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Nopsopon T, Brown A, Hahn G, Rank M, Huybrechts KF, Akenroye A. Temporal variation in the effectiveness of biologics in asthma: Effect modification by changing patient characteristics. Respir Med 2024; 234:107802. [PMID: 39260678 DOI: 10.1016/j.rmed.2024.107802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2024] [Revised: 08/19/2024] [Accepted: 09/06/2024] [Indexed: 09/13/2024]
Abstract
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.
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Affiliation(s)
- Tanawin Nopsopon
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Alyson Brown
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Georg Hahn
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Matthew Rank
- Mayo Clinic in Arizona and Phoenix Children's Hospital, Scottsdale and Phoenix, AZ, USA
| | - Krista F Huybrechts
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Ayobami Akenroye
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA; Channing Division of Network Medicine, Brigham and Women's Hospital, Boston, MA, USA.
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Abu Elhassan U, Al-Mani SY, Alqahtani SMA, Elnamaky M, Alfaifi A, Alshehri MA, Alasiri HA, Kadasah AS, Musleh A, Alshafa FA, Qureshi MSS, Assiri AY, Falqi AI, Asiri BI, Ahmed HMO, Alshehry S, Abdalla AM. 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. Multidiscip Respir Med 2024; 19. [PMID: 39250180 DOI: 10.5826/mrm.2024.985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2024] [Accepted: 08/05/2024] [Indexed: 09/10/2024] Open
Abstract
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.
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Affiliation(s)
- Usama Abu Elhassan
- Assistant Professor of Pulmonary Medicine, Department of Pulmonary Medicine, Faculty of Medicine, Cairo University, Cairo, Egypt. Consultant of Pulmonary Medicine, Department of Internal Medicine, Armed Forces Hospital Southern Region (AFHSR), Khamis Mushayt, Saudi Arabia
| | - Salihah Y Al-Mani
- Department of Internal Medicine, Armed Forces Hospital Southern Region (AFHSR), Khamis Mushayt, Saudi Arabia
| | - Saad M A Alqahtani
- Department of Internal Medicine, Armed Forces Hospital Southern Region (AFHSR), Khamis Mushayt, Saudi Arabia
| | - Medhat Elnamaky
- Department of Internal Medicine, Armed Forces Hospital Southern Region (AFHSR), Khamis Mushayt, Saudi Arabia. Department of Pulmonary Medicine, Faculty of Medicine, Al-Azhar University, Assiut Branch, Assiut, Egypt
| | - Abdulaziz Alfaifi
- Department of Internal Medicine, Armed Forces Hospital Southern Region (AFHSR), Khamis Mushayt, Saudi Arabia
| | - Mohammed A Alshehri
- 2Department of Internal Medicine, Armed Forces Hospital Southern Region (AFHSR), Khamis Mushayt, Saudi Arabia
| | - Haneen A Alasiri
- 2Department of Internal Medicine, Armed Forces Hospital Southern Region (AFHSR), Khamis Mushayt, Saudi Arabia
| | - Ali S Kadasah
- 2Department of Internal Medicine, Armed Forces Hospital Southern Region (AFHSR), Khamis Mushayt, Saudi Arabia
| | - Abdullah Musleh
- Otorhinolaryngology Division, Surgery Department, College of Medicine, King Khalid University, Abha, Saudi Arabia
| | - Fawwaz A Alshafa
- Department of Internal Medicine, Armed Forces Hospital Southern Region (AFHSR), Khamis Mushayt, Saudi Arabia
| | - Muhammad S S Qureshi
- Department of Internal Medicine, Armed Forces Hospital Southern Region (AFHSR), Khamis Mushayt, Saudi Arabia
| | - Abdulmohsen Y Assiri
- Pharmaceutical Care Administration, Armed Forces Hospital Southern Region (AFHSR), Khamis Mushayt, Saudi Arabia
| | - Abdulrahman I Falqi
- Pharmaceutical Care Administration, Armed Forces Hospital Southern Region (AFHSR), Khamis Mushayt, Saudi Arabia
| | - Bader I Asiri
- Department of Internal Medicine, Armed Forces Hospital Southern Region (AFHSR), Khamis Mushayt, Saudi Arabia
| | - Haider M O Ahmed
- Department of Internal Medicine, Armed Forces Hospital Southern Region (AFHSR), Khamis Mushayt, Saudi Arabia
| | - Saleem Alshehry
- Internal Medicine Department, College of Medicine, King Khalid University, Abha, Saudi Arabia
| | - Abdelrahman M Abdalla
- Department of Pulmonary Medicine, Faculty of Medicine, Beni Seuf University, Egypt. 2Department of Internal Medicine, Armed Forces Hospital Southern Region (AFHSR), Khamis Mushayt, Saudi Arabia
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Akenroye A, Hvisdas C, Stern J, Jackson JW, Louisias M. Race and ethnicity, not just insurance, is associated with biologics initiation in asthma and related conditions. J Allergy Clin Immunol 2024:S0091-6749(24)00780-2. [PMID: 39116950 DOI: 10.1016/j.jaci.2024.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Revised: 07/17/2024] [Accepted: 08/02/2024] [Indexed: 08/10/2024]
Abstract
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.
