Severe asthma: oral corticosteroid alternatives and the need for optimal referral pathways

Asthma control and opportunities to optimize management and the healthcare provider experience using the AsthmaOptimiser online tool in Dutch general practice: the CAPTURE study

Patients seen in general practices can achieve improved asthma control with better identification of factors that contribute to uncontrolled asthma. Information is lacking on the proportion of patients with uncontrolled asthma, associated patient characteristics, and opportunities to improve management. The objectives of this study were to determine the proportion of general practice patients with uncontrolled asthma, as assessed during a regular consultation with the AsthmaOptimiser digital tool, identify the opportunities for improved management, and to evaluate the usability of this tool which is based on treatment recommendations from GINA. The CAPTURE study was a non-interventional, prospective, observational study of the AsthmaOptimiser in general practice settings in the Netherlands. Patients were at least 18 years of age with an asthma diagnosis. A total of 34 Dutch general practitioners or nurse practitioners participated in the study and planned to use the AsthmaOptimiser with 5 to 10 adult patients per practice. Interviews were conducted to gather information from practitioners about the tool's usability, its content, and areas for improvement. Of the 220 patients enrolled, 60% had uncontrolled asthma, of whom 64% had opportunities for management improvement that could be initiated during a primary care visit. Specialist referrals were advisable according to the AsthmaOptimiser in 45 patients with uncontrolled asthma. Practitioners reported that the AsthmaOptimiser was an added value and had suggestions on how to improve the tool. In Dutch general practices, the AsthmaOptimiser helped general practitioners identify opportunities for improved disease management by addressing poor disease control. Overall, the general practitioners found the AsthmaOptimiser easy to use and a good addition to asthma consultations.

Modelling Adverse Events in Patients Receiving Chronic Oral Corticosteroids in the UK

BACKGROUND

Oral corticosteroids (OCS) are effective anti-inflammatory agents used across a range of conditions. However, substantial evidence associates their use with increased risks for adverse events (AEs), causing high burden on healthcare resources. Emerging biologics present as alternative agents, enabling the reduction of OCS use. However, current modelling approaches may underestimate their effects by not capturing OCS-sparing effects. In this study, we present a modelling approach designed to capture the health economic benefits of OCS-sparing regimens and agents.

METHODS

We developed a disease-agnostic model using a UK health technology assessment (HTA) perspective, with discounting of 3.5% for costs and outcomes, a lifetime horizon, and 4-week cycle length. The model structure included type 2 diabetes mellitus, established cardiovascular disease, and osteoporosis as key AEs and drivers of morbidity and mortality, as well as capturing transient events. Quality-adjusted life-years (QALYs), life-years, and costs were determined for OCS-only and OCS-sparing treatment arms. Outcomes were determined using baseline 50% OCS-sparing, considering several OCS average daily doses (5, 10, 15 mg).

RESULTS

A treatment regimen with 50% OCS dose-sparing led to lifetime incremental cost savings per patient of £1107 (95% confidence interval £1014-£1229) at 5 mg, £2403 (£2203-£2668) at 10 mg, and £19,501 (£748-£51,836) at 15 mg. Patients also gained 0.033 (0.030-0.036) to 0.356 (0.022-2.404) QALYs dependent on dose. The benefits of OCS sparing were long-term, plateauing after 35-40 years of treatment.

CONCLUSIONS

We present a modelling approach that captures additional long-term health economic benefits from OCS sparing that would otherwise be missed from current modelling approaches. These results may help inform future decision making for emerging OCS-sparing therapeutics by comparing them against the cost of such treatments.

The Path to Diagnosis of Severe Asthma-A Qualitative Exploration

Purpose

Severe asthma poses a significant health burden in those with the disease, therefore a timely diagnosis can ensure patients receive specialist care and appropriate medication management. This study qualitatively explored the patient experience of adult Australians with severe asthma regarding specialist referral, to identify potential opportunities to streamline the process of severe asthma diagnosis and treatment and optimise referral pathways.

Patients and Methods

Adults currently being treated with medication for severe asthma were invited to participate in this study. Participants were interviewed and asked to describe initial diagnosis of their asthma or severe asthma, and how they came to be referred to secondary care. Interviews were transcribed verbatim, coded by two members of the research team and thematically analysed.

Results

Thirty-two people completed the study; 72% were female. Mean interview length was 33 minutes. The major themes generated were patient-related factors contributing to seeking a severe asthma diagnosis; perceptions of health care provision; diagnosis of severe asthma and the referral journey. Key findings were that both patient and healthcare provider attitudes contributed to participants' willingness to seek or receive a referral, and referral to respiratory specialists was often delayed. Contributing factors included a mismatch between patient expectations and general practice, lack of continuity of primary care, and a lack of patient understanding of the role of the respiratory specialist.

Conclusion

Timely severe asthma diagnosis in Australia appears to be hampered by an absence of a clear referral process, lack of general practitioner (GP) knowledge of additional treatment options, underutilisation of pharmacists, and multiple specialists treating patient comorbidities. Directions for future research might include interviewing healthcare providers regarding how well the referral process works for severe asthma patients, and researching the time between referral and when a patient sees the respiratory specialist.

Prevalence and characteristics in long COVID among adults with asthma in the United States

OBJECTIVE

The purpose of this study was to assess: (1) the prevalence of long COVID by asthma status, and (2) the characteristics associated with developing long COVID among adults with asthma in the United States.

METHODS

Data from the 2022 National Health Interview Survey were used. The prevalence of long COVID was reported and stratified by asthma status. The multivariable logistic regression model was conducted to identify the factors associated with developing long COVID.

RESULTS

In 2022, the overall prevalence of long COVID among U.S. adults was 6.9%. When stratified by asthma status, the prevalence of long COVID was 13.9% among adults with asthma, and 6.2% among adults without asthma. Among adults with asthma, certain characteristics, including age over 55 years, female sex, obesity, problems paying medical bills and a history of asthma attacks, were significantly associated with developing long COVID.

