Comparative effectiveness of omalizumab, mepolizumab, and dupilumab in asthma: A target trial emulation

Integrative epidemiology and immunotranscriptomics uncover a risk and potential mechanism for cutaneous lymphoma unmasking or progression with dupilumab therapy

BACKGROUND

There have been multiple reports of the anti-IL-4Rα agent, dupilumab, being associated with the onset and/or progression of cutaneous T-cell lymphoma (CTCL).

OBJECTIVE

We sought to evaluate safety signals associated with dupilumab, with a focus on CTCL, and to evaluate the possible underlying mechanism or mechanisms for the potential association.

METHODS

First, we used the Food and Drug Administration's pharmacovigilance database, FAERS (FDA Adverse Event Reporting System), to evaluate whether dupilumab was associated with CTCL, including both positive outcome controls (conjunctivitis, eosinophilia, and arthralgia) and exposure controls (other medications with similar indications, including JAK inhibitors and the anti-IL-13 agent, tralokinumab) to evaluate confounding bias. Thereafter, we used publicly available bulk and single-cell RNA sequencing datasets to probe possible underlying mechanisms through which dupilumab might be associated with CTCL.

RESULTS

Between January 2017 and the fourth quarter of 2023, there were 181,575 unique reports of dupilumab-related adverse events (AEs) in FAERS, with 606 of these being for a neoplasm. Dupilumab had 30.0 times the proportional reporting ratio (PRR) (95% confidence interval, 25.0-35.9) for CTCL compared to all other medications in FAERS. The risk was highest in men aged 45 to 65. The PRR for conjunctivitis, eosinophilia, and arthralgia, known adverse effects of dupilumab, were 35.6 (34.4-36.8), 2.15 (2.00-2.31), and 2.14 (2.07-2.18), respectively. Using the log-count normalized PRR (AE score) to account for PRR inflation when reports were small, the top safety signals included conjunctivitis (AE score 8.3) and CTCL (AE score 4.9). Bulk RNA sequencing data showed changes in IL-4RA and IL-13RA1 expression in CTCL and in epidermal layers of atopic dermatitis (AD) biopsy samples. Single-cell transcriptomic studies revealed that this change was similar in AD and CTCL, and that keratinocytes seemed to be the most divergent cell type with regards to IL-4R and IL-13RA1. An effect on keratinocyte-specific gene expression was also independently observed in available bulk RNA sequencing data.

CONCLUSION

These data suggest that dupilumab might be causing an unmasking or progression of CTCL via the same mechanism through which it improves AD: IL-13 receptor blockade, which leads to increased IL-13 in the local milieu, driving CTCL stimulation and progression. However, these associations need further evaluation given the inherent limitations of the FAERS database and our nonexperimental approach.

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.

Role of Monoclonal Antibodies in the Management of Eosinophilic Chronic Obstructive Pulmonary Disease: A Meta-analysis of Randomized Controlled Trials

Rationale: Chronic obstructive pulmonary disease (COPD) remains a leading cause of morbidity and mortality worldwide. Acute exacerbations are associated with progressive decline in lung function and quality of life. After recognition of the role of type 2 inflammation in the pathogenesis of eosinophilic COPD, there was increased interest in studying monoclonal antibodies as a therapeutic agent. Multiple randomized controlled trials showed promising results, yet no consensus exists. Objectives: Our study aims to summarize the current evidence regarding the role of monoclonal antibodies in the management of patients with eosinophilic COPD. Methods: We systematically searched multiple databases using prespecified search terms. We included only randomized controlled trials that compared monoclonal antibodies versus placebo in patients with objective evidence of eosinophilic COPD receiving standard-of-care therapy. The primary outcome of interest was the annualized rate of COPD exacerbation. Absolute changes in forced expiratory volume in 1 second and St. George's Respiratory Questionnaire scores were secondary outcomes. We also reported serious adverse effects and all-cause mortality. Statistical analysis was conducted via random effects model using RevMan software. Results: We identified and included eight double blinded, placebo-controlled trials with a total of 4,512 patients and a median follow up of 52 weeks. The patients' mean age was 65 ± 8 years, with 85% male. Seventy percent of patients were former smokers, with a mean of 43 ± 25 pack-years of smoking history. The majority of patients were receiving triple inhaled therapy. The mean serum eosinophil count at enrollment was 398 ± 297 cells/μl. The monoclonal antibodies studied were dupilumab, mepolizumab, benralizumab, astegolimab, and itepekimab. Compared with placebo, patients who received monoclonal antibodies had a significantly decreased annualized COPD exacerbation rate (rate ratio, 0.79; 95% confidence interval [CI], 0.73-0.86; P < 0.001). The serious adverse effect rate was significantly lower in the monoclonal antibody arm compared with placebo (odds ratio, 0.80; 95% CI, 0.69-0.93; P = 0.004). The all-cause mortality rates were not statistically different between the groups (odds ratio, 0.91; 95% CI, 0.63-1.3; P = 0.6). Dupilumab showed a trend of improved efficacy over mepolizumab and benralizumab. Conclusions: In patients with eosinophilic COPD receiving standard-of-care therapy, the use of monoclonal antibodies led to a significant reduction in annualized COPD exacerbation rate compared with placebo. Monoclonal antibodies have an acceptable tolerability and safety profile.

