment, long-term remission is a challenging target to achieve. Objectives: This review will address the path to remission in asthma with focus on the role of biologic agents in severe asthma management and on the question as to whether long-term disease control and remission are a reality. Methods: A systematic literature review from 1971 to 2025 was conducted through databases such as PubMed, MEDLINE, Scopus, and Web of Science. Clinical trials, meta-analyses, and real-world evidence concerning biologic therapies, such as monoclonal antibodies targeting interleukin -5 (IL-5), IL-4/IL-13, immunoglobulin E, and thymic stromal lymphopoietin, were considered. Symptom control, exacerbation frequency, lung function, and oral corticosteroid (OCS) use were some of the outcomes considered. Results: Biologic treatments have yielded significant gains in asthma control and reduction of exacerbation. Complete remission-long-term resolution of symptoms, inflammation, and drug dependence-is still difficult to achieve. Early intervention with biologics may prevent irreversible airway remodeling, but long-term remission is not in sight. These drugs reduce OCS dependency, but sustainability of remission remains to be investigated. Conclusions: Biologic therapies have advanced asthma treatment, particularly in severe cases, by improving symptoms and reducing exacerbations. However, complete remission remains a distant goal. The development of standardized remission criteria, better patient stratification, and long-term clinical studies are necessary to help achieve sustained asthma control and remission.

Early clinical remission and its role in lung function decline and exacerbation in adult Korean patients with asthma

INTRODUCTION

Despite advancements in asthma management, many patients continue to experience poor disease control, lung function decline, and frequent exacerbations. Clinical remission (CR) has been proposed as a novel treatment target and surrogate marker for long-term outcomes. This study evaluates whether early CR at 1 year after inhaled corticosteroid (ICS) initiation influences lung function decline and exacerbation risk in asthma.

METHODS

This retrospective cohort study evaluated 492 asthma patients treated with ICS at two teaching hospitals. Patients were classified into early CR and non-early CR groups. Early CR was defined based on a composite set of criteria, including sustained absence of exacerbations, no systemic corticosteroid use, symptom control and stable or improved lung function in the first year following ICS initiation. Study outcomes were the annual forced expiratory volume in one second (FEV1) decline and the moderate-to-severe exacerbations.

RESULTS

Early CR was significantly associated with slower annual FEV1 decline (4-component CR, adjusted β=31.6 mL/year, p=0.001; 3-component CR, adjusted β=15.7 mL/year, p=0.043). The benefits of early 4-component CR on attenuating annual FEV1 decline were more pronounced in specific phenotypes, including type-2 high asthma, persistent airflow limitation, severe asthma and patients requiring add-on long-acting muscarinic antagonists. Early 4-component CR had a reduced risk of moderate-to-severe (adjusted HR (aHR)=0.591, p=0.011) and severe exacerbations (aHR=0.508, p=0.025).

CONCLUSIONS

Achieving CR within 1 year of ICS initiation was associated with improved lung function preservation and reduced exacerbation risk. These findings suggest the importance of achieving early CR as a clinical target in asthma management.

Asthma in the Biologics Era: Should Oral Corticosteroid Therapy Be Relegated to History?

Oral corticosteroids (OCS) have been used for both maintenance and burst treatment of asthma since the 1950s owing to their beneficial effect on symptoms and exacerbations coupled with a historical lack of alternative therapies. Despite the current availability of well-tolerated and effective treatment with biologics, chronic OCS use remains high. This is of great concern because evidence suggests that a lifetime cumulative exposure even as low as 0.5 to 1.0 g prednisolone equivalent (about three to four bursts of OCS) significantly increases the risk of a wide range of acute and long-term adverse effects, some of which may not be fully reversible. Conversely, biologics have demonstrated a more favorable benefit-risk profile compared with OCS, while reducing exacerbations and improving symptom control. Here, we review the current situation, highlight the need for improved stewardship of OCS use, describe the cumulative and potentially irreversible toxicity seen with even short bursts of OCS, and discuss the role of biologics in minimizing their use. Finally, we provide our opinion on how maintenance OCS therapy in asthma can be relegated to history, with early patient risk evaluation to identify and measure biomarkers and/or clinical traits that may predict risk of future exacerbations, enabling proactive preventative intervention.

Con: clinical remission in asthma - not yet there

The ideal definition of asthma remission should be practical, measurable and meaningful for both patients and physicians, while also representing true disease modification. Unfortunately, current proposals to define asthma remission fall short of this standard, not for lack of careful consideration, but due to the challenges presented by asthma, including but not limited to variability in symptom perception, intrinsic variability in lung function, seasonality and the impact of comorbidities. This article discusses obstacles and challenges to developing a widely adopted, consensus definition of asthma remission. We searched the literature for keywords including "asthma", "remission" and "super-responder" and identified interventional trials in asthma that highlight the challenges inherent in defining asthma remission.

Promoting Prevention and Targeting Remission of Asthma: A EUFOREA Consensus Statement on Raising the Bar in Asthma Care

Asthma is a common, multifaceted respiratory disease with a major impact on quality of life. Despite increased insights into mechanisms underlying various asthma phenotypes and endotypes and the availability of targeted biologic treatment options, the disease remains uncontrolled in a substantial proportion of patients with risk of exacerbations, requiring systemic corticosteroids, and with progressive disease. Current international guidelines advocate for a personalized management approach to patients with uncontrolled severe asthma. The European Forum for Research and Education in Allergy and Airway Diseases (EUFOREA) asthma expert panel was convened to discuss strategies to optimize asthma care and to prevent systemic corticosteroid overuse and disease progression. In this meeting report, we summarize current concepts and recommendations and provide a rationale to implement personalized asthma management at earlier stages of the disease. The ultimate goal is to move away from the current one-size-fits-most concept, which focuses on a symptom-driven treatment strategy, and shift toward a phenotype- and endotype-targeted approach aimed at curbing the disease course by improving clinical outcomes and preserving health-related quality of life. Herein, we provide a consensus view on asthma care that advocates a holistic approach and highlight some unmet needs to be addressed in future clinical trials and population studies.

How to move towards more sustainable asthma care in Europe: an expert opinion paper

The healthcare sector is one of the primary emitters of greenhouse gases in the public sector; this viewpoint's distillation of expert opinions emphasises what more sustainable asthma care could look like and presents possible solutions to achieving it https://bit.ly/41fQ364.

What We Know to Date About Early Treatment With Biologics in Severe Asthma: A Scoping Review About the Use of Biologics in Severe Asthma and Possible Parallels With Early Rheumatoid Arthritis

Introduction

Theoretically, an early intervention with biologics in severe asthma (SA) patients may attenuate inflammatory processes and potentially halt disease progression and remodeling. Changing the approach to a more preventive one could alter the course of the disease, avoid its progression, and improve the likelihood of achieving clinical remission. The aims of this study were to gather scientific evidence on this topic, to draw a parallel between SA and rheumathoid arthritis (RA) and to analyze the potential benefits of establishing early treatment in SA.

Material and methods

A systematic scoping review, conducted in accordance with the methodological guidance of the Arksey and O'Malley framework and focusing on early treatment intervention with biological drugs in SA and RA is presented.

Results

Evidence supports the early intervention with biologics in RA to improve outcomes. Evidence regarding early intervention with biologics in SA is scarce. To date, the literature reviewed suggests that better clinical condition of the patient and more preserved lung function at the onset of biological treatment, together with a shorter duration of asthma, are associated with better response to biologics.