CONCLUSIONS

This study revealed that the prevalence of long COVID among adults with asthma was much higher than the general adult population in the United States. The limited validity of the collected information in this study should prompt caution when interpreting our findings. Further studies on the association between asthma and long COVID could be valuable for the clinical practice.

Health Insurance Type and Outpatient Specialist Care Among Children With Asthma

Importance

Although children with asthma are often successfully treated by primary care clinicians, outpatient specialist care is recommended for those with poorly controlled disease. Little is known about differences in specialist use for asthma among children with Medicaid vs private insurance.

Objective

To examine differences among children with asthma regarding receipt of asthma specialist care by insurance type.

Design, Setting, and Participants

In this cross-sectional study using data from the Massachusetts All Payer Claims Database (APCD) between 2014 to 2020, children with asthma were identified and differences in receipt of outpatient specialist care by whether their insurance was public (Medicaid and the Children's Health Insurance Program) or private were examined. Eligible participants included children with asthma in 2015 to 2020 aged 2 to 17 years. Data analysis was conducted from January 2023 to April 2024.

Exposure

Medicaid vs private insurance.

Main Outcomes and Measures

The primary outcome was receipt of specialist care (any outpatient visit with a pulmonology, allergy and immunology, or otolaryngology physician). Multivariable logistic regression models estimated differences in receipt of specialist care by insurance type accounting for child and area characteristics including demographics, health status, persistent asthma, calendar year, and zip code characteristics. Additional analyses examined if the associations of specialist care with insurance type varied by asthma persistence and severity, and whether associations varied over time.

Results

Among 198 101 unique children, there were 432 455 child-year observations (186 296 female [43.1%] and 246 159 male [56.9%]; 211 269 aged 5 to 11 years [48.9%]; 82 108 [19.0%] with persistent asthma) including 286 408 (66.2%) that were Medicaid insured and 146 047 (33.8%) that were privately insured. Although persistent asthma was more common among child-year observations with Medicaid vs private insurance (57 381 [20.0%] vs 24 727 [16.9%]), children with Medicaid were less likely to receive specialist care. Overall, 64 239 child-year observations (14.9%) received specialist care, with substantially lower rates for children with Medicaid vs private insurance (34 093 child-year observations [11.9%] vs 30 146 child-year observations [20.6%]). Regression-based estimates confirmed these disparities; children with Medicaid had 55% lower odds of receiving specialist care (adjusted odds ratio, 0.45; 95% CI, 0.43 to 0.47) and a regression-adjusted 9.7 percentage point (95% CI, -10.4 percentage points to -9.1 percentage points) lower rate of receipt of specialist care. Compared with children with private insurance, there was an additional 3.2 percentage point (95% CI, 2.0 percentage points to 4.4 percentage points) deficit for children with Medicaid with persistent asthma.

Conclusions and Relevance

In this cross-sectional study, children with Medicaid were less likely to receive specialist care, with the largest gaps among those with persistent asthma. These findings suggest that closing this care gap may be one approach to addressing ongoing disparities in asthma outcomes.

The Effects of Benralizumab on Lung Volumes and Airway Resistance in Severe Eosinophilic Asthma: A Real-World Study

INTRODUCTION

Add-on biological monoclonal antibodies such as benralizumab (anti-IL-5Ra) are recommended by international guidelines to reduce exacerbations in severe eosinophilic asthma (SEA). However, few studies have assessed the impact of these therapies on lung function-related outcomes. Our goal was to evaluate the effectiveness of benralizumab on lung function, including lung volumes and airway resistance, in SEA patients in Portugal.

METHODS

This was a real-world, observational, prospective, multicentric study including adult patients diagnosed with SEA (January-June 2023). Spirometry and plethysmography were performed at baseline (T0) and after six months of treatment (T6) with benralizumab to assess: total lung capacity (TLC), residual volume (RV), forced expiratory volume in one second (FEV1), forced vital capacity (FVC), mean forced expiratory flow between 25% and 75% of FVC (mFEF-25/75), intrathoracic gas volume (ITGV), and respiratory airway resistance (Raw). Descriptive statistics (with categorical variables described as frequencies and continuous values as mean and standard deviation (SD)) and paired t-test and Cohen's d effect size were calculated (analyses performed in StataCorp v.15.1; StataCorp LLC, TX, USA).

RESULTS

Overall, 30 SEA patients were evaluated, mostly women (n=18, 60.0%), with atopy (n=22, 73.3%), a mean age of 58.4 years (SD 11.7), and assisted by pulmonology (n=19, 63.3%) or immunology-allergology (n=11, 36.7%) services. Mean eosinophilia at baseline was 1103.57 cells/mcL (SD 604.88; minimum-maximum 460-2400); after the use of benralizumab, the count dropped to zero. After six months of treatment, a significant increase (p<0.0001) in FVC (15.3%), FEV1 (22.6%), and mFEF-25/75 (17.7%) were observed from baseline (Cohen's d between 0.78 and 1.11). ITGV, RV, RV/TLC, and Raw significantly decreased (p<0.0001) during the study period (-17.3%, -29.7%, -8.9%, and -100.6%, respectively) (Cohen's d between -0.79 and -1.06). No differences in TLC were obtained (p=0.173). No differences between sexes were observed for any measure. Patients with more significant eosinophilia (>900 cells/mcL count; n=15) presented better responses in FEV1 (p=0.001) and mFEF-25/75 (p=0.007).

CONCLUSIONS

A notable eosinophil depletion with add-on benralizumab led to significant improvements in SEA patients' respiratory function (static lung volumes and airway resistance) in real-world settings after six months. The significant deflating effect of benralizumab on patients' hyperinflated lungs led to enhanced expiratory flow (increased FEV1 and mFEF-25/75) and air trapping (decreased RV/TLC), suggesting this antibody improves bronchial obstruction, lung hyperinflation, and airway resistance. Further studies in a larger population are required to confirm these findings.