Type 2 inflammation, a common denominator in chronic airway disease?

PURPOSE OF REVIEW

This review addresses the growing understanding that a specific subset of patients with a respiratory disease, including asthma, chronic obstructive pulmonary disease (COPD), or bronchiectasis may have one thing in common: type 2 inflammation. In the era of personalized medicine, we need to refine clinical markers combined with molecular and cellular endotyping to improve patient outcomes.

RECENT FINDINGS

Recent literature reveals that type 2 markers such as blood eosinophils, fractional exhaled nitric oxide (FeNO), and immunglobulin E (IgE), can provide valuable insights into disease progression, exacerbation risk, and treatment response, but their stability remains to be investigated. Treating asthma and COPD patients with biologics to target IL-4/IL-13, IL-5, and alarmins have shown potential, although efficacy varied. In bronchiectasis, a subset of patients with type 2 inflammation may benefit from corticosteroid therapy, despite broader concerns regarding its use.

SUMMARY

This underscores the importance of improved disease endotyping to better characterize patients who may benefit from targeted therapies. In clinical practice, personalized treatment based on inflammatory profiles has been shown to improve outcomes in heterogeneous lung diseases. Future research needs to focus on validating reliable biomarkers and optimizing clinical trial designs to advance therapeutic strategies in respiratory diseases.

Comparative Effectiveness of Dupilumab Versus Mepolizumab and Benralizumab in Asthma: A Multinational Retrospective Cohort Study

BACKGROUND

Several biologic agents have been approved for asthma treatment. However, previous comparative effectiveness studies have been indirect treatment comparisons or restricted in geographical scope.

OBJECTIVE

To compare the effectiveness of dupilumab versus mepolizumab and benralizumab in reducing asthma exacerbations among patients with asthma.

METHODS

Data from the Global Collaborative Network of TriNetX were used. Patients aged ≥18 years who received dupilumab, mepolizumab, or benralizumab for asthma between November 1, 2018, and January 1, 2024, were included. The primary outcome was time to the first asthma exacerbation within the 1-year follow-up period. Two comparisons were performed: (1) dupilumab versus mepolizumab and (2) dupilumab versus benralizumab. Propensity score matching was used to balance covariates between the groups. The risk of asthma exacerbations was estimated using Kaplan-Meier curves and Cox proportional hazards models. Subgroup analyses were conducted based on eosinophil counts (≥300, ≥150 to <300, and <150 cells/μL), the presence of chronic obstructive pulmonary disease (COPD), and exacerbation history (0 and ≥1 events).

RESULTS

Dupilumab was associated with a lower risk of asthma exacerbations compared with mepolizumab (hazard ratio [HR], 0.68; 95% confidence interval [CI], 0.62-0.76) and benralizumab (HR, 0.74; 95% CI, 0.67-0.82). Benefits of dupilumab were pronounced in patients with eosinophil counts ≥300 cells/μL, those with COPD, and those without an exacerbation history.

CONCLUSION

Dupilumab was associated with a decreased risk of asthma exacerbations compared with both mepolizumab and benralizumab among patients with asthma. Further research incorporating comprehensive biomarker data is needed to optimize biologic selection.

Importance of cohort and target trial emulation in clinical research

Advances in cohort studies and target trial emulation provide substantial evidence for policymaking to enhance global health. Moving forward, key priorities should focus on standardizing data processing protocols, advancing life-course research, establishing global health data-sharing platforms, and integrating population studies with omics research to support disease prevention and treatment development.

Head-to-Head Effectiveness Comparison of Biological Therapies in Patients With Mixed Eosinophilic and Allergic Severe Asthma

BACKGROUND

Studies comparing biologic therapies for severe asthma usually have a selection bias considering that some of these therapies are indicated for allergic asthma and others for eosinophilic asthma. Severe mixed asthma (SMA) was considered in patients with both allergic and eosinophilic (mixed) severe asthma. In SMA, dupilumab, omalizumab, mepolizumab, and benralizumab can be used. Currently there are no head-to-head studies comparing the clinical response of biologic therapies in this group of patients.

OBJECTIVE

To compare the effectiveness of four biologic therapies in SMA.

METHODS

This was a prospective study with 1 year of follow-up. Patients with severe asthma with markers for allergic asthma (total IgE greater than 100 IU/L and specific IgE to aeroallergens) and eosinophilic asthma (eosinophils greater than 150 cells/mL) were recruited. Sociodemographic and clinical characteristics were evaluated at baseline to assess significant differences between groups. The primary outcome was the proportion of patients achieving greater than 20 points on the Asthma Control Test (ACT). As a secondary outcomes, we evaluated the number of severe exacerbations of asthma per year and changes in FEV1.