Conclusions

Data suggests that the more preventive approach may lead to improved results. The scarcity of scientific evidence highlights the importance of pursuing this line of research.

Early Reduction of FeNO on Anti-IL5 Biologics Is Associated With Clinical Remission of Severe Asthma

BACKGROUND

In patients with severe asthma, treatment with anti-interleukin-5 (IL-5) biologics can lead to a reduction in fractional exhaled nitric oxide (FeNO) in some patients. The clinical implications of varying FeNO responses to anti-IL-5 biologics remain unclear. This study aims to categorise patients based on their FeNO response to anti-IL-5 biologics and evaluate the association of these categories with clinical outcomes.

METHODS

We used the Danish Severe Asthma Register (DSAR) to identify the early FeNO response profiles in patients receiving anti-IL5 biologics. We defined FeNO responders as patients with elevated FeNO levels at baseline and a decrease corresponding to the minimal clinically important difference (MCID) at 4 months of follow-up and FeNO non-responders as those who did not experience a decrease.

RESULTS

We identified 403 patients on anti-IL5 treatment in DSAR, and 265 (66%) had elevated FeNO levels at baseline. After 4 months of treatment, 151 (57%) patients showed a significant decrease in FeNO levels, and 114 (43%) did not. FeNO responders were more likely to achieve clinical remission of asthma (34% vs. 19%, p = 0.01, OR 2.11, CI 1.04, 5.18, p = 0.03) than FeNO non-responders after 12 months of treatment. The higher remission rates in FeNO responders mainly reflected a higher rate of normalisation of lung function.

CONCLUSIONS

FeNO levels were reduced after anti-IL5 treatment in a significant proportion of patients treated with anti-IL5, and this was associated with clinical remission. Early FeNO response to anti-IL5 could potentially be used as a biomarker to guide management decisions with biologics towards remission of disease in severe asthma.

Pre-biologic disease trajectories are associated with morbidity burden and biologic treatment response in severe asthma

BACKGROUND

Biologics can induce remission in some patients with severe asthma; however, little is known about pre-biologic disease trajectories and their association with outcomes from biological treatment. We aimed to identify long-term trajectories of disease progression in patients initiating biologics and investigate trajectory associations with disease burden and impact on biologic therapy efficacy.

METHODS

Patients in the Danish Severe Asthma Register initiating biologic therapy between 2016 and 2022 were included and followed retrospectively in prescription databases starting 1995. We performed sequence analysis for inhaled corticosteroid treatment intensity over time combined with unsupervised trajectory clustering.

RESULTS

In total, 755 patients were included and three pre-biologic disease trajectories were identified: "Chronic severe asthma" (26%), "Gradual onset severe asthma" (35%) and "Recent, sudden onset severe asthma" (39%). "Chronic severe asthma" patients were older, had the longest disease duration (35 years), the most impaired pulmonary function, the highest comorbidity prevalence and the lowest employment rate. "Recent, sudden onset severe asthma" patients were younger, had shorter disease duration (5 years), more tobacco exposure and the least impaired lung function. "Gradual onset severe asthma" patients had an intermediate burden of disease. The "Chronic severe asthma" cluster demonstrated the lowest prevalence of remission (17%) compared to the "Gradual onset severe asthma" (29%) and "Recent, sudden onset severe asthma" (32%) clusters.

CONCLUSIONS

Three pre-biologic disease trajectories were identified, with increased disease duration and activity associating with asthma and comorbidity burden. Early intervention may be key to prevent irreversible adverse outcomes for patients with severe asthma.

Pro: Clinical remission in asthma - implications for asthma management

Asthma treatment has seen significant advancements over the recent years. However, despite improvements in disease control, some patients continue to experience persistent symptoms and exacerbations, necessitating a deeper understanding of disease mechanisms and optimisation of treatment strategies. The introduction of biologics has marked a new era in severe asthma management, targeting underlying molecular mechanisms and raising the possibility of achieving asthma remission. Key indicators of remission include high asthma control, absence of exacerbations and stabilised, or normalised, lung function. However, there is currently no common definition for remission, with various studies using different criteria. Real-world studies and post hoc analyses of clinical trials emphasise the potential of biologics in achieving clinical remission in a significant proportion of patients. Here, we provide a comprehensive review of studies in support of incorporating asthma remission as potential goal in asthma management. Despite the lack of a universally accepted definition and large prospective studies focused on remission, we believe that incorporating long-term outcomes and the currently accepted elements of remission in the approach to asthma care will shift the emphasis from reactive symptom control to proactive disease management, ultimately aiming for better asthma outcomes.

Response to IL-5/IL-5R Antagonists and Remission Rate in Patients With Severe Asthma Who Would Have Been Excluded From the Pivotal Clinical Trials

BACKGROUND

Randomized controlled trials (RCTs) assessing the efficacy of IL-5/IL-5R antagonists showed a significant reduction in asthma exacerbations as well as a corticosteroid-sparing effect in selected patients with severe eosinophilic asthma.

OBJECTIVE

To compare the response and remission rate after treatment with IL-5/IL-5R antagonists in patients with asthma who would or would not have met inclusion criteria of pivotal RCTs.

METHODS

This was a retrospective cohort study of patients with severe eosinophilic asthma aged 18 and older treated with IL-5/IL-5R antagonists between 2012 and 2020 in a tertiary outpatient asthma clinic. Patients aged 75 years or younger, with a smoking history of less than 10 pack-years and a reversible FEV1 less than 80% predicted in the previous year were considered to fulfill the pivotal RCT inclusion criteria. Response to treatment and clinical remission of asthma were assessed in those who did or did not fulfill pivotal RCT inclusion criteria.

RESULTS

A total of 108 subjects were included. Only 22 patients (20.4%) met all pivotal RCT inclusion criteria. There was no significant difference in response to treatment of these patients compared with those who did not fulfill inclusion criteria (odds ratio [95% CI] = 0.66 [0.15-2.85]). However, RCT eligibility was associated with a higher likelihood of achieving clinical remission (odds ratio [95% CI] = 4.09 [1.02-16.45]).

CONCLUSION

IL-5/IL-5R antagonists seem to be as effective in subjects who would have been excluded from pivotal RCTs as in those who met the RCT inclusion criteria, but RCT eligibility increases the likelihood of achieving clinical remission of asthma.

Younger severe asthma patients with interleukin 4 (CC variant) and dupilumab treatment are more likely to achieve clinical remission

BACKGROUND AND OBJECTIVES

Asthma is a complex condition characterized by variable respiratory symptoms and chronic inflammation. In recent years, the use of biologics in severe asthma patients led to significant improvements in symptom control and disease outcomes. This has prompted healthcare providers to explore the possibility of achieving clinical remission (CR). This study aimed to evaluate the prevalence of clinical remission in severe asthma patients treated with biologics. Additionally, to identify factors associated with achieving clinical remission.

METHODS

The study recruited 116 patients from a national severe asthma registry in Kuwait, focusing on patients who had been treated with biologic therapy for at least 12 months. CR was defined as the absence of exacerbations and oral corticosteroids (OCS) use, an Asthma Control Test (ACT) score of ≥ 20, Asthma Control Questionnaire (ACQ-6) score of ≤ 0.75 and forced expiratory volume in one second (FEV1) ≥ 80% predicted. Data were collected on demographics, clinical, and functional parameters; including biomarkers such as blood eosinophils count (BEC), total immunoglobulin E (IgE), and fractional exhaled nitric oxide (FeNO), as well as the polymorphism patterns of the interleukin-4 (IL-4) and tumor necrosis factor-alpha (TNF-α) genes.