A cost comparison of benralizumab, mepolizumab, and dupilumab in patients with severe asthma: A US third-party payer perspective

BACKGROUND: Clinical trials and real-world evidence (RWE) studies of biologics have demonstrated reduced exacerbations, decreased use of oral corticosteroids (OCS), and improvements in daily symptoms and health-related quality of life in patients with severe eosinophilic asthma (SEA). OBJECTIVE: To compare direct health care costs associated with biologic use for the treatment of SEA from a US third-party payer perspective. METHODS: We developed a cost-minimization model to compare costs and cost offsets associated with 3 biologics-benralizumab, mepolizumab, and dupilumab-for 2- and 4-year periods. The model relied on longitudinal data from clinical trials to inform the primary (base case) analysis cost comparison and RWE study data, in a separate scenario, to compare costs in nonclinical trial settings. Primary model outcomes included exacerbations (including hospitalizations), OCS-dependent years (including associated complications), and total direct health care biologic costs. Results were calculated at the per patient and population level (per 1,000 patients). Sensitivity analyses with key model parameters were performed. RESULTS: Benralizumab had the lowest total biologic costs per patient for both the 2- and 4-year periods. Over 4 years, the marginal cost difference in total biologic costs per patient was $23,061 lower for benralizumab vs mepolizumab and $17,242 lower for benralizumab vs dupilumab. The 4-year population level analysis of benralizumab vs mepolizumab revealed $4.8 million in marginal cost offsets due to 582 fewer exacerbations and 153 fewer OCS-dependent years and a marginal total cost savings of $27.9 million per 1,000 patients for benralizumab. The 4-year population level analysis of benralizumab vs dupilumab revealed $2.3 million in marginal cost offsets due to 291 fewer exacerbations and 64 fewer OCS-dependent years and marginal total cost savings of $19.5 million per 1,000 patients for benralizumab. RWE data were available for a 2-year cost comparison scenario of benralizumab vs mepolizumab, which showed similar results to the base case analysis. Sensitivity analyses varying assumptions on key model parameter estimates confirmed results, with benralizumab having lower total direct health care costs in all scenarios tested, and showed that model results were most sensitive to changes in biologic costs and exacerbation reduction rates. CONCLUSIONS: Patients receiving benralizumab had higher nonbiologic cost offsets because of reductions in exacerbations and OCS-dependent years, leading to greater cost savings for third-party payers compared with patients receiving mepolizumab or dupilumab. Taken together with biologic costs, benralizumab presents greater savings in health care costs for payers than patients with SEA who use mepolizumab or dupilumab. DISCLOSURES: This study was funded by AstraZeneca (Cambridge, UK). Drs Xu, Chung, Genofre, and Katial are or were AstraZeneca employees at the time this research was conducted and may be shareholders of AstraZeneca. Ms Schaefer and Dr Szende are employees of Labcorp Drug Development, which received funding from AstraZeneca to perform this research.

Long-term efficacy of dupilumab in severe asthma by baseline oral corticosteroid dose

Background

Dupilumab has been shown to improve clinical outcomes long term while reducing oral corticosteroid (OCS) dose in patients with severe OCS-dependent asthma. This post hoc analysis assesses the impact of OCS dose at baseline (≤10 or >10 mg·day-1) on long-term outcomes of dupilumab treatment.

Methods

Annualised severe asthma exacerbation rates, forced expiratory volume in 1 s (FEV1), measures of asthma control and quality of life, and OCS dose were evaluated in patients from the phase 3 VENTURE trial with severe OCS-dependent asthma, further categorised by OCS dose ≤10 or >10 mg·day-1 at parent study baseline (PSBL), who enrolled in TRAVERSE.

Results

Dupilumab reduced the annualised exacerbation rate in VENTURE, and it remained low throughout TRAVERSE (0.202-0.265 (OCS ≤10 mg·day-1 at PSBL) and 0.221-0.366 (OCS >10 mg·day-1 at PSBL)). Improvements in pre-bronchodilator FEV1, asthma control and quality of life observed in VENTURE dupilumab patients were sustained throughout TRAVERSE. Patients on placebo during VENTURE showed rapid improvements in FEV1 upon initiating dupilumab in TRAVERSE, which were sustained to the end of TRAVERSE. Reductions in OCS dose observed in VENTURE were maintained throughout TRAVERSE, with more than two-thirds of patients achieving reductions in OCS doses to ≤5 mg·day-1 by TRAVERSE week 48.

Conclusions

Improvements in clinical outcomes and reductions in OCS dose with dupilumab observed in VENTURE were maintained throughout TRAVERSE, regardless of baseline disease severity. Patients who switched from placebo in VENTURE to dupilumab in TRAVERSE had improved clinical outcomes and reductions in OCS dose comparable to those given dupilumab in VENTURE.

miRNAs as Modern Biomarkers in Asthma Therapy

Asthma is a chronic inflammatory disease of the airways characterized by shortness of breath, chest tightness, coughing, and wheezing. For several decades (approximately 30 years), miRNAs and their role in asthma have been of constant interest among scientists. These small, non-coding RNA fragments, 18-25 nucleotides long, regulate gene expression at the post-transcriptional level by binding to the target mRNA. In this way, they affect several biological processes, e.g., shaping airway structures, producing cytokines and immune mediators, and controlling defense mechanisms. Publications confirm their potential role in the diagnosis and monitoring of the disease, but only some articles address the use of miRNAs in the treatment of asthma. The following paper reviews the latest available studies and presents miRNAs as a useful tool for predicting the effectiveness of the included treatment, early diagnosis of exacerbations, and in assessing patient compliance for different groups of drugs used in asthma. The latest known pathways underlying the pathogenesis of the disease, which are associated with a change in miRNA expression, may be precise targets of therapeutic activity in the future.

Severe Asthma Standard-of-Care Background Medication Reduction With Benralizumab: ANDHI in Practice Substudy

BACKGROUND

The phase IIIb, randomized, parallel-group, placebo-controlled ANDHI double-blind (DB) study extended understanding of the efficacy of benralizumab for patients with severe eosinophilic asthma. Patients from ANDHI DB could join the 56-week ANDHI in Practice (IP) single-arm, open-label extension substudy.

OBJECTIVE

Assess potential for standard-of-care background medication reductions while maintaining asthma control with benralizumab.