RESULTS

A total of 133 patients participated in the study (dupilumab, n = 43; omalizumab, n = 32; mepolizumab, n = 32; and benralizumab, n = 26). At baseline, the groups did not have significant differences in sociodemographic or clinical characteristics. After 1 year with biologic therapies, the four groups had significant improvement in clinical outcomes with few between-group differences. There was no difference for the main outcome (ACT) in the four groups. Dupilumab and mepolizumab demonstrated a higher interval improvement in FEV1 compared with omalizumab. Dupilumab users had the highest proportion of patients who achieved a 200-mL improvement in FEV1 over omalizumab and benralizumab. The greatest adherence was observed among benralizumab users.

CONCLUSIONS

In SMA the four biologic therapies offer similar symptom control according to the ACT, but there are some differences according to FEV1 and adherence. Therefore, the selection of these therapies in SMA must be based on the particular aspects of each patient.

Race and ethnicity, not just insurance, is associated with biologics initiation in asthma and related conditions

BACKGROUND

There are pre-existing inequities in asthma care.

OBJECTIVES

We sought to evaluate effect modification by race of the effect of insurance on biologic therapy use in patients with asthma and related diseases.

METHODS

We conducted inverse probability weighted analyses using electronic health records data from 2011 to 2020 from a large health care system in Boston, Mass. We evaluated the odds of not initiating omalizumab or mepolizumab therapy within 1 year of prescription for an approved indication.

RESULTS

We identified 1132 individuals who met study criteria. Twenty-seven percent of these patients had public insurance and 12% belonged to a historically marginalized group (HMG). One-quarter of patients did not initiate the prescribed biologic. Among patients with asthma, individuals belonging to HMG had higher exacerbation rates in the period before initiation compared to non-HMG individuals, regardless of insurance type. Among HMG patients with asthma, those with private insurance were less likely to not initiate therapy compared to those with public insurance (odds ratio [OR]: 0.67, and 95% CI: 0.56-0.79). Among non-HMG with asthma, privately insured and publicly insured individuals had similar rates of not initiating the prescribed biologic (OR: 1.02; 95% CI: 0.95-1.09). Among those publicly insured with asthma, HMGs had higher odds of not initiating therapy compared to non-HMGs (OR: 1.16; 95% CI: 1.03-1.31), but privately insured HMG and non-HMG did not differ significantly (OR: 0.99; 95% CI: 0.91-1.07).

CONCLUSIONS

Publicly insured individuals belonging to HMG are less likely to initiate biologics when prescribed despite having more severe asthma, while there are no inequities by insurance in individuals belonging to other groups.

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.

A real-world study to evaluate effectiveness of mepolizumab in treating severe asthma in Taiwan (REMIT)

BACKGROUND

REMIT is the first real-world study of mepolizumab effectiveness in patients with severe asthma (SA) in Taiwan.

OBJECTIVES

The primary objective evaluated changes in clinically significant exacerbations (CSEs; defined as use of oral corticosteroids (OCS) or emergency department (ED) visits and/or hospitalizations) in the 12 months pre- and post-mepolizumab treatment. Secondary objectives assessed changes in the number of CSEs requiring ED visits/hospitalizations and daily maintenance OCS (mOCS) dosage 12 months pre- and post-mepolizumab treatment. Three- and four-component clinical remissions were analyzed based on OCS-free, exacerbation-free, and asthma control (± stability in lung function).

DESIGN

REMIT was a retrospective, observational, self-controlled study analyzing patients in Taiwan with SA who were newly prescribed subcutaneous mepolizumab 100 mg Q4W.

METHODS

Data were extracted from records of 15 medical centers in Taiwan for patients indexed between November 1, 2018 and October 31, 2020.

RESULTS

A total of 170 patients were included: mean age at index date, 58.7 years; 53.5% female; 100% Chinese; 7.1% with chronic rhinosinusitis with nasal polyps, 1.8% with eosinophilic granulomatosis with polyangiitis, 1.2% with hypereosinophilic syndrome; and 55.7% with blood eosinophil count >300/µL. Pre-treatment, 71.2% had ⩾2 exacerbations, and 28.7% were on mOCS; 75.3% had no prior biologic treatment, and 24.7% had switched from other biologics. Most patients (80.0%) completed ⩾10 mepolizumab doses. Following the first mepolizumab administration (index date), CSEs reduced by 46.0% (rate ratio (RR): 0.545, 95% confidence interval (CI): 0.418-0.710; p < 0.0001) in the 12 months post-index. Exacerbations requiring ED visits/hospitalization reduced by 46.9% (RR: 0.531, 95% CI: 0.349-0.808; p = 0.0031). Median mOCS dose reduced by 100% by end of study and 81.8% of patients discontinued mOCS post-treatment. After 1 year of mepolizumab treatment, 28% and 23% patients achieved three- and four-component clinical remission, respectively.

CONCLUSION

Mepolizumab use in a patient population in Taiwan with SA significantly reduced CSEs and mOCS use in routine clinical practice.