RESULTS

Patients with severe asthma were predominantly female (68.9%) with an average age of 54.09 years. Most had adult-onset asthma (67.3%), comorbid allergic rhinitis (AR) (81.03%), and experienced frequent exacerbations, with a median of four corticosteroids-requiring flare-ups per year. The allergic eosinophilic phenotype was common (74.14%), and a significant portion carried the CC genotype of the IL-4 gene (51.72%) or the GG genotype of the TNFα gene (57.76%). Biologic therapy significantly improved asthma control, reduced exacerbations and OCS use while improved lung function (p = 0.001 for all). About 18.1% of patients achieved CR after at least 12 months of biologic therapy, with dupilumab being the most effective, especially in biologic-naive patients. A multiple logistic regression analysis found that increasing age was negatively associated with CR (OR 0.95, p = 0.02), while the CC genotype of the IL-4 gene (OR 4.57, p = 0.008) and the use of dupilumab (OR 3.63, p = 0.001) were strong positive predictors of CR.

CONCLUSION

This study suggested that CR can be achieved in patients with severe asthma. However, biologic therapy, particularly dupilumab, offers a promising avenue for achieving CR in comparison to other biologics, especially in younger patients with specific genetic profiles (CC genotype of the IL-4 gene).

Long-Term Clinical Remission on Benralizumab Treatment in Severe Eosinophilic Asthma: A Four-Year Real-Life Study

Background: The current availability of monoclonal antibodies against key mediators of type-2 (T2) inflammation has led to a redefinition of the ultimate objectives of severe asthma treatment to a more composite concept of disease remission. Objectives: The aim of this real-life study was to estimate the percentage of patients who achieved clinical remission over 4 years of treatment with benralizumab, and to identify baseline predictors for the achievement of such a composite outcome in the long term. Methods: Data from a 4-year follow-up of 23 patients who were prescribed benralizumab as an add-on therapy because of uncontrolled severe eosinophilic asthma were retrospectively analyzed and compared. Clinical remission was considered to be "complete" if oral corticosteroid (OCS) use was not required, there were no exacerbations, an asthma control test (ACT) score ≥ 20 was achieved and a pre-bronchodilation percent predicted a forced expiratory volume in 1 s (FEV1%) ≥ 80%. Clinical remission was considered to be "partial" if OCS use was not required, plus at least two of the other three aforementioned criteria. Results: The overall percentage of patients who achieved clinical remission was 86.9% after 12 months, and 91.3% after 24 and 48 months of treatment. The rate of complete remission over partial remission increased over time. After 12 months of treatment, 65% of patients fulfilled the criteria for complete remission and 35.0% for partial remission. After 48 months of treatment, 71.4% of patients were in a status of complete remission and 28.6% in a status of partial remission. A long-term composite outcome of complete clinical remission was more likely to be achieved by severe eosinophilic asthma patients with comorbid nasal polyposis, bronchiectasis and osteoporosis, and with OCS dependency, a predicted pre-bronchodilation FEV1% ≥ 80% and a predicted FEF25-75% < 65% at baseline. Conclusions: Our real-life experience suggests that treatment with benralizumab may allow the achievement and long-term maintenance of clinical remission in a high percentage of severe eosinophilic asthma patients, up to 4 years of follow-up.

Supratherapeutic Inhaled Corticosteroid Use in Patients Initiating on Biologic Therapies for Severe Asthma: A Nationwide Cohort Study

BACKGROUND

In severe asthma, intensive ("supratherapeutic") doses of inhaled corticosteroids (ICS) are often used. The prevalence of supratherapeutic ICS use and its impact on corticosteroid-related comorbidities is poorly understood. We aimed to describe the prevalence of supratherapeutic ICS use in severe asthma, its relation to corticosteroid-related comorbidities, and changes in prescribed and redeemed ICS dose after 12 months of biologic therapy.

METHODS

Patients from the nationwide Danish Severe Asthma Register (DSAR) receiving biologic therapy > 12 months were included. Supratherapeutic doses were defined as > 1600 µg budesonide daily. Baseline characteristics, comorbidity burden, and change in ICS use after 12 months of biologic therapy was stratified according to ICS use at baseline.

RESULTS

We included 652 patients in our analyses and 156 (24%) were supratherapeutic ICS users prior to initiation of biologic therapy. Supratherapeutic ICS users had a higher baseline prevalence of cataracts at 14 vs 8.1%; p = 0.025. No differences in other corticosteroid-related comorbidities were observed. No change in prevalence of prescribed supratherapeutic ICS was seen after 12 months of biologic therapy. However, a reduction in ICS adherence among supratherapeutic users was observed with 72% of patients demonstrating > 80% adherence at 12 months, compared to 83% at baseline (p < 0.001).

CONCLUSION

Supratherapeutic doses of ICS were used by almost one-fourth of the patients prior to initiation of biologic therapy and were associated with a higher prevalence of cataracts. Physician-driven ICS reduction was rare, yet supratherapeutic ICS users were found to self-regulate ICS therapy when treated with biologic therapy.

Proinflammatory Cytokines in Chronic Respiratory Diseases and Their Management

Pulmonary homeostasis can be agitated either by external environmental insults or endogenous factors produced during respiratory/pulmonary diseases. The lungs counter these insults by initiating mechanisms of inflammation as a localized, non-specific first-line defense response. Cytokines are small signaling glycoprotein molecules that control the immune response. They are formed by numerous categories of cell types and induce the movement, growth, differentiation, and death of cells. During respiratory diseases, multiple proinflammatory cytokines play a crucial role in orchestrating chronic inflammation and structural changes in the respiratory tract by recruiting inflammatory cells and maintaining the release of growth factors to maintain inflammation. The issue aggravates when the inflammatory response is exaggerated and/or cytokine production becomes dysregulated. In such instances, unresolving and chronic inflammatory reactions and cytokine production accelerate airway remodeling and maladaptive outcomes. Pro-inflammatory cytokines generate these deleterious consequences through interactions with receptors, which in turn initiate a signal in the cell, triggering a response. The cytokine profile and inflammatory cascade seen in different pulmonary diseases vary and have become fundamental targets for advancement in new therapeutic strategies for lung diseases. There are considerable therapeutic approaches that target cytokine-mediated inflammation in pulmonary diseases; however, blocking specific cytokines may not contribute to clinical benefit. Alternatively, broad-spectrum anti-inflammatory approaches are more likely to be clinically effective. Herein, this comprehensive review of the literature identifies various cytokines (e.g., interleukins, chemokines, and growth factors) involved in pulmonary inflammation and the pathogenesis of respiratory diseases (e.g., asthma, chronic obstructive pulmonary, lung cancer, pneumonia, and pulmonary fibrosis) and investigates targeted therapeutic treatment approaches.

The impact of biologic therapy on work capacity and workforce attachment in patients with severe asthma

INTRODUCTION

Severe asthma impacts work capacity, but little is known about the effects of biologic therapy on patients' ability to work. We aimed to assess the impact of biologic therapy for severe asthma on work capacity and workforce attachment.

METHODS

This cohort study used the Danish Severe Asthma Register, comprising all Danish patients with severe asthma initiating biologic therapy. Earned income, hours worked, and workforce attachment were tracked in national databases from one year prior to biologic therapy as well as during 2 years of biologic therapy. Outcomes were compared to age-, sex-, cohabitation- and residence-matched controls from the general population.