METHODS

Following ANDHI DB completion, eligible adults were enrolled in ANDHI IP. After an 8-week run-in with benralizumab, there were 5 visits to potentially reduce background asthma medications for patients achieving and maintaining protocol-defined asthma control with benralizumab. Main outcome measures for non-oral corticosteroid (OCS)-dependent patients were the proportions with at least 1 background medication reduction (ie, lower inhaled corticosteroid dose, background medication discontinuation) and the number of adapted Global Initiative for Asthma (GINA) step reductions at end of treatment (EOT). Main outcomes for OCS-dependent patients were reductions in daily OCS dosage and proportion achieving OCS dosage of 5 mg or lower at EOT.

RESULTS

For non-OCS-dependent patients, 53.3% (n = 208 of 390) achieved at least 1 background medication reduction, increasing to 72.6% (n = 130 of 179) for patients who maintained protocol-defined asthma control at EOT. A total of 41.9% (n = 163 of 389) achieved at least 1 adapted GINA step reduction, increasing to 61.8% (n = 110 of 178) for patients with protocol-defined EOT asthma control. At ANDHI IP baseline, OCS dosages were 5 mg or lower for 40.4% (n = 40 of 99) of OCS-dependent patients. Of OCS-dependent patients, 50.5% (n = 50 of 99) eliminated OCS and 74.7% (n = 74 of 99) achieved dosages of 5 mg or lower at EOT.

CONCLUSIONS

These findings demonstrate benralizumab's ability to improve asthma control, thereby allowing background medication reduction.

Systemic corticosteroids in asthma: A call to action from World Allergy Organization and Respiratory Effectiveness Group

Systemic corticosteroids (SCS) are a highly effective treatment for acute exacerbations and long-term symptom control in asthma. Long-term SCS use is highly prevalent across all asthma severities, occurring in over 20% of patients with severe or uncontrolled disease globally. It is now well known that exposure to both long-term and repeated acute courses of SCS is associated with a high risk of serious adverse effects (AEs), such as osteoporosis, and metabolic and cardiovascular complications, especially when prescribed onto a background of other corticosteroids. The aim of this call-to-action article, endorsed by the World Allergy Organization and the Respiratory Effectiveness Group, is to review the accumulating evidence on the burden of SCS on patients with asthma and provide an overview of potential strategies for implementing SCS Stewardship. Primary prevention of exacerbations and improvement of asthma control is a key first step in achieving SCS Stewardship, by optimizing maintenance asthma medications and addressing modifiable risk factors, such as adherence and inhaler technique. Other key elements of SCS Stewardship include increasing appropriate specialist referrals for multidisciplinary review, assessment of biomarkers, and consideration of oral corticosteroid-sparing add-on therapies (eg, biologics). In cases where SCS use is deemed clinically justified, it should be tapered to the lowest possible dose. In addition, patients receiving long-term SCS or frequent acute courses should be closely monitored for emergence of SCS-related AEs. Because of the extensive data available on the costly and burdensome AEs associated with SCS use, as well as the range of treatment options now available, there is a need for healthcare providers (HCPs) to carefully evaluate whether the benefits of SCS outweigh the potential harms, to adopt SCS-sparing and Stewardship strategies, and to consider alternative therapies where possible. Development of a structured and collaborative SCS Stewardship approach is urgently required to protect patients from the potential harm of SCS use.

Patient uptake and outcomes following pharmacist-initiated referrals to general practitioners for asthma review

Uptake and outcomes of pharmacist-initiated general practitioner (GP) referrals for patients with poorly controlled asthma were investigated. Pharmacists referred at-risk patients for GP assessment. Patients were categorized as action takers (consulted their GP on pharmacist’s advice) or action avoiders (did not action the referral). Patient clinical data were compared to explore predictors of uptake and association with health outcomes. In total, 58% of patients (n = 148) received a GP referral, of whom 78% (n = 115) were action takers, and 44% (n = 50) reported changes to their asthma therapy. Patient rurality and more frequent pre-trial GP visits were associated with action takers. Action takers were more likely to have an asthma action plan (P = 0.001) at month 12, and had significantly more GP visits during the trial period (P = 0.034). Patient uptake of pharmacist-initiated GP referrals was high and led to GP review and therapy changes in patients with poorly controlled asthma.

Epidemiology, Treatment and Health Care Resource Use of Patients with severe Asthma in Germany – a retrospective Claims Data Analysis

BACKGROUND

Asthma causes various clinical symptoms, including unpredictable severe exacerbations, and even though most patients can achieve a reasonable disease control due to adequate treatment, some patients do not. This study seeks to describe healthcare resource utilization (HCRU) and treatment of asthma and severe asthma patients in Germany.

METHOD

A retrospective claims data analysis has been conducted on adult asthma patients and a subset of patients with severe asthma, identified during July 2017 - June 2018. A proxy was used to identify severe asthma patients based on therapy options recommended within the German treatment guideline for treating these patients. These include (i) biologics, (ii) medium/high-dose inhaled corticosteroids (ICS) in conjunction with LABA/montelukast and antibiotics/oral corticosteroids (OCS), and (iii) long-term OCS therapy. HCRU and treatment of patients were observed during a 1-year follow-up period (July 2018 - June 2019).

RESULTS

The study included 388 932 adult asthma patients (prevalence: 7.90%), with 2.51%-12.88% affected by severe asthma (depending on the definition). 22.60% of all asthma patients experienced hospitalizations (severe asthma: 36.11%). Furthermore, 13.59% received OCS (severe asthma: 39.91%), but only 0.18% (severe asthma: 1.25%) received biologics. Only 23.95% (severe asthma: 41.17%) visited a pulmonologist.

CONCLUSIONS

A considerable proportion of severe asthma patients receive long-term OCS therapy. However, less than 50% have seen a pulmonologist who would typically seek a change in treatment to avoid the long-term consequences of OCS. To optimize the treatment of severe asthma in Germany, better referral of these patients to specialists is needed and considering potential treatment alternatives.