Comparative effectiveness of dupilumab and omalizumab on asthma exacerbations and systemic corticosteroid prescriptions: Real-world US ADVANTAGE study

BACKGROUND

In the United States, dupilumab is approved for moderate-to-severe eosinophilic or oral corticosteroid-dependent asthma, and omalizumab is approved for managing moderate-to-severe allergic asthma uncontrolled by inhaled corticosteroids. However, limited comparative effectiveness data exist for these biologics due to differing patient characteristics and treatment histories.

OBJECTIVE

This study assessed the real-world effectiveness of dupilumab and omalizumab for asthma in patients in the United States.

METHODS

In this retrospective observational study, TriNetX Dataworks electronic medical record data were used to identify patients with asthma age ≥12 years who initiated (index) dupilumab or omalizumab between November 2018 and September 2020 and who had at least 12 months of pre- and post-index clinical information. Inverse probability of treatment weighting was applied to balance potential confounding in treatment groups. Asthma exacerbation rates and systemic corticosteroid (SCS) prescriptions were compared using a doubly robust negative binomial regression model, adjusting for baseline exacerbation/SCS rates and patient characteristics with ≥10% standardized differences after inverse probability of treatment weighting.

RESULTS

All inclusion and exclusion criteria were met by 2138 dupilumab patients and 1313 omalizumab patients. After weighting, the majority of baseline characteristics were balanced (standard difference <10%) between the 2 groups. Dupilumab was associated with a 44% lower asthma exacerbation rate (P < .0001) versus omalizumab. Additionally, dupilumab treatment significantly (P < .05) reduced SCS prescriptions by 28% during the follow-up period compared with omalizumab treatment.

CONCLUSIONS

The US ADVANTAGE real-world study demonstrated a significant reduction in severe asthma exacerbations and SCS prescriptions for patients prescribed dupilumab compared with patients prescribed omalizumab during 12 months of follow-up.

Temporal variation in the effectiveness of biologics in asthma: Effect modification by changing patient characteristics

BACKGROUND

The underlying population of patients selected for each respiratory monoclonal antibody might change as other biologics are approved.

OBJECTIVE

To evaluate effect modification by calendar time of the effectiveness of each respiratory biologics in asthma.

METHODS

The Effectiveness of Respiratory biologics in Asthma (ERA) is a retrospective cohort of severe asthma patients from the Mass General Brigham clinics between January 2013 and September 2023. Periods were pre-specified as the anti-IgE (2013-2015), anti-IL5 (2016-2018), anti-IL4/13 (2019-2021) or anti-alarmin (2022-2023) era. We evaluated each biologic's effect on asthma-related exacerbations comparing the one-year period before and after therapy initiation using Poisson regression and Cox regression for time-to-first exacerbation.

RESULTS

Of 647 biologic-naïve patients, 165 initiated omalizumab, 235 anti-IL5, 227 dupilumab, and 20 tezepelumab. Omalizumab's effectiveness improved as more biologics were approved: incidence rate ratio (IRR) 1.16 [0.94-1.43] anti-IgE era vs. 0.54 [0.37-0.80] anti-IL4/13-alarmin era. Omalizumab patients in the anti-IL4/13-alarmin era had lower blood eosinophil counts and less chronic rhinosinusitis with nasal polyps (CRSwNP). For anti-IL5s, effectiveness peaked in the anti-IL4/13 era (IRR 0.52 [0.42-0.64]) when patients had higher BMI and less concomitant CRSwNP. Dupilumab was most effective in the anti-IL4/13 era (IRR 0.60 [0.50-0.72]). There were fewer current smokers in dupilumab patients in the anti-IL4/13 era. Results were similar in time-to-event analyses and in sensitivity analyses accounting for the COVID-19 pandemic.

CONCLUSION

There are temporal variations in the effectiveness of biologics partly explained by the shift in the underlying population, particularly for omalizumab. Though having more choices was associated with better patient selection for omalizumab, this was inconsistent for other biologics.

Efficacy of Biologic Therapies in the Management of Allergic Rhinitis: A Systematic Review

Allergic rhinitis (AR) is a common chronic condition characterized by nasal congestion, sneezing, and itching, which significantly impacts quality of life. Traditional treatments, including antihistamines and intranasal corticosteroids, often fall short in managing moderate-to-severe cases. Recently, biologic therapies such as omalizumab and dupilumab have emerged as potential alternatives. This systematic review aims to evaluate the efficacy and safety of these biologic therapies in the management of AR. A comprehensive literature search was conducted across PubMed, Embase, Cochrane Library, and Web of Science to identify studies published between 2000 and 2024. Studies included were randomized controlled trials, cohort studies, and post-hoc analyses that assessed the impact of biologics on AR symptoms. Data on study characteristics, population demographics, intervention details, and outcomes were extracted and analyzed. The review included nine studies evaluating omalizumab and dupilumab. Omalizumab demonstrated significant improvements in nasal symptoms and quality of life, with notable efficacy in reducing symptoms and improving asthma control in patients with moderate-to-severe AR. Dupilumab also showed positive outcomes, particularly in patients with comorbid asthma and perennial AR, by reducing severe exacerbations and improving symptom scores. Biologic therapies, including omalizumab and dupilumab, offer promising alternatives for the management of AR, especially in cases that are severe or refractory to conventional treatments. The evidence supports their efficacy in improving symptoms and quality of life. Nevertheless, further research is required to address the limitations identified, including the need for long-term data and clarification of the mechanisms of action. These findings underscore the potential of biologics in advancing the treatment of AR and highlight the importance of ongoing research to optimize patient outcomes.