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Affiliation(s)
- Ayobami Akenroye
- Division of Allergy and Clinical Immunology, Department of Medicine, Brigham and Women's Hospital, Boston, Mass; Channing Division of Network Medicine, Brigham and Women's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass.
| | | | - Jessica Stern
- Division of Allergy, Immunology and Rheumatology, Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - John W Jackson
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Md
| | - Margee Louisias
- Division of Allergy and Clinical Immunology, Department of Medicine, Brigham and Women's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass
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Bernstein JA, Silver J, Packnett E, Lew CR, Robles Y, Deb A. Real-world unified airway benefits of mepolizumab: Effectiveness in patients with asthma and comorbid nasal polyps. Ann Allergy Asthma Immunol 2024:S1081-1206(24)00421-6. [PMID: 38972449 DOI: 10.1016/j.anai.2024.06.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Revised: 06/28/2024] [Accepted: 06/28/2024] [Indexed: 07/09/2024]
Abstract
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.
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Affiliation(s)
| | - Jared Silver
- US Medical Affairs-Respiratory, GSK, Durham, North Carolina
| | | | | | | | - Arijita Deb
- US Value Evidence and Outcomes, GSK, Upper Providence, Pennsylvania.
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Akenroye A, Keet C. Emulating Hypothetical Target Trials of the Broad-Spectrum T2 Biologic Dupilumab. Ann Am Thorac Soc 2024; 21:1111-1112. [PMID: 38949603 DOI: 10.1513/annalsats.202403-268le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/02/2024] Open
Affiliation(s)
| | - Corinne Keet
- University of North Carolina Chapel Hill, North Carolina
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Shim D, Bak Y, Choi HG, Lee S, Park SC. Effects of Panax species and their bioactive components on allergic airway diseases. J Ginseng Res 2024; 48:354-365. [PMID: 39036733 PMCID: PMC11258390 DOI: 10.1016/j.jgr.2024.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 04/17/2024] [Accepted: 04/17/2024] [Indexed: 07/23/2024] Open
Abstract
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.
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Affiliation(s)
- Dahee Shim
- Industry-Academic Cooperation Foundation, Hallym University, Chuncheon, Republic of Korea
| | - Yeeun Bak
- Department of Biomedical Science, Hallym University College of Medicine, Chuncheon, Republic of Korea
| | - Han-Gyu Choi
- Department of Microbiology and Medical Science, College of Medicine, Chungnam National University, Daejeon, Republic of Korea
| | - Seunghyun Lee
- Department of Microbiology, Institute for Immunology and Immunological Disease, Graduate School of Medical Science, Brain Korea 21 Project, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sang Chul Park
- Department of Otorhinolaryngology-Head and Neck Surgery, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
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Shu J, Xie W, Chen Z, Offringa R, Hu Y, Mei H. The enchanting canvas of CAR technology: Unveiling its wonders in non-neoplastic diseases. MED 2024; 5:495-529. [PMID: 38608709 DOI: 10.1016/j.medj.2024.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Revised: 12/08/2023] [Accepted: 03/19/2024] [Indexed: 04/14/2024]
Abstract
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.