REALITI-A Study: Real-World Oral Corticosteroid-Sparing Effect of Mepolizumab in Severe Asthma

BACKGROUND

Patients with severe asthma may require maintenance oral corticosteroids (mOCS) for disease control as well as systemic corticosteroid (SCS) bursts for clinically significant exacerbations. However, mOCS and SCS use are associated with adverse effects, which increases patient disease burden.

OBJECTIVE

To assess the real-world corticosteroid-sparing effect of mepolizumab in patients with severe asthma.

METHODS

REALITI-A was a 24-month international, prospective, observational cohort study involving 84 centers across Europe, Canada, and the United States, with a 1-year pre-post mepolizumab treatment preplanned interim analysis. A total of 822 adults with a clinical diagnosis of asthma and a physician decision to initiate mepolizumab treatment (100 mg subcutaneously) were included. End points included daily mOCS dose at baseline (penultimate 28 days of pretreatment) and 1 year after treatment; percent reduction from baseline in mOCS dose; patients discontinuing mOCS 1 year after treatment; and the rate of clinically significant exacerbations (those requiring OCS for 3 days or more [or parenteral administration], emergency room visit, and/or hospital admission) before and after treatment.

RESULTS

A total of 319 patients received mOCS at baseline (median [interquartile range]: 10.0 [5.0-15.0] mg/d). At 1 year after treatment, median mOCS dose was reduced by 75% (2.5 [0.0-5.0] mg/d); 64% of patients had a reduction in mOCS dose of 50% or greater compared with baseline and 43% discontinued mOCS. Clinically significant exacerbations decreased between pretreatment and posttreatment (rate ratio [95% confidence interval] 0.29 [0.26-0.32]; P < .001).

CONCLUSION

This 1-year analysis demonstrates that real-world mepolizumab treatment is clinically effective in patients with severe asthma, providing disease control while reducing the need for mOCS and SCS bursts.

The comparison between children and adolescents with asthma provided by the real-world "ControL'Asma" study

OBJECTIVE

Because asthma is a disease that changes over time, the Italian Society of Pediatric Allergy and Immunology launched a nationwide study on asthma control (the ControL'Asma study). The intent was to test the hypothesis that children with asthma could present a different pattern compared to adolescents. In the study, we compared children with adolescents in a real-world setting by analyzing the asthma control grade and other asthma-related parameters.

METHODS

This cross-sectional real-world study included 471 asthmatic children (

RESULTS

There was no difference between the age groups in asthma control as determined by both GINA criteria and the cACT/ACT questionnaires. However, adolescents with asthma had significantly more frequent rhinitis comorbidity (p = 0.02; OR = 2.07) and allergy (p = 0.012; OR = 3.72) than children. Asthma severity, lung function, and symptom perception were not different between age groups.

CONCLUSIONS

The current study showed that asthma control is not associated with age in young people. Adolescents with asthma did experience rhinitis and allergy more frequently than children. These findings reflect the progressive nature of the allergic phenotype in young patients.

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Key Words

• Asthma
• VAS
• adolescents
• allergy
• asthma control
• children
• lung function
• respiratory symptoms
• rhinitis

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MESH Headings

• Asthma/diagnosis
• Cross-Sectional Studies
• Female
• Humans
• Male
• Rhinitis
• Surveys and Questionnaires
• Visual Analog Scale

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Affiliation(s)

Maria Angela Tosca Allergy Center, Department of Pediatrics, Istituto Giannina Gaslini, Genoa, Italy
Angela Pistorio Epidemiology, Biostatistics and Committe, Department of Direction, Istituto Giannina Gaslini, Genoa, Italy
Michela Silvestri Allergy Center, Department of Pediatrics, Istituto Giannina Gaslini, Genoa, Italy
Gian Luigi Marseglia Pediatrics Clinic, Pediatrics Department, Policlinico San Matteo, University of Pavia, Pavia, Italy
Giorgio Ciprandi Allergy Clinic, Department of Outpatients, Casa di Cura Villa Montallegro, Genoa, Italy

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Dupilumab Efficacy in Steroid-Dependent Severe Asthma by Baseline Oral Corticosteroid Dose

BACKGROUND

Dupilumab, a fully human monoclonal antibody, blocks the shared receptor component for interleukin-4/-13, key and central drivers of type 2 inflammation in multiple diseases. In the phase 3 LIBERTY ASTHMA VENTURE (VENTURE) study (NCT02528214), dupilumab versus placebo reduced oral corticosteroid (OCS) dose and improved clinical outcomes in patients with OCS-dependent severe asthma. Dupilumab efficacy in patients with varying disease burden (defined by baseline OCS dose) has not been assessed.

OBJECTIVE

This post hoc analysis of VENTURE evaluated dupilumab efficacy across subgroups defined by baseline OCS dose.

METHODS

The OCS dose, proportion no longer needing OCS at week 24, annualized severe exacerbation rate, and least squares mean change from baseline in pre- and post-bronchodilator forced expiratory volume in 1 second at week 24 were evaluated in VENTURE patients with OCS-dependent severe asthma receiving dupilumab 300 mg every 2 weeks versus placebo, categorized by a baseline OCS dose of less than 10 mg/d or 10 or more mg/d.

RESULTS

Dupilumab reduced daily OCS dose from baseline at week 24 in both dose groups. In dupilumab-/placebo-treated patients with a baseline OCS dose of less than 10 mg/d and 10 or more mg/d, 72%/42% and 37%/23% stopped OCS by week 24 (P < .01/P < .05), respectively. Dupilumab significantly reduced the annualized severe exacerbation rate by 71% and 48% (P < .01/P < .05). At week 24, dupilumab improved pre- and post-bronchodilator forced expiratory volume in 1 second in patients in both dose groups.

CONCLUSIONS

In patients with OCS-dependent severe asthma receiving lower or higher baseline OCS doses, dupilumab significantly reduced the OCS dose and improved the likelihood of no longer requiring OCS while also reducing exacerbations and improving lung function.