Anti-IL-4R versus anti-IL-5/5R after anti-IL-5/5R failure in asthma: An emulated target trial

BACKGROUND

Switching biologics is now common practice in severe eosinophilic asthma. After insufficient response to anti-IL-5 or 5 receptor (anti-IL-5/5R), the optimal switch between an anti-IL-4R mAb (interclass) or another anti-IL-5/5R drug (intraclass) remains unknown.

OBJECTIVE

We sought to compare the effectiveness of these 2 strategies in asthma control in patients with severe eosinophilic asthma and insufficient response to an anti-IL-5/5R mAb.

METHODS

We emulated a target randomized trial using observational data from the Recherche sur les AsthMes SEvèreS (RAMSES) cohort. Eligible patients were switched to an anti-IL-4R mAb or another anti-IL-5/5R drug after insufficient response to an anti-IL-5/5R mAb. The primary outcome was the change in Asthma Control Test score at 6 months.

RESULTS

Among the 2046 patients in the cohort, 151 were included in the study: 103 switched to an anti-IL-4R mAb and 48 to another anti-IL-5/5R. At 6 months, the difference in Asthma Control Test score improvement was not statistically significant (mean difference groups, 0.82 [-0.47 to 2.10], P = .213). The interclass group exhibited greater cumulative reduction in oral corticosteroid dose (Pinter-intra, -1.05 g [-1.76 to -0.34], P = .041). The interclass group had a better effect, although not significantly, on reducing exacerbations (Δinter-intra, -0.37 [-0.77 to 0.02], P = .124) and increasing lung function (FEV1) (126.8 mL [-12.7 to 266.4], P = .124).

CONCLUSIONS

After anti-IL-5/5R mAb insufficient response, switching to dupilumab demonstrated similar improvement in Asthma Control Test scores compared with intraclass switching. However, it appeared more effective in reducing oral corticosteroid use. Larger studies are warranted to confirm these results.

Real-world unified airway benefits of mepolizumab: Effectiveness in patients with asthma and comorbid nasal polyps

BACKGROUND

Nasal polyps (NPs) are commonly associated with chronic rhinosinusitis (CRS). In keeping with the unified airway hypothesis, asthma and CRS with NP (CRSwNP) frequently co-occur, share a similar pathophysiology, and are often treated with oral corticosteroids (OCS); however, a need for alternative treatment options for patients with comorbid asthma and CRSwNP remains.

OBJECTIVE

To characterize the short- and long-term dual airway effectiveness of the anti-interleukin-5 monoclonal antibody, mepolizumab, in real-world patients with asthma and comorbid NP.

METHODS

Adult patients with CRSwNP who initiated mepolizumab from November 1, 2014, to September 30, 2021, were identified from 2 Merative MarketScan Research Databases. Outcomes were compared for the 12 months pre- and post-mepolizumab initiation and a variable follow-up period. Primary outcomes included the following: annual rate and proportion of patients with NP- and asthma-related exacerbations; NP surgery occurrences; all-cause OCS claims, number of OCS bursts, and daily OCS dose; all-cause and NP-related health care resource utilization.

RESULTS

During the 12 months post-index, patients experienced fewer NP- and asthma-related exacerbations, required fewer sinus surgeries, and reduced use of OCS, with fewer all-cause OCS claims and OCS bursts. Significant reductions in asthma exacerbation-related and NP-related health care resource utilization were also observed.

CONCLUSION

This study illustrated the near- and long-term real-world effectiveness of mepolizumab treatment, with a focus on dual lower and upper airway benefit from single-agent add-on therapy. These results may aid physicians in clinical decision-making for patients with asthma and comorbid CRSwNP with complex care needs.

Impact of biological therapies on laboratory outcomes and FEV1 in patients with severe eosinophilic asthma with chronic rhinosinusitis: a real-life study from Saudi Arabia

                                                                 Abstract Background: Few studies have addressed the effects of biological therapies on laboratory outcomes and changes in FEV1 in patients with severe asthma (SA) and chronic rhinosinusitis (CRS). We aimed to study the effect of three biological therapies on laboratory outcomes and FEV1 in Saudi Arabian patients with SA and CRS.

METHODS

From March to September 2022, a retrospective observational cohort study was undertaken at the severe asthma clinics of the Armed Forces Hospital-Southern Region (AFHSR) and King Khalid University Hospital, Abha, Saudi Arabia, to delineate the effects of 3 biological therapies (benralizumab, dupilumab, and omalizumab) in adults with SA and concomitant CRS in terms of FEV1 and laboratory parameters (serum IgE and eosinophilic counts).