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Affiliation(s)
- Jinhui Shu
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, Hubei 430022, China; Hubei Clinical Medical Center of Cell Therapy for Neoplastic Disease, Wuhan 430022, China
| | - Wei Xie
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, Hubei 430022, China; Hubei Clinical Medical Center of Cell Therapy for Neoplastic Disease, Wuhan 430022, China
| | - Zhaozhao Chen
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, Hubei 430022, China; Hubei Clinical Medical Center of Cell Therapy for Neoplastic Disease, Wuhan 430022, China
| | - Rienk Offringa
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, 69120 Heidelberg, Germany; Division of Molecular Oncology of Gastrointestinal Tumors, German Cancer Research Center, 69120 Heidelberg, Germany
| | - Yu Hu
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, Hubei 430022, China; Hubei Clinical Medical Center of Cell Therapy for Neoplastic Disease, Wuhan 430022, China
| | - Heng Mei
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, Hubei 430022, China; Hubei Clinical Medical Center of Cell Therapy for Neoplastic Disease, Wuhan 430022, China.
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Valery S, Simon-Tillaux N, Devouassoux G, Bonniaud P, Beurnier A, Boudjemaa A, Chenivesse C, Bourdin A, Gauquelin L, Guillo S, Taillé C, Estellat C. Anti-IL-4R versus anti-IL-5/5R after anti-IL-5/5R failure in asthma: An emulated target trial. J Allergy Clin Immunol 2024:S0091-6749(24)00567-0. [PMID: 38848878 DOI: 10.1016/j.jaci.2024.05.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Revised: 04/27/2024] [Accepted: 05/16/2024] [Indexed: 06/09/2024]
Abstract
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.
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Affiliation(s)
- Solène Valery
- Service de Pneumologie et Centre de référence pour les maladies respiratoires rares, Hôpital Bichat, AP-HP Nord-Université Paris Cité, Paris, France; UMR 1152, Paris, France; CRISALIS F-CRIN Network, Toulouse, France; Sorbonne Université, INSERM, Institut Pierre Louis d'Épidémiologie et de Santé Publique, équipe PEPITES, AP-HP, Hôpital Pitié-Salpêtrière, Département de Santé Publique, Centre de Pharmacoépidémiologie (Cephepi), Paris, France
| | - Noémie Simon-Tillaux
- Equipe 2-Oncostat U1018, Inserm, University Paris-Saclay, labeled Ligue Contre le Cancer, Department of Biostatistics and Epidemiology, Gustave Roussy, Villejuif, France
| | - Gilles Devouassoux
- CRISALIS F-CRIN Network, Toulouse, France; Service de Pneumologie, Hôpital de la Croix Rousse, Lyon, France
| | - Philippe Bonniaud
- CRISALIS F-CRIN Network, Toulouse, France; Service de Pneumologie et Soins Intensifs Respiratoire, Centre Hospitalier Universitaire de Bourgogne, Dijon, France; INSERM U1231, Equipe HSP-pathies, Faculty of Medicine and Pharmacy, University of Bourgogne-Franche Comté, Dijon, France
| | - Antoine Beurnier
- CRISALIS F-CRIN Network, Toulouse, France; Department of Respiratory and Intensive Care Medicine, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Amel Boudjemaa
- Service de pneumologie, Centre Hospitalier intercommunal de Créteil, Créteil, France
| | - Cécile Chenivesse
- CRISALIS F-CRIN Network, Toulouse, France; Université de Lille, CNRS, Inserm, CHU Lille, Service de Pneumologie et Immuno-Allergologie, U1019 - UMR 9017- CIIL - Center for Infection and Immunity of Lille, Lille, France
| | - Arnaud Bourdin
- CRISALIS F-CRIN Network, Toulouse, France; Department of Respiratory Diseases, University of Montpellier, Montpellier, France; PhyMedExp, University of Montpellier, CNRS, INSERM CHU Montpellier, Montpellier, France
| | - Lisa Gauquelin
- Sorbonne Université, INSERM, Institut Pierre Louis d'Épidémiologie et de Santé Publique, équipe PEPITES, AP-HP, Hôpital Pitié-Salpêtrière, Département de Santé Publique, Centre de Pharmacoépidémiologie (Cephepi), Paris, France
| | - Sylvie Guillo
- Sorbonne Université, INSERM, Institut Pierre Louis d'Épidémiologie et de Santé Publique, équipe PEPITES, AP-HP, Hôpital Pitié-Salpêtrière, Département de Santé Publique, Centre de Pharmacoépidémiologie (Cephepi), Paris, France
| | - Camille Taillé
- Service de Pneumologie et Centre de référence pour les maladies respiratoires rares, Hôpital Bichat, AP-HP Nord-Université Paris Cité, Paris, France; UMR 1152, Paris, France; CRISALIS F-CRIN Network, Toulouse, France
| | - Candice Estellat
- Sorbonne Université, INSERM, Institut Pierre Louis d'Épidémiologie et de Santé Publique, équipe PEPITES, AP-HP, Hôpital Pitié-Salpêtrière, Département de Santé Publique, Centre de Pharmacoépidémiologie (Cephepi), Paris, France.