Documento de consenso de asma grave en adultos. Actualización 2022

Severe asthma is a heterogeneous syndrome with several clinical variants and often represents a complex disease requiring a specialized and multidisciplinary approach, as well as the use of multiple drugs. The prevalence of severe asthma varies from one country to another, and it is estimated that 50% of these patients present a poor control of their disease. For the best management of the patient, it is necessary a correct diagnosis, an adequate follow-up and undoubtedly to offer the best available treatment, including biologic treatments with monoclonal antibodies. With this objective, this consensus process was born, which began in its first version in 2018, whose goal is to offer the patient the best possible management of their disease in order to minimize their symptomatology. For this 2020 consensus update, a literature review was conducted by the authors. Subsequently, through a two-round interactive Delphi process, a broad panel of asthma experts from SEPAR and the regional pulmonology societies proposed the recommendations and conclusions contained in this document.

Improving Care in Eosinophil-Associated Diseases: A Charter

Eosinophil-associated diseases (EADs) are a range of heterogeneous conditions in which eosinophils are believed to play a critical pathological role. EADs include common illnesses such as eosinophilic asthma and chronic rhinosinusitis and rare conditions such as hypereosinophilic syndromes (HES) and eosinophilic gastrointestinal disorders (EGIDs). EADs are associated with substantial burdens for the patient, including chronic, debilitating symptoms, increased financial burden, decreased health-related quality of life, and the need for repeated visits to multiple different healthcare professionals (HCPs), emergency departments, and/or hospitals. Poor EAD recognition by HCPs often contributes to delayed diagnoses, which further delays patient access to appropriate care and effective treatments, contributing to poor health outcomes. The objective of this charter is to outline key patient rights and expectations with respect to the management of their condition(s) and to set forth an ambitious action plan to improve health outcomes for patients with EADs: (1) people with EADs, their caretakers, HCPs, and the public must have greater awareness and education about EADs; (2) people with EADs must receive a timely, accurate diagnosis; (3) all people with EADs must have access to an appropriate multidisciplinary team, when necessary; and (4) people with EADs must have access to safe and effective treatment options without unnecessary regulatory delays. The principles described in this charter demonstrate the core elements of quality care that people with EADs must receive, and they represent clear steps by which to reduce patient and caregiver burden and improve patient outcomes. We urge HCPs, healthcare systems, and policymakers worldwide to swiftly adopt these principles to ensure patients with EADs have an accurate diagnosis in a timely manner and access to high-level care and treatment in an appropriate setting.

Clinical Remission in Severe Asthma: A Pooled Post Hoc Analysis of the Patient Journey with Benralizumab

Introduction

Consensus definitions for clinical remission and super-response were recently established for severe asthma. Benralizumab is an interleukin-5 (IL-5) receptor α-directed monoclonal antibody for severe, uncontrolled asthma; efficacy and safety were demonstrated in previous pivotal phase 3 trials (SIROCCO, CALIMA, ZONDA). This analysis applied a composite remission definition to characterize individual responses to benralizumab after 6 and 12 months.

Methods

In previous phase 3 studies, eligible patients were those with severe, uncontrolled asthma receiving medium- or high-dosage inhaled corticosteroids plus long-acting β₂-agonists. This post hoc analysis included patients randomized to the approved benralizumab dose and not receiving oral corticosteroids (OCS) at baseline (SIROCCO/CALIMA) or OCS ≤ 12.5 mg per day (ZONDA). Individual remission components were zero exacerbations; zero OCS use; Asthma Control Questionnaire-6 (ACQ-6) score < 1.5 or ≤ 0.75; and pre-bronchodilator forced expiratory volume in 1 s (FEV₁) increase ≥ 100 mL; clinical remission incorporated zero exacerbations, zero OCS use, ACQ-6 score ≤ 0.75, and pre-bronchodilator FEV₁ increase ≥ 100 mL after 6 or 12 months.

Results

Overall, 609 patients (N = 301 and N = 308) and 586 patients (N = 293 and N = 293) receiving benralizumab in SIROCCO and CALIMA were included at 6 and 12 months, respectively; 40 ZONDA patients were included after 6 months. In SIROCCO/CALIMA, similar to 6-month findings,  approx. 83% and approx. 49% receiving benralizumab, and 77% and 37% on placebo achieved ≥ 2 and ≥ 3 remission components after 12 months; 14.5% (85/586) on benralizumab and 7.7% (48/620) on placebo achieved clinical remission at 12 months. Among ZONDA patients, 75% and approx. 48% on benralizumab and 35% and 20% on placebo achieved ≥ 2 and ≥ 3 remission components at 6 months, respectively; 22.5% (9/40) on benralizumab and 7.5% on placebo achieved clinical remission.

Conclusions

This analysis demonstrates clinical remission is achievable by targeting the underlying drivers of inflammation. Precision medicines can help shift treatment paradigms toward treat-to-target, with clinical remission as the ultimate therapeutic goal in severe asthma.

Clinical trial registration

SIROCCO (NCT01928771); CALIMA (NCT01914757); ZONDA (NCT02075255).

Pharmacological Strategies and Recent Advancement in Nano-Drug Delivery for Targeting Asthma

With a high prevalence globally, asthma is a severe hazard to human health, as well as an economic and social burden. There are now novel therapies available for asthma with the use of nanotechnology. Recent developments in nanoscience and medicine have encouraged the creation of inhalable nanomedicines that can enhance the efficacy, patient compliance, and life quality for sufferers of asthma. Nanocarriers for asthma therapy, including liposomes, micelles, polymers, dendrimers, and inorganics, are presented in depth in this study as well as the current research status of these nanocarriers. Aerosolized nanomaterial-based drug transport systems are currently being developed, and some examples of these systems, as well as prospective future paths, are discussed. New research subjects include nano-modification of medicines and the development of innovative nano-drugs. Clinical experiments have proven that nanocarriers are both safe and effective. Before nanotherapy can be applied in clinical practice, several obstacles must be addressed. We look at some of the most recent research discoveries in the subject of nanotechnology and asthma therapy in this article.