RESULTS

Eighty patients were enrolled, with a mean age of 46.68. There were 45 (56%) females and 35 (44%) males. There were significant improvements in FEV1 and laboratory parameters (serum IgE and eosinophilic counts) after 6 &12 months of biological therapies compared to pre-biological therapies (p<0.001, each). The response was different among different biological therapies. The improvements in FEV1, serum IgE, and eosinophilic counts were manifest with benralizumab and dupilumab but not with omalizumab.

CONCLUSIONS

Results from the first study from two large Saudi Arabian tertiary centers for patients with severe asthma and chronic rhinosinusitis agree with and support those of worldwide real-life ones. One-year follow-up of patients with SA and CRS showed the effectiveness of benralizumab and dupilumab, but not omalizumab, regarding FEV1, serum IgE, and eosinophilic counts. Further prospective multicenter studies are warranted.

Effects of Panax species and their bioactive components on allergic airway diseases

Panax species include Panax ginseng Meyer, Panax quinquefolium L., Panax notoginseng, Panax japonicum, Panax trifolium, and Panax pseudoginseng, which contain bioactive components (BCs) such as ginsenosides and polysaccharides. Recently, growing evidence has revealed the pharmacological effects of Panax species and their BCs on allergic airway diseases (AADs), including allergic asthma (AA) and allergic rhinitis (AR). AADs are characterized by damaged epithelium, sustained acquired immune responses with enforced Th2 responses, allergen-specific IgE production, and enhanced production of histamine and leukotrienes by activated mast cells and basophils. In this review, we summarize how Panax species and their BCs modulate acquired immune responses involving interactions between dendritic cells and T cells, reduce the pro-inflammatory responses of epithelial cells, and reduce allergenic responses from basophils and mast cells in vitro. In addition, we highlight the current understanding of the alleviative effects of Panax species and their BCs against AA and AR in vivo. Moreover, we discuss the unmet needs of research and considerations for the treatment of patients to provide basic scientific knowledge for the treatment of AADs using Panax species and their BCs.

The enchanting canvas of CAR technology: Unveiling its wonders in non-neoplastic diseases

Chimeric antigen receptor (CAR) T cells have made a groundbreaking advancement in personalized immunotherapy and achieved widespread success in hematological malignancies. As CAR technology continues to evolve, numerous studies have unveiled its potential far beyond the realm of oncology. This review focuses on the current applications of CAR-based cellular platforms in non-neoplastic indications, such as autoimmune, infectious, fibrotic, and cellular senescence-associated diseases. Furthermore, we delve into the utilization of CARs in non-T cell populations such as natural killer (NK) cells and macrophages, highlighting their therapeutic potential in non-neoplastic conditions and offering the potential for targeted, personalized therapies to improve patient outcomes and enhanced quality of life.

Smaller Differences in the Comparative Effectiveness of Biologics in Reducing Asthma-Related Hospitalizations Compared With Overall Exacerbations

BACKGROUND

Evidence on the comparative effectiveness of respiratory biologics remains sparse.

OBJECTIVE

We sought to evaluate the comparative effectiveness of omalizumab, mepolizumab, benralizumab, and dupilumab in a matched retrospective cohort of patients with asthma.

METHODS

We identified patients with asthma aged ≥18 years who were incident users of these biologics between November 1, 2018, and June 30, 2023, in administrative claims data from the Food and Drug Administration's Sentinel System and Merative MarketScan Commercial Database. We compared asthma-related exacerbations and hospitalizations in the 12 months since biologic prescription in pairwise comparisons of propensity score-matched cohorts. Covariates used in matching included age, sex, allergic comorbidities, baseline asthma medications use, and the Charlson Comorbidity Index. Incidence rate ratios (IRR) and 95% confidence intervals (CI) were estimated using negative binomial regression models.

RESULTS

A total of 893 patients on mepolizumab, 1300 on benralizumab, 1170 on omalizumab, and 1863 on dupilumab were identified. The average age was 55 years, and two-thirds of the participants were female. At baseline, over 80% of these individuals had an active prescription for an inhaled corticosteroid. Almost half of patients on dupilumab had concomitant nasal polyposis compared with 6% to 13% of patients on the other biologics. Covariates were balanced after matching. In matched analyses, dupilumab was associated with the lowest incidence of exacerbations over the follow-up period (vs dupilumab): mepolizumab (IRR: 1.36; 95% CI: 1.12, 1.64), omalizumab (IRR: 1.33; 95% CI: 1.13, 1.58), benralizumab (IRR: 1.19; 95% CI: 1.00, 1.41). For exacerbations leading to hospitalizations, benralizumab and mepolizumab were associated with the lowest incidence of hospitalizations, and the greatest difference was between mepolizumab versus dupilumab (IRR: 0.76; 95% CI: 0.56, 1.03).

CONCLUSIONS

Dupilumab was associated with the lowest incidence of overall exacerbations, and mepolizumab with the lowest incidence of asthma hospitalizations in this administrative claims-based cohort of individuals with asthma. Despite matching propensity scores, residual confounding, such as baseline eosinophil count, may explain some of these findings.