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Akenroye A, Marshall J, Simon AL, Hague C, Costa R, Jamal-Allial A, McMahill-Walraven CN, Haffenreffer K, Han A, Wu AC. Smaller Differences in the Comparative Effectiveness of Biologics in Reducing Asthma-Related Hospitalizations Compared With Overall Exacerbations. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:1568-1574.e2. [PMID: 38431251 DOI: 10.1016/j.jaip.2024.02.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Revised: 02/22/2024] [Accepted: 02/23/2024] [Indexed: 03/05/2024]
Abstract
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.
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Affiliation(s)
- Ayobami Akenroye
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass; Channing Division of Network Medicine, Brigham and Women's Hospital, Boston, Mass; Department of Medicine, Harvard Medical School, Boston, Mass.
| | - James Marshall
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Mass
| | - Andrew L Simon
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Mass
| | - Christian Hague
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Mass
| | - Rebecca Costa
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Mass
| | | | | | - Katie Haffenreffer
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Mass
| | - Amy Han
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Mass
| | - Ann Chen Wu
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Mass
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10
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Kearney CM, Sangani R, Shankar D, O’Connor GT, Law AC, Walkey AJ, Bosch NA. Comparative Effectiveness of Mepolizumab, Benralizumab, and Dupilumab among Patients with Difficult-to-Control Asthma: A Multicenter Retrospective Propensity-matched Analysis. Ann Am Thorac Soc 2024; 21:866-874. [PMID: 38241013 PMCID: PMC11160126 DOI: 10.1513/annalsats.202306-566oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 01/18/2024] [Indexed: 01/25/2024] Open
Abstract
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.
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Affiliation(s)
| | | | - Divya Shankar
- The Pulmonary Center, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - George T. O’Connor
- The Pulmonary Center, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Anica C. Law
- The Pulmonary Center, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | | | - Nicholas A. Bosch
- The Pulmonary Center, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
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11
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Akenroye A, Nopsopon T, Hacker JJ, Laidlaw TM. Ratio of plasma IL-13/TNF- ∝ and CXCL10/CCL17 predicts mepolizumab and omalizumab response in asthma better than eosinophil count or immunoglobulin E level. Sci Rep 2024; 14:10404. [PMID: 38710930 PMCID: PMC11074109 DOI: 10.1038/s41598-024-60864-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Accepted: 04/29/2024] [Indexed: 05/08/2024] Open
Abstract
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.
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Affiliation(s)
- Ayobami Akenroye
- Division of Allergy and Clinical Immunology, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, 60 Fenwood Road, Boston, MA, 02115, USA.
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.
| | - Tanawin Nopsopon
- Division of Allergy and Clinical Immunology, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, 60 Fenwood Road, Boston, MA, 02115, USA
| | - Jonathan J Hacker
- Division of Allergy and Clinical Immunology, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, 60 Fenwood Road, Boston, MA, 02115, USA
| | - Tanya M Laidlaw
- Division of Allergy and Clinical Immunology, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, 60 Fenwood Road, Boston, MA, 02115, USA
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12
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Nopsopon T, Barrett NA, Phipatanakul W, Laidlaw TM, Weiss ST, Akenroye A. Lung function trajectories in a cohort of patients with moderate-to-severe asthma on mepolizumab, omalizumab, or dupilumab. Allergy 2024; 79:1195-1207. [PMID: 38164813 PMCID: PMC11062846 DOI: 10.1111/all.16002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 11/15/2023] [Accepted: 12/17/2023] [Indexed: 01/03/2024]
Abstract
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.