Use of Biologic Therapies in the Treatment of Asthma - A Comparative Real World Data Analysis on Healthcare Resource Utilization and Costs Before and After Therapy Initiation

Background

Asthma is one of the most common chronic diseases in Germany. While many patients achieve asthma control under standard therapies, some patients still experience exacerbations and persistent airway obstructions. Thus, further pharmacological treatment is needed, and biologics could fill this gap, as they have shown clinical benefit in patients with severe asthma. Therefore, this real-world study aimed to compare healthcare resource utilization (HCRU) and associated costs before and after biologic therapy initiation.

Methods

A retrospective claims data analysis has been conducted on adult asthma patients who initiated a long-term biologic therapy between January 2015 and June 2018. Patients were therapy-naïve to biologics for at least 12 months. HCRU and cost incurred by patients during 12 months before and after therapy initiation were compared.

Results

Overall, 571 asthma patients initiated a biologic therapy during the observational period (316 omalizumab, 232 mepolizumab, 16 benralizumab, and 7 reslizumab). Patients had a mean age of 54.86 (62.70% female), and the majority (93.70%) received at least one follow-up prescription of their index-biologic agent within one year. During baseline, patients received on average 2.75 OCS prescriptions compared to 2.17 during follow-up. Most patients received less or the same amount of OCS after therapy initiation. Moreover, hospitalizations and asthma-related sick leave days decreased significantly. The average total costs per patient were €6618.90 during baseline and €22,832.33 during follow-up. Biologics mainly drove the increase; however, hospitalization costs were reduced significantly (€2443.37 vs €1941.93; p<0.001).

Conclusion

Our study demonstrates an improved asthma control due to the initiation of a biologic therapy in terms of decreased hospitalization frequency, OCS consumption, and sick leave days. However, biologics are associated with high costs for healthcare providers during the first year after initiation. Therefore, short- and long-term clinical benefits and financial burden must be considered in the overall context of healthcare.

Effective Management of Severe Asthma with Biologic Medications in Adult Patients: A Literature Review and International Expert Opinion

Severe asthma often remains uncontrolled despite effective treatments and evidence-based guidelines. A group of global experts in asthma and biologic medications from 9 countries considered the most relevant clinical variables to manage severe asthma in adult patients and guide treatment choice. The resulting recommendations address the investigation of biomarker levels (blood eosinophil count along with fractional concentration of exhaled nitric oxide [FeNO]), clinical features (oral corticosteroid [OCS] dependence, specific comorbid disease entities associated with severe type 2 asthma), and safety considerations. Current evidence suggests that biomarkers, including both blood or sputum eosinophil counts as well as FeNO, add prognostic and predictive value and should be measured in all patients with severe asthma. OCS use is an important factor in biologic selection, especially given the documented ability of some biologics to reduce OCS dependence. Comorbid diseases and relevant safety considerations to each biologic should also be considered. More data are needed to determine whether biomarker profiles identify patients suited to one biologic versus another as limited data support differential predictors of response. Further prospective head-to-head trials and post hoc analyses of clinical trial data are warranted. The authors believe that these recommendations have value as they offer expert opinion to assist health care providers in making difficult decisions regarding the quality of care in severe, type 2 asthma with biologic medications. They remain conditional and are based on limited data owing to a lack of head-to-head comparisons.

A Renewed Charter: Key Principles to Improve Patient Care in Severe Asthma

Asthma is a heterogenous respiratory disease, usually associated with chronic airway inflammation and hyper-responsiveness, which affects an estimated 339 million people worldwide. Severe asthma affects approximately 5-10% of patients with asthma, approximately 17-34 million people globally, more than half of whom have uncontrolled disease. Severe asthma carries a substantial burden of disease, including unpredictable symptoms and potentially life-threatening flare-ups. Furthermore, severe asthma has a substantial burden on health care systems and economies worldwide. In 2018, a group of experts from the clinical community, patient support groups, and professional organisations joined together to develop the Severe Asthma Patient Charter, which set out six principles to define what patients should expect for the management of their severe asthma and what should constitute a basic standard of care. Since the publication of that original Charter in 2018, several important changes have occurred, including an improved understanding of asthma and effective asthma management; several new therapies have become available; and finally, the COVID-19 pandemic has placed a spotlight on respiratory conditions, the workforces that treat them, and the fundamental importance of health care system resilience. With those developments in mind, we, representatives of the academic, clinical, and patient advocacy group communities, have updated the Charter to Improve Patient Care in Severe Asthma with a focus on six principles: (1) I deserve a timely, comprehensive assessment of my asthma and its severity; (2) I deserve a timely, straightforward referral to an appropriate specialist for my asthma when it is not well controlled; (3) I deserve to understand what makes my asthma worse; (4) I deserve access to treatment and care that reduces the impact of asthma on my daily life; (5) I deserve not to be reliant on systemic corticosteroids; (6) I deserve to be involved in decisions about my treatment and care.

Integrated Safety and Efficacy Among Patients Receiving Benralizumab for Up to 5 Years

BACKGROUND

Benralizumab is an IL-5Rα-directed monoclonal antibody indicated for patients with severe, uncontrolled eosinophilic asthma.

OBJECTIVE

To evaluate the long-term safety and tolerability of benralizumab among adults treated for up to 5 years.

METHODS

This analysis included adults treated with placebo or subcutaneous benralizumab 30 mg every 4 or 8 weeks in the 48-week SIROCCO, 56-week CALIMA, and 28-week ZONDA pivotal trials, who were subsequently enrolled in the 56-week double-blind BORA extension and continued assigned regimens or initiated benralizumab (if previously on placebo) for 16 to 40 weeks, before entering the open-label MELTEMI extension. Safety was measured by adverse and serious adverse event rates. Exacerbations were evaluated in patients with blood eosinophils greater than or equal to 300 cells/μL receiving high-dose inhaled corticosteroids at baseline.