Comparative Effectiveness of Mepolizumab, Benralizumab, and Dupilumab among Patients with Difficult-to-Control Asthma: A Multicenter Retrospective Propensity-matched Analysis

Rationale: The comparative effectiveness of biologic agents used as add-on therapy in the management of difficult-to-control asthma is unclear. Objective: To compare the effectiveness of dupilumab, mepolizumab, and benralizumab among patients with difficult-to-control asthma. Methods: Retrospective multicenter cohort study of adult patients with difficult-to-control asthma starting treatment with dupilumab, mepolizumab, or benralizumab as documented in a multicenter electronic health record and claims-based database between October 19, 2018, and September 30, 2022. Propensity-score matching was used to minimize bias from nonrandomized treatment assignment; a prespecified α-level was set at 0.017 to account for three primary comparisons. The exposure of interest was the new initiation of dupilumab, benralizumab, or mepolizumab treatment. The primary outcome was the rate of asthma exacerbations in the 1 year after initiation of biologic therapy modeled using a negative binomial approach. Results: Among 893,668 patients with asthma who were prescribed an inhaled corticosteroid and were ⩾12 years old (65% female; mean age, 49 yr), 3,943 started dupilumab, 1,902 started benralizumab, and 2,012 started mepolizumab, all without an alternative indication for biologic therapy. After matching, there were 1,805 patients in each group for comparisons between dupilumab and benralizumab, 1,865 for comparisons between dupilumab and mepolizumab, and 1,721 for comparisons between mepolizumab and benralizumab. For all pairwise comparisons, covariates were well balanced after matching (all standardized mean differences <0.1). Patients who initiated dupilumab had a significantly lower rate of asthma exacerbations (1.07 per year) compared with benralizumab (1.47 per year), with a rate ratio (RR) of 0.73 (95% confidence interval, 0.63-0.85), and also had a significantly lower rate of asthma exacerbations compared with mepolizumab (1.04 per year vs. 1.45 per year), with an RR of 0.72 (0.62-0.84). There was no statistically significant difference in the rate of asthma exacerbations between mepolizumab (1.40 per year) and benralizumab (1.41 per year), with an RR of 1.00 (0.85-1.17). Conclusions: In patients with difficult-to-control asthma who had newly initiated biologic therapy, dupilumab was associated with a decreased rate of asthma exacerbations in the 1 year after initiation compared with mepolizumab or benralizumab.

Ratio of plasma IL-13/TNF- ∝ and CXCL10/CCL17 predicts mepolizumab and omalizumab response in asthma better than eosinophil count or immunoglobulin E level

To date, most studies to identify biomarkers associated with response to the anti-interleukin 5 agent, mepolizumab, and to the anti-immunoglobulin E agent, omalizumab have focused on clinically available biomarkers, such as the peripheral blood eosinophil counts (BEC) and total immunoglobulin E (IgE). However, these biomarkers often have low predictive accuracy, with many patients with eosinophilic or allergic asthma failing to demonstrate clinical response to mepolizumab or omalizumab respectively. In this study, we evaluated the association of baseline pre-biologic plasma levels of 26 cytokines and chemokines, including T-helper 1 (Th1)-, Th2-, Th17-related cytokines, and their ratios with subsequent clinical response to mepolizumab or omalizumab. We defined clinical response as a reduction in the baseline annual exacerbation rate by half or more over the one-year period following initiation of the biologic. Baseline levels of plasma IL-13 were differentially elevated in responders versus non-responders to mepolizumab and plasma CXCL10 levels were differentially elevated in responders to omalizumab. The ratio of IL-13/TNF-α had the best sensitivity and specificity in predicting response to mepolizumab and CXCL10/CCL17 to omalizumab, and these performed better as predictive biomarkers of response than BEC and IgE. Cytokines and chemokines associated with airway eosinophilia, allergic inflammation, or Th2 inflammation, such as IL-13 and CXCL10, may be better predictors of clinical response to mepolizumab and omalizumab, than IL-5 or IgE, the targets of mepolizumab and omalizumab.

Lung function trajectories in a cohort of patients with moderate-to-severe asthma on mepolizumab, omalizumab, or dupilumab

BACKGROUND

Lung function is an independent predictor of mortality. We evaluated the lung function trajectories of a cohort of patients with asthma receiving biologic therapy.

METHODS

We identified 229 monoclonal antibody-naïve adult patients with moderate-to-severe asthma who initiated omalizumab, mepolizumab, or dupilumab between 2010 and 2022 in a large healthcare system in Boston, MA. Generalized additive mixed models were used to estimate the lung function trajectories during the 156 weeks following biologic initiation. Response was defined as an improvement in FEV1 or a decrease of ≤0.5% per year. The Kaplan-Meier estimator was used to assess time to no additional improvement in FEV1 in responders. All models were adjusted for age, sex, body mass index, smoking status, baseline exacerbation rate, and baseline blood eosinophil count.