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Affiliation(s)
- Tanawin Nopsopon
- Division of Allergy and Clinical Immunology, Brigham and Women’s Hospital, Boston, MA
| | - Nora A. Barrett
- Division of Allergy and Clinical Immunology, Brigham and Women’s Hospital, Boston, MA
| | | | - Tanya M. Laidlaw
- Division of Allergy and Clinical Immunology, Brigham and Women’s Hospital, Boston, MA
| | - Scott T. Weiss
- Channing Division of Network Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Ayobami Akenroye
- Division of Allergy and Clinical Immunology, Brigham and Women’s Hospital, Boston, MA
- Channing Division of Network Medicine, Brigham and Women’s Hospital, Boston, MA
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13
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Inan MI, Balaban YA. Comment on case of benralizumab-induced exacerbations of chronic spontaneous urticaria. Clin Case Rep 2024; 12:e8802. [PMID: 38634097 PMCID: PMC11022288 DOI: 10.1002/ccr3.8802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2024] [Accepted: 03/27/2024] [Indexed: 04/19/2024] Open
Affiliation(s)
- Mustafa Ilker Inan
- Division of Immunology and Allergic DiseasesAnkara Gulhane Training And Research HospitalAnkaraTurkey
| | - Yasemin Akgul Balaban
- Division of Immunology and Allergic DiseasesAnkara Gulhane Training And Research HospitalAnkaraTurkey
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14
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Esteban S, Szmulewicz A. Making causal inferences from transactional data: A narrative review of opportunities and challenges when implementing the target trial framework. J Int Med Res 2024; 52:3000605241241920. [PMID: 38548473 PMCID: PMC10981242 DOI: 10.1177/03000605241241920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 03/10/2024] [Indexed: 04/01/2024] Open
Abstract
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.
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Affiliation(s)
- Santiago Esteban
- Instituto de Efectividad Clínica y Sanitaria, Centro de Implementación e Innovación en Políticas de Salud, Buenos Aires, Argentina
- Hospital Italiano de Buenos Aires, Family and Community Medicine Division Buenos Aires, Buenos Aires, Argentina
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15
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Schepel IRM, Banzon TM, Phipatanakul W. Future of biologics in pediatric asthma: Optimizing response, early introduction, and equitable access to treatment. Ann Allergy Asthma Immunol 2024; 132:13-20. [PMID: 37652232 PMCID: PMC10842489 DOI: 10.1016/j.anai.2023.08.597] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Revised: 08/13/2023] [Accepted: 08/21/2023] [Indexed: 09/02/2023]
Abstract
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.
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Affiliation(s)
- Ianthe R M Schepel
- Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Tina M Banzon
- Division of Allergy and Immunology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Wanda Phipatanakul
- Division of Allergy and Immunology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts.
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16
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Cazzola M, Page CP, Matera MG, Rogliani P, Hanania NA. Revisiting asthma pharmacotherapy: where do we stand and where do we want to go? Eur Respir J 2023; 62:2300700. [PMID: 37474159 DOI: 10.1183/13993003.00700-2023] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 06/25/2023] [Indexed: 07/22/2023]
Abstract
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.
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Affiliation(s)
- Mario Cazzola
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Clive P Page
- Sackler Institute of Pulmonary Pharmacology, Institute of Pharmaceutical Science, King's College London, London, UK
| | - Maria Gabriella Matera
- Unit of Pharmacology, Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Paola Rogliani
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Nicola A Hanania
- Section of Pulmonary and Critical Care Medicine, Baylor College of Medicine, Houston, TX, USA
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17
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Baseline Characteristics of Patients Enrolled in Clinical Trials of Biologics for Severe Asthma as Potential Predictors of Outcomes. J Clin Med 2023; 12:jcm12041546. [PMID: 36836079 PMCID: PMC9960148 DOI: 10.3390/jcm12041546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 02/12/2023] [Accepted: 02/15/2023] [Indexed: 02/18/2023] Open
Abstract
(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).
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