RESULTS

Overall, 381 patients aged 20-62 years (52% females) were included. Annual weeks worked were lower among patients with severe asthma (adjusted incidence rate ratio (aIRR) 0.82 (0.80-0.84)), driven by increases in sick leave (aIRR 2.77 (2.58-2.98)), unemployment (aIRR 1.38 (1.30-1.46)) and disability pension (aIRR 1.85 (1.76-1.94)). After initiating biologic therapy, patients saw modest increases in annual hours worked during the second year of treatment (aIRR 1.03 (1.03-1.04)). However, patients remained at risk for temporary (OR 1.83 (1.15-2.93)) and permanent (OR 2.67 (1.16-6.16)) workforce withdrawal. Patients achieving on-treatment remission worked significantly more hours compared to non- and clinical responders and had lower unemployment-, sick-leave and disability pension rates both at baseline and after two years.

CONCLUSION

Biologic therapy resulted in a modest increase in hours worked, yet patients remain at significant risk of early workforce withdrawal. Patients achieving remission had a stronger attachment to the workforce, also prior to biologic therapy.

Is Disease Stability an Attainable Chronic Obstructive Pulmonary Disease Treatment Goal?

Chronic obstructive pulmonary disease (COPD) is a heterogeneous lung condition characterized by progressive airflow obstruction. Despite advancements in diagnosis and treatment, the disease burden remains high; although clinical trials have shown improvements in outcomes such as exacerbations, quality of life, and lung function, improvement may not be attainable for many patients. For patients who do experience improvement, it is challenging to set management goals given the progressive nature of COPD. We therefore propose disease stability as an appropriate and attainable treatment goal. Other disease areas have developed definitions of no disease activity or remission, which provide relevant information for defining and achieving stability for patients with COPD. Disease stability builds on related concepts already defined in COPD, such as clinical control and clinically important deterioration. Current components that could form part of a disease stability definition include exacerbations, health status (including quality of life and symptoms), and lung function. Considerations should be given to intervals over which stability is defined and assessed, appropriate thresholds, and defining a composite. Ensuring a holistic approach, objective measurements, and harmonious, clear communication between patients and physicians can further support establishing disease stability. Here we propose a preliminary definition of disease stability, informed by existing research in COPD. Further research will be needed to validate the framework for use in clinical and research settings. Exploring disease stability as a goal, however, is an opportunity to develop and validate an attainable treatment target to advance the standard of care for patients with COPD.

Explore the application effect of acupoint massage combined with ear point pressing beans in the remission stage of asthma

OBJECTIVE

To explore the application effect of acupoint massage combined with ear point pressing beans in the remission stage of bronchial asthma.

METHODS

A total of 120 children with asthma in remission who were treated in the paediatric outpatient department between January 2016 and October 2022 were randomly divided into the experimental and control groups, with 60 patients in each group. The patients in both groups were treated with salmeterol and fluticasone inhalation powder, 1 puff each time, twice a day. The patients in the control group received acupoint massage in addition to this treatment, with acupoint massage performed once a day, Monday to Friday, lasting 30 min each time. The patients in the experimental group received ear point pressing beans in addition to the treatment in the control group. Ear point press bean paste bean once a week,press 3-5 times a day,press each point for i minute. Changes in pulmonary function and asthma control were observed before and after treatment in both groups, with forced expiratory volume in 1 second (FEV1), forced expiratory vital capacity (FVC), FEV1/FVC ratio and the Asthma Control Test (ACT) score compared.

RESULTS

After 8 weeks of treatment, FEV1, FVC, FEV1/FVC ratio and the ACT scores of both groups improved to different degrees (P<0.05). In terms of the effective control rate, the total clinical effective control rate (95 %) of patients in the experimental group was significantly higher than that in the control group (81.67 %) (P < 0.05).

CONCLUSION

Acupoint massage combined with ear point pressing beans has a good effect on the treatment of asthma remission and can effectively improve the quality of life, making it worthy of further promotion in clinical practice.

Beneficial effects of pleuran on asthma control and respiratory tract-infection frequency in children with perennial asthma

The aim of this study was to evaluate the effects of pleuran (β-glucan isolated from Pleurotus ostreatus) on asthma control and respiratory morbidity in children on conventional GINA-based asthma treatment who had partially controlled perennial asthma. A double-blind, placebo-controlled multicentre clinical trial with a 2-arm, parallel design was conducted across three countries; 230 children aged 7 to 17 years were randomised (1:1) into an active group (receiving a pleuran/vitamin C combination) or a placebo group (receiving vitamin C only). This study consisted of 24 weeks of treatment (2 capsules a day) and then 24 weeks of follow-up. The primary endpoints included the effects of active treatment versus placebo on asthma control and respiratory tract infections (RTIs). Secondary endpoints included changes in the following measures: number of asthma exacerbations, with or without respiratory infection; quality of life of both asthmatic children and their caregivers; spirometric indices; fractional exhaled nitric oxide (FeNO) levels; safety after 24 weeks of treatment and also after the full 48-week study period. Overall, 206 children completed this study; 113 of these children were in the active group and received a pleuran/vitamin C combination for 24 weeks. After the 24-week treatment period, children below 12 years of age who were in the active group achieved significant improvements in asthma control compared to those in the placebo group (21.8 ± 3.5 vs. 20.3 ± 4.0; P = 0.02); while children at least 12 years old who were in the active group reported lower numbers of RTIs (0.7 ± 1.0 vs. 1.9 ± 1.7; P = 0.002) compared to children of this age in the placebo group. In addition, children below 12 years of age in the active group showed a significant decrease in asthma exacerbations compared to those in the placebo group (2.5 ± 1.6 vs. 3.3 ± 1.9; P = 0.05). At the end of the 48-week trial, a statistically significant improvement in asthma control was observed in 84.7% of children who received pleuran/vitamin C treatment compared to 67.0% of children who received vitamin C only (P = 0.01). The pleuran/vitamin C combined treatment was safe and well-tolerated, and no related serious adverse events were reported. This study highlights the favourable safety profile of pleuran/vitamin C supplementation and demonstrates positive effects of this treatment on asthma control and RTI incidence in children with allergic perennial asthma that was partially controlled by conventional therapy.

Benralizumab Outcomes in Patients with Severe Eosinophilic Asthma Treated in Real-Life Settings: Results of the BREEZE Study in 5 Countries From Central Eastern Europe and Baltics

Purpose

To describe real-world clinical characteristics, treatment patterns and outcomes of severe eosinophilic asthma (SEA) patients initiated on benralizumab after treatment authorization in Central Eastern Europe and Baltic Area.

Patients and Methods

BREEZE was a retrospective, medical chart review with a pre-post design conducted in 42 clinical centers from Bulgaria, Czech Republic, Hungary, Lithuania and Romania. Eligibility included diagnosis of SEA and at least one dose of benralizumab administered in real-life settings. Descriptive statistics were used in the full analysis set and key subgroups stratified by blood eosinophils (bEOS) number, maintenance oral corticosteroids (mOCS) use and prior biologics exposure and included calculation of the annualized exacerbation rate (AER) at baseline, and weeks (W) 16 and 48.