RESULTS

Overall, 446 received treatment and 384 (86.1%) completed the study; 157 (35.2%) received benralizumab for 4 or more years. Adverse and serious adverse event rates (28.5-32.4 and 6.3-8.4 per 100 patient-years, respectively) were low, stable over time, and did not increase with exposure; few (n = 8) discontinued because of adverse events. Serious infections and hypersensitivity event rates were consistent with those in previous studies. Among patients with blood eosinophils greater than or equal to 300 cells/μL-high-dosage inhaled corticosteroids receiving benralizumab every 8 weeks, at least 75% had zero exacerbations annually during the integrated analysis period.

CONCLUSIONS

In patients with severe, uncontrolled eosinophilic asthma, long-term benralizumab was safe and well tolerated for up to 5 years. There were no new safety signals, and exacerbations were eliminated in similar percentages of patients as in predecessor studies.

Diagnosis and Management of Severe Asthma in Switzerland: Analysis of Survey Results Conducted with Specialists and General Practitioners

BACKGROUND

Severe asthma commonly affects 5-10% of the asthmatic population and accounts for approximately 50% of the overall asthma costs.

OBJECTIVE

This analysis investigated how severe asthma is diagnosed, treated, and managed by specialists and general practitioners (GPs) in Switzerland.

METHODS

Two surveys, one each among specialists (N = 44) and GPs (N = 153), were conducted to understand their self-perception on diagnosis, treatment, and management of severe asthma.

RESULTS

Fifty-five percent of the specialists felt very confident and 43% confident in recognizing the symptoms of severe asthma and diagnosing severe asthma. In contrast, 9% of the GPs were very confident and 59% confident in diagnosing severe asthma. More specific diagnostic tests for severe asthma, like total and specific immunoglobulin E levels and measurement of the fraction of exhaled nitric oxide, were run by specialists (χ2 = 171.4; df = 15, p < 0.001). GPs and specialists were using different measurements to assess severe asthma (χ2 = 385.2; df = 13, p < 0.001) and their prescribing patterns differed significantly (χ2 = 189.8; df = 10, p < 0.001). GPs referred patients with severe asthma if the diagnosis was unclear (24%), if treatment failure occurred (26%), and if the patients were at high risk (41%).

CONCLUSIONS

Oral corticosteroids (OCSs) are considered as background therapy for severe asthma by GPs and specialists. In order to reduce the OCS burden, there is a need to improve the awareness for other add-on therapies. A joint collaboration between GPs and specialists is the key to leverage therapeutic strategies together.

Chronic oral corticosteroids use and persistent eosinophilia in severe asthmatics from the Belgian severe asthma registry

BACKGROUND

Severe asthma (SA) may require frequent courses or chronic use of oral corticosteroids (OCS), inducing many known side effects and complications. Therefore, it is important to identify risk factors of chronic use of OCS in SA, considering the heterogeneity of clinical and inflammatory asthma phenotypes. Another aim of the present analysis is to characterize a subpopulation of severe asthmatics, in whom blood eosinophil counts (BEC) remain elevated despite chronic OCS treatment.

METHODS

In a cross-sectional analysis of 982 SA patients enrolled in the Belgian Severe Asthma Registry (BSAR) between March 2009 and February 2019, we investigated the characteristics of the OCS treated patients with special attention to their inflammatory profile.

RESULTS

At enrollment, 211 (21%) SA patients were taking maintenance OCS (median dose: 8 [IQR: 5-10]) mg prednisone equivalent). BEC was high (> 400/mm3) in 44% of the OCS treated population. Multivariable logistic regression analysis showed that risk factors for chronic use of OCS in SA were late-onset asthma (i.e. age of onset > 40 yr), frequent exacerbations (i.e. ≥2 exacerbations in the previous year) and non-atopic asthma. Late-onset asthma was also a predictor for persistently high BEC in OCS treated SA patients.

CONCLUSION

These data showed a significant association between a persistently high BEC and late-onset asthma in OCS treated SA patients. Whether it is poor compliance to treatment or corticosteroid insensitivity the reasons for this association warrants further investigation.

Real-life experience with benralizumab during 6 months

BACKGROUND

Benralizumab is a monoclonal antibody that binds to the human interleukin-5 (IL-5) receptor (IL-5R), thereby preventing IL-5 from binding to its receptor and inhibiting differentiation and maturation of eosinophils in the bone marrow. Because of its recent marketing approval, sufficient real-life evidence is lacking to confirm the efficacy and safety data from clinical trials. The purpose of this study was to evaluate the efficacy and safety of benralizumab for the treatment of severe refractory eosinophilic asthma in a real-world cohort of patients.

METHODS

This was a cross-sectional multicentre study of consecutive patients with severe refractory eosinophilic asthma who received treatment with benralizumab during at least 6 months. Patient follow-up was performed in specialised severe asthma units.

RESULTS

A total of 42 patients were enrolled and treated with benralizumab. Asthma control, as measured by the asthma control test (ACT), improved in all patients both at 3 months of treatment compared with baseline (13.9 ± 4 vs 20.1 ± 3.7, p < 0.001) and at 6 months of treatment compared with the results obtained at 3 months (20.1 ± 3.7 vs 21 ± 2.7, p = 0.037). Similarly, the number of emergency department visits decreased both at 3 months compared with baseline (1 [IR:0.7] vs 0 [IR:0.75], p < 0.001) and at 6 months compared with the results at 3 months (0 [IR:0.75] vs 0 [IR:0], p = 0.012). Reductions in the number of oral corticosteroid cycles, percentage of corticosteroid-dependent patients, and mean daily dose of oral or inhaled corticosteroid were also evidenced. Finally, mean lung function improvement was 291 mL (p < 0.001), and FEV1% improved both at 3 months compared with baseline (64.4 ± 9.3 vs 73.1 ± 9.1, p < 0.001) and at 6 months compared to 3 months (73.1 ± 9.1 vs 76.1 ± 12, p = 0.002). Side effects were mild and did not lead to treatment discontinuation.

CONCLUSIONS

This study confirms the efficacy and safety of benralizumab in a real-life setting with improved asthma control and lung function, and a reduced oral and inhaled corticosteroid use as well as fewer emergency department visits. In addition to a rapid initial improvement, it appears that patients continue to improve during the first 6 months of treatment.