RESULTS

Eighty-eight patients initiated mepolizumab, 76 omalizumab, and 65 dupilumab. Baseline eosinophil count was highest in the mepolizumab group (405 cells/mcL) and lowest for omalizumab (250 cells/mcL). Both FEV1 and FVC improved in the mepolizumab group (FEV1 + 20 mL/year; FVC +43 mL/year). For omalizumab, there was an initial improvement in the first year followed by decline with an overall FEV1 loss of -44 mL/year and FVC -32 mL/year. For dupilumab, both FEV1 (+61 mL/year) and FVC (+74 mL/year) improved over time. Fifty percent of the mepolizumab group, 58% omalizumab, and 72% of dupilumab were responders. The median time to no additional FEV1 improvement in responders was 24 weeks for omalizumab, 48 weeks for mepolizumab, and 57 weeks for dupilumab.

CONCLUSION

In this clinical cohort, mepolizumab, omalizumab, and dupilumab had beneficial effects on FEV1 and FVC with distinct post-initiation trajectories.

Making causal inferences from transactional data: A narrative review of opportunities and challenges when implementing the target trial framework

The target trial framework has emerged as a powerful tool for addressing causal questions in clinical practice and in public health. In the healthcare sector, where decision-making is increasingly data-driven, transactional databases, such as electronic health records (EHR) and insurance claims, present an untapped potential for answering complex causal questions. This narrative review explores the potential of the integration of the target trial framework with real-world data to enhance healthcare decision-making processes. We outline essential elements of the target trial framework, and identify pertinent challenges in data quality, privacy concerns, and methodological limitations, proposing solutions to overcome these obstacles and optimize the framework's application.

Future of biologics in pediatric asthma: Optimizing response, early introduction, and equitable access to treatment

OBJECTIVE

To evaluate the current evidence, its limitations, and future research directions for the use of biologics in pediatric asthma, with a particular focus on the potential use of biologics to prevent pediatric asthma and equity issues in access to biologic treatment and research participation.

DATA SOURCES

PubMed articles about the use of biologics in pediatric asthma were searched up to May 2023.

STUDY SELECTIONS

Recent (2019-2023) original research articles and reviews were prioritized.

RESULTS

Although there are now 5 U.S. Food and Drug Administration-approved biologics for use in pediatric asthma, there are important knowledge gaps that ongoing research seeks to address, which include (1) the long-term efficacy and safety of using biologics in children, (2) the comparative efficacy of different biologics, (3) multi-omics-based classification of asthma endotypes and phenotypes in children to find potential new therapeutic targets and enable identification and validation of new biomarkers that may predict and help monitor response to treatment, and (4) whether starting biologics in early childhood can modify the natural history of asthma and potentially prevent asthma development.

SUMMARY

To promote equitable access to biologics and optimize asthma outcomes, future research should recruit patients across the full spectrum of socioeconomic and racial/ethnic backgrounds. Large-scale national and international collaborations between asthma researchers and clinicians are also necessary to fully understand the role of biologics in pediatric asthma.

Revisiting asthma pharmacotherapy: where do we stand and where do we want to go?

Several current guidelines/strategies outline a treatment approach to asthma, which primarily consider the goals of improving lung function and quality of life and reducing symptoms and exacerbations. They suggest a strategy of stepping up or down treatment, depending on the patient's overall current asthma symptom control and future risk of exacerbation. While this stepwise approach is undeniably practical for daily practice, it does not always address the underlying mechanisms of this heterogeneous disease. In the last decade, there have been attempts to improve the treatment of severe asthma, such as the addition of a long-acting antimuscarinic agent to the traditional inhaled corticosteroid/long-acting β2-agonist treatment and the introduction of therapies targeting key cytokines. However, despite such strategies several unmet needs in this population remain, motivating research to identify novel targets and develop improved therapeutic and/or preventative asthma treatments. Pending the availability of such therapies, it is essential to re-evaluate the current conventional "one-size-fits-all" approach to a more precise asthma management. Although challenging, identifying "treatable traits" that contribute to respiratory symptoms in individual patients with asthma may allow a more pragmatic approach to establish more personalised therapeutic goals.

Baseline Characteristics of Patients Enrolled in Clinical Trials of Biologics for Severe Asthma as Potential Predictors of Outcomes

(1) Background: Over the past 20 years, monoclonal antibodies have been developed for the treatment of severe asthma, with numerous randomised controlled trials (RCTs) conducted to define their safety and efficacy. The growing availability of biologics, which until now have only been available for T2-high asthma, has been further enriched by the arrival of tezepelumab. (2) Methods: This review aims to evaluate the baseline characteristics of patients enrolled in RCTs of biologics for severe asthma to understand how they could potentially predict outcomes and how they can help differentiate between available options. (3) Results: The studies reviewed demonstrated that all biologic agents are effective in improving asthma control, especially with regard to reducing exacerbation rates and OCS use. As we have seen, in this regard, there are few data on omalizumab and none yet on tezepelumab. In analysing exacerbations and average doses of OCSs, pivotal studies on benralizumab have enrolled more seriously ill patients. Secondary outcomes, such as improvement in lung function and quality of life, showed better results-especially for dupilumab and tezepelumab. (4) Conclusion: Biologics are all effective, albeit with important differences. What fundamentally guides the choice is the patient's clinical history, the endotype represented by biomarkers (especially blood eosinophils), and comorbidities (especially nasal polyposis).