Results

Of 381 patients included, 66% were female with overall mean age 56 ±12 years at benralizumab start. At baseline: median bEOS 580 cells/μL (74% bEOS>400), forced expiratory volume in 1 second (FEV1) 1660 mL, mOCS use in 25% of patients (10 mg/day prednisone equivalent, 68% >5 mg/day), AER 3.05 (95% CI 2.9-3.2), and poorly controlled asthma (Asthma Control Test [ACT] <16) in 63% of patients. Median duration of exposure to benralizumab was 11.5 (95% CI 7.7-12.3) months, and discontinuation rate was 1.3% (95% CI 0.4%-3.0%). Median bEOS decreased to 0 at W16 and maintained thereafter; FEV1 increases of +240 mL at W16 and +335 mL at W48 were reported (p <0.001 for both). Overall relative reduction in AER at W16 and W48 was 92% and 93%, respectively, and 82-94% across key subgroups. mOCS dose reduction was 50%, and proportion of patients requiring >5 mg/day decreased constantly (25% at W16, 28% at W48). ACT scores increased from W16 to W56 (p <0.001 for all).

Conclusion

Our findings indicate clinically meaningful benefits of benralizumab across multiple geographies and various subgroups of patients with SEA.

Health loss and economic burden of asthma in China: a qualitative review based on existing literature

BACKGROUND

Asthma is a significant public health issue that cannot be ignored in China and around the world, bringing a huge social burden.

OBJECTIVES

To evaluate the disease burden of asthma in China, including health loss and cost of illness, and identify its influencing factors.

METHODS

A systematic literature review and qualitative descriptive analysis were conducted, Literature was accessed through PubMed, EMBASE, Web of Science, CNKI, Wangfang Data, and VIP databases, with a cutoff date of April 3, 2024. The analysis focused on two main aspects: health loss burden, measured by disability-adjusted life years (DALYs), including years of life lost (YLLs) and years lived with disability (YLDs); and economic burden, assessed through direct and indirect costs. The risk of bias in economic studies was assessed using an 11-item methodological checklist for cost of illness, while cross-sectional studies were evaluated using the Agency for Healthcare Research and Quality's recommendation rating tool.

RESULTS

The analysis included 50 studies, with eight focused on health loss and 42 on economic burden. The health loss studies showed a 51% decrease in asthma's age-standardized DALYs rate over 30 years, from 209.24 to 102.81 per 100,000 person-years. The health loss burden is influenced by factors such as high BMI, smoking, and occupational exposure. Economic burden studies reported annual direct costs from $348 to $1187 per capita, indirect costs from $7 to $1195, and hospitalization costs from $177 to $1547, influenced by frequency and severity of acute exacerbation, comorbidities, and treatment adherence. Quality assessment revealed moderate overall quality, with gaps in sensitivity analyses and cost data transparency.

CONCLUSION

The health loss burden of asthma in China has significantly decreased from 1990 to 2019, with males experiencing a higher burden. However, regional disparities in the economic burden persist, highlighting the need for improved management and adherence to standardized treatment protocols to address these disparities.

Clinical Remission in Patients With Biologic-Naïve Asthma: A Multicenter Study in Japan

BACKGROUND

Clinical remission (CR) is a new realistic management goal for patients with asthma, regardless of the disease severity.

OBJECTIVE

To investigate the rate of achievement of CR in patients treated with inhaled corticosteroid/long-acting β2-agonist (ICS/LABA) and nonbiologics and the characteristics of patients who achieved CR.

METHODS

We performed a post hoc analysis from a multicenter, cross-sectional survey in Japan. 3-way CR was defined as the absence of exacerbation, no use of maintenance oral corticosteroids, and the absence of significant asthma symptoms (5-item Asthma Control Questionnaire < 1.5). We defined 4-way CR as 3-way CR plus having normalized lung function (forced expiratory volume in 1 second [%FEV1] ≥ 80%). Deep remission was defined as 4-way CR plus suppressed type 2 airway inflammation (fraction of exhaled nitric oxide [FeNO] < 35 ppb).

RESULTS

The criteria for 3-way CR, 4-way CR, and deep remission were met by 56.9%, 35.0%, and 24.7% of patients, respectively. Compared with patients who achieved the 3-way CR, unachieved patients have lower %FEV1 (77.6% vs 85.4%; P < .0001) and higher FeNO levels (42 ppb vs 34 ppb; P = .0182), and there were more discordances in asthma control perception between patient and physicians (38.5% vs 9.3%; P < .0001). Physician-patient discordance was an independent factor that prevented the achievement of the 3-way CR in the logistic regression analysis, even when adjusted for %FEV1 and FeNO (odds ratio 0.397; P < 0.0001).

CONCLUSIONS

Achieving CR in patients treated with ICS/LABA without biologics is challenging. Discrepancies between patient and physician perceptions on asthma control are significant barriers to achieving CR.

Long-term effects of dupilumab on chronic rhinosinusitis with nasal polyps: A step towards clinical remission

Background and objectives

Clinical remission, defined as the absence of disease activity and symptoms, is an emerging goal in the management of chronic rhinosinusitis with nasal polyps (CRSwNP). This study aimed to evaluate the long-term effects of dupilumab on patients with CRSwNP, with or without asthma, and explore the potential for achieving clinical remission.

Methods

A two-year prospective study was conducted on 109 patients with CRSwNP, with or without asthma, who were eligible for dupilumab as an add-on therapy. Comprehensive assessments, including clinical, laboratory, and radiological evaluations, were performed before and after treatment. Clinical remission of CRSwNP was defined as 12 months of dupilumab treatment, no exacerbations requiring oral corticosteroids (OCS), no need for nasal sinus operation, no anosmia or hyposmia, a Sino-Nasal Outcome Test (SNOT-22) score under 20, and a Lund-Mackay score (LMS) below 10. For those with comorbid asthma, clinical remission was defined as an asthma control test (ACT) score of 19 or higher, no asthma exacerbations, and no need for OCS.

Results

Dupilumab significantly improved CRSwNP outcomes in both groups, including SNOT-22 scores, nasal polyp size (LMS), and anosmia/hyposmia. Comorbid asthma was highly prevalent (79.8%), and patients with asthma had significantly larger nasal polyps, both before and after dupilumab therapy, despite similar symptom improvement. Higher fractional exhaled nitric oxide (FeNO) and blood eosinophil count (BEC) levels, along with anosmia/hyposmia, predicted larger polyp size. Dupilumab also significantly improved asthma outcomes, increasing forced expiratory volume in 1 s (FEV1) and decreasing FeNO. Clinical remission was achieved in 11% of patients, with a slightly lower rate in those with asthma (7.3%).

Conclusion

Dupilumab treatment can achieve clinical remission in CRSwNP. However, comorbid asthma appears to reduce the likelihood of remission and is associated with larger nasal polyps, even with similar symptom improvement. Asthma may independently influence polyp development, potentially impacting long-term outcomes in CRSwNP.

On-treatment clinical remission of severe asthma with real-world longer-term biologic use

Background

There are limited real-world data describing the proportion of patients with severe asthma (SA) who achieve on-treatment clinical remission with long-term biologic treatment.

Objective

Our aim was to examine the proportion and characteristics of adults with SA who achieved clinical remission with biologic therapy.

Methods

CHRONICLE is an observational study of US subspecialist-treated adults with SA. Sites reported exacerbations and biologic use from 12 months before enrollment forward. Monthly Asthma Control Test scores and 6-monthly specialist assessments of asthma control were collected. Patients who enrolled from February 2018 to February 2023, began taking a biologic during the study observation period, and continued use of that biologic for at least 12 months were evaluated. Incident on-treatment clinical remission was defined in a 12-month interval as the absence of exacerbations and systemic corticosteroid use, a 50% or greater improvement in Asthma Control Test scores of least 20 points in the latest 6 months, and specialist report of asthma control.

Results

Among the evaluable patients (n = 611), the median duration of biologic use was 39.6 months. In at least one 12-month interval during the study, 79.9% of patients had no exacerbations or systemic corticosteroid use and 46.0% met the definition of clinical remission at any point. The point prevalence of clinical remission increased from 22.3% at 12 to 13 months of biologic use to 34.3% at 47 to 48 months of biologic use.

Conclusions

In a real-world cohort of patients with SA with longer-term biologic treatment, almost one-half achieved on-treatment clinical remission. With at least 1 year of biologic therapy, clinical remission is a feasible treatment goal in SA.

Baseline forced oscillation technique predicting lack of exacerbations in adult patients with asthma: A 12-month prospective

BACKGROUND

The forced oscillation technique (FOT) is a minimally invasive test to evaluate asthma during resting ventilation. However, its role in longitudinal assessments, such as clinical remission, remains unclear.

OBJECTIVE

To longitudinally assess asthma clinical remission and identify parameters that predict clinical remission at 12 months from baseline FOT.

METHODS

Adult patients with asthma at our university hospital between April 2022 and May 2023 were enrolled in this prospective observational study. They were evaluated for 12 months after enrollment to determine whether they met the following clinical remission criteria: asthma control test score of more than or equal to 20 at enrollment and 12 months, no asthma exacerbations for 12 months, and no regular oral corticosteroid use during the 12 months. FOT parameters at enrollment were analyzed for associations with clinical remission.

RESULTS

A total of 94 patients with asthma completed the study and were categorized into clinical and nonclinical remission groups. Comparison of pulmonary function tests, including the FOT, between the 2 groups revealed significant differences in resistance at 5 Hz and resistance at 20 Hz (R20) but not in forced expiratory volume in 1 second. Multivariate logistic regression analysis revealed that R20 was associated with clinical remission, with adjusted odds ratios of 0.32 (95% CI: 0.12-0.91, P = .033) for R20.

CONCLUSION

R20 can be a useful predictor of future exacerbations in patients with asthma. These findings may assist in evaluating adult patients with asthma and normal forced expiratory volume in 1 second.

The impact of blood eosinophil count and FeNO on benralizumab effectiveness in clinical practice: An ORBE II subanalysis

BACKGROUND

The ORBE II study showed the real-world effectiveness of benralizumab in severe eosinophilic asthma (SEA). This subgroup analysis aimed to characterize patients and outcomes based on baseline blood eosinophil count (BEC) and/or fractional exhaled nitric oxide (FeNO) levels.

METHODS

In this analysis of the ORBE II retrospective study, SEA patients receiving benralizumab were categorized into subgroups based on individual or combined BEC/FeNO levels, according to the following thresholds: high BEC (hiBEC): ≥300 cells/μL; low BEC (loBEC): <300 cells/μL; high FeNO (hiFeNO): ≥50 ppb; low FeNO (loFeNO): <50 ppb. Baseline and up to 1 year of follow-up data are described.

RESULTS

Most patients with available data were classified as hiBEC (72.6 %) and 38.3 % as hiFeNO. The distribution according to combined baseline BEC and FeNO levels revealed a heterogeneous patient population. Although common SEA features were shared among subgroups, some distinct characteristics were observed, including elevated allergic asthma prevalence in hiBEC/loFeNO patients, high obesity prevalence and fewer non-smokers in loBEC/loFeNO patients, remarkable severe exacerbation rates in loBEC/hiFeNO patients [5.5 SD (6.0)], and more severe symptoms in the hiBEC/loBEC subgroup. All subgroups showed benefits following benralizumab treatment, with super-responder rates ranging from 68.2 % to 83.3 % and clinical remission rates reaching 70.0 %. Particularly good responses were noted in hiBEC/hiFeNO patients.

CONCLUSIONS

This study shows the variability of T2 biomarkers in ORBE II SEA patients, emphasizing the prevalence of high BEC values. While benralizumab benefits were important regardless of BEC, high BEC predicted good outcomes and FeNO had less influence on treatment effectiveness.

Early Treatment Response to Mepolizumab Predicts Clinical Remission in Severe Eosinophilic Asthma

BACKGROUND

Mepolizumab can induce an early response and clinical remission in people with severe eosinophilic asthma (SEA).

OBJECTIVE

To find whether early response to mepolizumab (100 mg) could predict future asthma remission and to identify the best predictor of treatment response to mepolizumab for achieving remission.

METHODS

The Australian Mepolizumab Registry was used to investigate the early response to mepolizumab at 3 and 6 months and relate this to clinical remission at 12 months. Treatment response was assessed using the 5-item Asthma Control Questionnaire (ACQ-5), oral corticosteroid (OCS) dose, exacerbation frequency, and postbronchodilator FEV1. Clinical remission, assessed at 12 months, was defined as an ACQ-5 score less than or equal to 1.0 at 12 months, no exacerbations in the previous 6 months, and no OCS use for asthma in the previous 6 months. We estimated the optimism-corrected area under the curve for internal validation.

RESULTS

We analyzed 255 participants with SEA. Seventy-eight (30.6%) participants achieved clinical remission at 12 months. A prediction model including ACQ-5 score, exacerbation frequency, OCS dose, and postbronchodilator FEV1 at 6 months was more predictive of achieving remission than measures at 3 months. The ACQ-5 score at 6 months had the highest optimism-corrected area under the curve of 0.778 (95% CI, 0.719-0.833). An ACQ-5 score less than 1.5 at 6 months had a sensitivity of 85.9% for achieving clinical remission, whereas an ACQ-5 score less than 0.75 had a specificity of 84.7%.

CONCLUSIONS

The ACQ-5 score at 6 months was the best predictor of achieving clinical remission at 12 months in people with SEA treated with mepolizumab. These results can be used to design a treat-to-target paradigm for asthma, in which treatment response is assessed at 6 months to predict clinical remission.

Thymus and activation-regulated chemokine (CCL17) as a clinical biomarker in atopic dermatitis: significance and limitations in the new treatment era

Thymus and activation-regulated chemokine (TARC; CCL17) is a T-helper-2 chemokine that reflects atopic dermatitis (AD) disease activity. Since 2008, serum TARC levels have been commercially measured in Japan, and clinical experience has shown the usefulness of TARC. The fallacy that eczema is always visible often hinders successful treatment, when there is subclinical inflammation which is inferable from the TARC level. AD treatment has entered a new era with higher therapeutic efficacy. TARC has a different meaning than it did previously, and its significance and limitations are discussed. First, a more appropriate topical therapy monitoring TARC would be useful in selecting truly necessitated patients for expensive new therapies. Dupilumab quickly lowers serum TARC before clinical improvement, and its normalization is not a criterion for dose reduction. However, in some severe cases, TARC may help determine whether to continue treatment. During treatment with JAK inhibitors, serum TARC levels are often elevated and may be abnormally high, leading to the exacerbation of dermatitis. Prurigo nodularis is divided into two types associated with elevated and normal TARC levels, which may aid in the selection of therapeutic agents. In this new era, TARC remains a useful biomarker for more accurate drug selection and the determination of therapeutic efficacy; Currently, in clinical trials of AD, all outcome measurements depend on the clinical score; however the use of a biomarker, such as TARC, as a secondary outcome measure will clarify the characteristics of each drug and the pathophysiological conditions for which it is expected to be effective.

Recent Advances and New Therapeutic Goals in the Management of Severe Asthma

Asthma is characterized by chronic airway inflammation as its primary pathological condition, which leads to various respiratory symptoms due to airway narrowing, with type 2 inflammation playing a central role. Asthma treatment, primarily centered on inhaled corticosteroids, aims to suppress type 2 inflammation and improve airway narrowing. However, severe asthma that cannot be controlled with high-dose inhaled corticosteroids or other asthma medications remains a clinical issue. The availability of multiple biological agents has recently improved the management of severe asthma. In addition, the concept of clinical remission has emerged as a treatment goal, further clarifying the objectives of asthma management. However, despite these advancements, the treatment of severe asthma driven primarily by non-type 2 inflammation remains a major challenge, and new biologics are currently being developed to address this issue.

Efficacy Assessment of Biological Treatments in Severe Asthma

Uncontrolled, severe asthma remains a significant clinical challenge, affecting a small proportion of asthma patients worldwide. Despite advancements in treatment options, a subset of patients continues to experience frequent exacerbations, uncontrolled symptoms, and impaired quality of life. The advent of biological therapies has revolutionized the management of severe asthma, offering targeted treatments that address specific inflammatory pathways. This review provides a comprehensive overview of the efficacy and response criteria of biological treatments in severe asthma, focusing on clinical, functional, and inflammatory markers used to help in the evaluation of the biologic treatment. Key response criteria include symptom control, reduction in exacerbations, improvement in lung function, and a reduction in or the discontinuation of oral corticosteroids. Biomarkers such as blood eosinophils and exhaled nitric oxide (FeNO) are essential tools in guiding treatment adjustments. Real-world studies underscore the importance of personalized treatment strategies, as variability in response to biological therapies can be significant. The emergence of tools such as the FEOS score and EXACTO questionnaire offer quantitative measures for assessing biological response and guiding clinical decisions. Additionally, predictive factors for better or poorer responses, such as pre-treatment lung function and comorbidities, like obesity and rhinosinusitis, are critical in patient selection. This review highlights the need for ongoing reassessments and potential modifications of therapy in cases of suboptimal response. Practical considerations for switching biological therapies are discussed, emphasizing the importance of tailoring treatments to individual patient profiles and disease phenotypes. With the continued development of personalized medicine, the outlook for patients with severe asthma is improving, selecting specific biomarkers to improve the selection of the biologic treatment.

Distinct trajectories of treatment response to mepolizumab toward remission in patients with severe eosinophilic asthma

BACKGROUND

Patients with severe eosinophilic asthma, characterised by a high disease burden, benefit from mepolizumab, which improves symptoms and reduces exacerbations, potentially leading to clinical remission in a subgroup. This study aimed to identify treatment response trajectories to mepolizumab for severe eosinophilic asthma and to assess the achievement of clinical remission.

METHODS

Data from the Australian Mepolizumab Registry were used to assess treatment responses at 3, 6 and 12 months. The treatment response trajectories were identified using a group-based trajectory model. The proportions achieving clinical remission at 12 months, which was defined as well-controlled symptoms, no exacerbations and no oral corticosteroid (OCS) use for asthma management, were compared between trajectories, and baseline predictors of the trajectories were identified using logistic regression analysis.

RESULTS

We identified three trajectory groups: Group 1, "Responsive asthma with less OCS use" (n=170); Group 2, "Responsive late-onset asthma" (n=58); and Group 3, "Obstructed and less responsive asthma" (n=70). Groups 1 and 2 demonstrated higher proportions achieving clinical remission at 36.5% and 25.9%, respectively, compared to Group 3 with 5.7% (p<0.001). Baseline predictors for assigned groups included lower OCS dose in Group 1; greater forced expiratory volume in 1 s percentage predicted, higher Asthma Quality of Life Questionnaire score, higher OCS dose and nasal polyps in Group 2; with Group 3 as the reference.

CONCLUSIONS

Treatment response to mepolizumab in severe eosinophilic asthma follows three trajectories with varying proportions achieving clinical remission and differing baseline characteristics. Treatment response variability may influence the achievement of clinical remission with mepolizumab therapy.

Clinical remission in patients with severe eosinophilic asthma treated with mepolizumab: A post-hoc analysis of RELIght study

Background: Remission of asthma can occur as part of the natural history of the disease; however, the use of biologics can result in disease remission in some patients. Objective: In this post hoc analysis of the RELIght study, we aimed to evaluate clinical remission in real life among patients treated with mepolizumab, to detect possible differences between "remitters" and "nonremitters," and to evaluate possible predictors of remission. Methods: Clinical remission was defined as the absence of asthma exacerbations, discontinuation of oral corticosteroids (OCS), achievement of asthma control (Asthma Control Test [ACT] ≥ 20), and stable or improved lung function. Results: A total of 146 patients were evaluated; remission was achieved in 40 (27.4%) and 29 (22%) after 12 and 24 months, respectively. At 12 months, the patients in remission had a better baseline ACT score (17.0 [14.0-19.0] versus 15.0 [12.0-17.0]; p = 0.027), were more rarely using OCS (35% versus 62.2%; p = 0.004), and required a lower baseline dose of OCS (5.0 mg/day [5.0-10.0 mg/day] versus 10.0 mg/day [5.0-15.0 mg/day]; p = 0.042) at baseline, whereas, at 24 months, they less frequently carried a baseline diagnosis of gastroesophageal reflux disease (GERD) (10.3% versus 32%; p = 0.031) and used lower doses of OCS at baseline (5.0 [1.0-5.0] versus 10.0 [5.0-15.0]; p = ≤0.001) versus nonremitters; 52.5% of patients had sustained remission, whereas 42.5% experienced relapse. These patients more frequently had GERD versus patients with sustained remission (52.9% versus 4.8%; p = 0.002). Finally, regression analysis has shown that GERD was the only predictor of relapse. Conclusion: Remitters had better asthma control and needed lower doses or no maintenance OCS at baseline, whereas GERD seems to be an important factor that affects remission and relapse.Clinical trial NCT04084613, www.clinical trials.gov.

Dupilumab Induces Long-Term On-Treatment Clinical Remission in Patients With Type 2 Asthma

BACKGROUND

Remission is proposed as a multicomponent outcome for patients with severe asthma.

OBJECTIVE

This post hoc analysis of QUEST (NCT02414854) and TRAVERSE (NCT02134028) evaluated whether dupilumab treatment leads to clinical asthma remission (≥12 months with no severe exacerbations, zero oral corticosteroid use, stabilized or improved lung function, patient-reported asthma control <1.5) and assessed its durability in patients with uncontrolled, moderate to severe type 2 asthma (blood eosinophils ≥150 cells/μL or fractional exhaled nitric oxide ≥20 ppb at parent-study baseline) who are not receiving maintenance oral corticosteroids.

METHODS

In QUEST, patients (aged ≥12 years) were randomized to dupilumab 200/300 mg or placebo every 2 weeks for 52 weeks. In TRAVERSE, all patients received dupilumab 300 mg every 2 weeks for up to 96 weeks. We assessed the proportion of patients meeting criteria for on-treatment clinical remission up to 48 weeks of TRAVERSE.

RESULTS

At QUEST baseline, 1,040 patients receiving dupilumab and 544 taking placebo had type 2 asthma; of those, 842 (dupilumab/dupilumab) and 437 (placebo/dupilumab) enrolled in TRAVERSE. At QUEST week 52 (year 1), 37.2% of patients receiving dupilumab met clinical remission criteria, compared with 22.2% taking placebo (all P < .001). At week 48 of TRAVERSE (year 2 overall), 42.8% (dupilumab/dupilumab) and 33.4% (placebo/dupilumab) of patients met clinical remission criteria. Overall, 29.5% of patients in the dupilumab/dupilumab group met the criteria at both years 1 and 2.

CONCLUSIONS

Dupilumab treatment enabled approximately one third of patients with type 2 asthma to meet the multicomponent end point for on-treatment clinical asthma remission for up to 2 years.

The role of biologics in inducing remission in asthma

Asthma remissions have been identified as a new treatment outcome and as based on experience with biologics. Remissions are defined as no symptoms, no exacerbations, no use of systemic corticosteroids, and stabilization (optimization) of lung functions; all these criteria need to be sustained for at least 1 year. This study discussed the evolution of remissions, the evolving criteria, and experiences in achieving remission after treatment with biologics. In severe, uncontrolled asthma, treatment with biologics has led to remissions in 20% to 35% of the subjects treated. It is proposed that remissions will become a new and important treatment outcome for asthma.

Clinical remission attainment, definitions, and correlates among patients with severe asthma treated with biologics: a systematic review and meta-analysis

BACKGROUND

Clinical remission has emerged as an important treatment goal in severe asthma; however, studies have reported variable attainment due to differences in study populations, definitions, and methods. We aimed to perform a systematic review and meta-analysis of clinical remission attainment, definitions, and correlates among patients with severe asthma who have been treated with biologics.

METHODS

In this systematic review and meta-analysis, we searched Web of Science, Embase, and MEDLINE, using the keywords "asthma" and "remission", for studies published between database inception and June 13, 2024, that reported clinical remission among patients with severe asthma treated with biologics. Studies were eligible for inclusion in both the systematic review and meta-analysis if they were published in English language peer-reviewed journals and reported rates of clinical remission for patients treated with biologics for severe asthma. There were no limitations by study design. Two reviewers independently screened identified papers (AS and CR), with disagreements resolved through consensus or referral to a third reviewer (JB). Study-level data on study characteristics, clinical remission definitions, clinical remission attainment, and the potential correlates of clinical remission were extracted independently by two reviewers (AS and CR) using Covidence. We defined a three-component definition of clinical remission, which included use of maintenance oral corticosteroids, exacerbations, and asthma symptom burden, and a four-component definition, which additionally included lung function. We meta-analysed the rate of attainment of clinical remission and assessed the correlates of clinical remission using DerSimonian-Laird random-effects models. Statistical heterogeneity was assessed using the I2 statistic. This study was registered with PROSPERO, CRD42024507233.

FINDINGS

Our search identified 3014 potentially eligible studies, of which 1812 were screened. 25 studies were included, which reported 28 analyses of clinical remission attainment. 68 definitions of clinical remission were identified, of which 48 were unique. Little consensus was found between studies in terms of the clinical remission definition, particularly for symptoms and lung function. Eight analyses used the three-component definition of clinical remission and 25 used the four-component definition. The pooled proportion of patients who attained clinical remission was 38% (95% CI 29-47; I2=93%) for the three-component definition and 30% (27-34; I2=83%) for the four-component definition. Several pulmonary factors were associated with lower clinical remission rates, including worse FEV1 (odds ratio 0·09 [95% CI 0·01-0·92]; I2=87%), worse asthma symptoms (0·23 [0·17-0·33]; I2=0%), longer asthma duration (0·49 [0·32-0·76]; I2=22%), and use of maintenance oral corticosteroids (0·57 [0·40-0·79]; I2=49%). The presence of comorbidities, in particular depression (0·38 [0·23-0·61]; I2=6%) and obesity (0·41 [0·31-0·54]; I2=0%), were important non-pulmonary barriers to clinical remission.

INTERPRETATION

Clinical remission is an achievable goal for a minority of patients with severe asthma treated with biologics. Definitions of clinical remission varied substantially between studies, and materially affected attainment, suggesting an urgent need for further consensus-driven definitions. Longer disease duration, higher asthma severity, and the presence of comorbidities were identified as important barriers to clinical remission, suggesting that earlier intervention with effective treatments and a broader treatable traits approach might improve outcomes.

FUNDING

Health Data Research UK, Inflammation and Immunity driver project.

Biologics as well as inhaled anti-asthmatic therapy achieve clinical remission: Evidence from the Severe Asthma Network in Italy (SANI)

Background

This study aimed to evaluate the impact of severe asthma (SA) treatments after 12 months in achieving clinical remission (CR) within the context of the Severe Asthma Network in Italy (SANI) using the recent SANI definition of CR on treatment.

Methods

CR has been defined by SANI as complete, partial, and no CR. Complete CR is defined by the absence of oral corticosteroids (OCS), no symptoms, no exacerbations, and stable lung function, and partial CR requires the absence of OCS and the fulfillment of 2 out of the other 3 criteria. Patients who do not meet the previous criteria do not reach CR.

Results

After 12 months of treatment, 283 patients were selected to evaluate the effectiveness of biologics (225 patients) and inhaled therapy (58 patients) in achieving CR. Among patients treated with biologic agents, 45.8% reached complete CR, 23.1% partial CR, and 31.1% no CR. Differences in CR achievement according to type of biologic agent administered were observed. Interesting results were found when assessing the inhaled therapy (ICS/LABA/LAMA and no biologics) effectiveness: 34.5% patients reached complete CR, 34.5% partial CR, and 31.0% did not reach CR. This finding is noteworthy since it further supports the efficacy of inhaled treatment in certain SA patients and highlights the relevance of using CR as a modern outcome of SA treatments. Chronic rhinosinusitis with nasal polyps (CRSwNP) comorbidity was associated, though not significantly, with CR achievement in patients treated with biologics. Asthma Control Test (ACT) and Asthma Control Questionnaire (ACQ) scores significantly impacted CR (p = 0.003 and p = 0.027, respectively), while biomarkers, namely IgE, blood eosinophils, or fractional exhaled nitric oxide (FeNO), were not associated with CR achievement.

Conclusions

This study confirmed the effectiveness of biologics in reaching CR and demonstrated also inhaled therapies able to achieve CR. These innovative findings should encourage post hoc analysis of randomized clinical trials or even retrospective analysis of SA patient cohorts to evaluate CR with different inhaled treatments and further define the populations eligible for each treatment.

Trial registration

ClinicalTrials.gov ID: NCT06625216; Central Ethics Committee: Comitato Etico Area Vasta Nord-Ovest Toscana (study number 1245/2016, protocol number:73714).

Biologics in severe asthma: a state-of-the-art review

Asthma is considered severe if it remains uncontrolled despite optimal conventional therapy, characterised by poor symptom control, frequent exacerbations and increased exposure to systemic corticosteroids. This has a significant impact on morbidity, mortality and healthcare resource utilisation. Recent advances in the understanding of asthma heterogeneity and immunopathogenesis have helped delineate precise disease pathways. The discovery of these pivotal pathways has led to the development of highly effective biologic therapies. Currently available asthma biologics target immunoglobulin E, interleukin (IL)-5/IL-5Rα, IL-4Rα and thymic stromal lymphopoietin. Identification of specific asthma phenotypes, utilising easily measurable biomarkers, has paved the way towards personalised and precision asthma management. Biologic therapies play a significant role in reducing exacerbations, hospitalisations and the need for maintenance systemic steroids, while also improving the quality of life in patients with severe asthma. The evidence for their clinical efficacy comes from randomised controlled trials (RCTs), extension studies, metanalyses and real-world data. This review synthesises findings from early, pivotal RCTs and subsequent studies following the approval of biologics for severe asthma. The safety and efficacy data from these studies, completed in a variety of settings, provide practical perspectives on their application and enhance their generalisability.