Stopping versus continuing long-term mepolizumab treatment in severe eosinophilic asthma (COMET study)

Improving patient outcomes: Mepolizumab's impact in IL-5-mediated diseases

ABSTRACT

The Interleukin-5 (IL-5)-mediated pathogenic role of eosinophils in airway disorders including severe eosinophilic asthma (SEA), chronic rhinosinusitis with nasal polyps (CRSwNP), eosinophilic granulomatosis with polyangiitis (EGPA), and rare hyper-eosinophilic syndrome (HES) is well established. Mepolizumab, an IL-5-targeting humanised antibody, is approved as an add-on maintenance therapy for SEA, EGPA, CRSwNP, and HES. Here, we review the safety and efficacy findings of mepolizumab in clinical trials and real-world evidence studies in patients with SEA, CRSwNP, EGPA, and HES. We specifically explore the data on mepolizumab that support early initiation of IL-5-targeted therapy to maximise its corticosteroid-sparing effect. This review consolidates the clinical data on mepolizumab, highlights other promising IL-5-targeting agents, and supports the IL-5 pathway as the key therapeutic target across eosinophilic indications.

Recent evidence for stepping down severe asthma therapies

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

Real-world effectiveness of mepolizumab in asthma: a systematic review and meta-analysis

OBJECTIVE

Exacerbations and suboptimal disease control are common in severe asthma with an eosinophilic phenotype (SAep). Mepolizumab, an anti-interleukin-5 monoclonal antibody, has demonstrated efficacy and safety in randomized controlled trials (RCTs). We aimed to strengthen the real-world evidence base for mepolizumab in SAep.

METHODS

We analyzed data from Italian participants of REALITI-A, a global, real-world, prospective, observational study (primary outcome: rate of clinically significant exacerbations [CSEs]). Using these data and those from Italian real-world studies of mepolizumab (identified by systematic literature review), we performed a meta-analysis.

RESULTS

In the Italian cohort of REALITI-A (n = 244), mean CSE rate was lower 12 months post-mepolizumab initiation versus 12 months pre-mepolizumab (0.67 vs. 3.74 CSEs/patient/year; relative risk [RR], 0.18; 95% confidence interval (CI), 0.15-0.22; p < .001). The meta-analysis included 863 patients. Mean CSE rate decreased from 4.2/patient/year at baseline to 0.71/patient/year post-mepolizumab initiation. Mean oral corticosteroid (OCS) dose reduced by 8.66 mg/day (95% CI, 6.17-11.16 mg/day; p < .0001) from baseline (10.0 mg/day). The RR for OCS maintenance, post- versus pre-mepolizumab, was 0.37 (95% CI, 0.27-0.52; p < .0001). A mean increase in Asthma Control Test score of 6.50 (95% CI, 5.67-7.33; p < .00001) was observed. Proportions of patients reporting adverse events were low.

CONCLUSIONS

Real-world experience in this unified health care system identifies that mepolizumab has a low adverse event rate and provides consistent clinical benefits. Mepolizumab represents an important treatment option for patients with SAep.

Evaluation of Long-Term Response to Biological Therapy in Severe Asthma and Considerations for Treatment Adjustment

Assessing long-term responses to biological therapies for severe asthma is critical for optimizing patient management and improving clinical outcomes [...].

Biologic Agents in Idiopathic Hypereosinophilic Syndrome

Background: Hypereosinophilic syndrome (HES) is a heterogeneous group of rare disorders defined by the presence of marked eosinophilia resulting in end organ damage. The diagnostic approach is multidisciplinary and treatment goals include reductions in flares and eosinophils with minimal drug-related side effects. Results: Eleven patients (n = 11) with a diagnosis of idiopathic HES were included in the study [M/F: 6/5, median age: 54 (95% CI: 38.2 to 68.5), smokers/never smokers: 5/6]. Asthma was present in the majority of them (n = 8, 72.7%); four patients (n = 4, 36.4%) presented with eosinophilic pleural effusions, two patients (n = 2, 18.2%) with cardiac arrhythmias, and one with bilateral eyelid angioedema. Eight patients (72.7%) were treated with mepolizumab (300 mg/month) and three (27.3%) with benralizumab (30 mg/4 weeks). The median values of eosinophils at baseline and 12 months after initiation of biologic agent were 3000 (95% CI: 2172 to 11,365) K/μL and 50 (95% CI: 3 to 190) K/μL, respectively, p = 0.0002. All patients with concomitant asthma (n = 8) experienced elimination of asthma flares, asthma control (ACQ < 0.75), functional improvement (mean ΔFEV1: 857 ± 594 mL), and an 82% reduction in oral corticosteroids, p = 0.0001. Materials and Methods: Patients with highly characterized idiopathic HES treated with anti-eosinophilic agents between 1 October 2019 and 1 October 2023 were retrospectively included in the study. The aim of this study was to present clinical, laboratory, and functional features and outcomes in patients with thoroughly investigated idiopathic HES treated with biologic agents targeting eosinophils. Conclusions: Biologic agents in patients with idiopathic HES-following thorough diagnostic investigation-are both safe and effective, sparing the toxicity of immunosuppressive agents. Real-life data from larger registries are greatly anticipated.

Con: clinical remission in asthma - not yet there

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

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

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

Pro: Clinical remission in asthma - implications for asthma management

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

Biologics for Chronic Rhinosinusitis With Nasal Polyps: Current Status and Clinical Considerations in Korea

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a prevalent condition that significantly impacts quality of life and places a burden on healthcare systems. The advent of biologics targeting type 2 immune pathways offers new therapeutic options for severe and/or uncontrolled CRSwNP. Initially, biologic use was guided by the European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS) 2020 and the European Forum for Research and Education in Allergy and Airway Diseases (EUFOREA) guidelines, despite limited data on clinical indications, response measures, and treatment duration. Since then, numerous studies and the EPOS/EUFOREA 2023 update have refined these guidelines. The update defines clinical indications for biologics based on type 2 inflammation markers by lowering the blood eosinophil threshold from 250 to 150 cells/μL. The response to biologics is now more simply categorized into three levels based on reductions in nasal polyp size, improvements in quality of life, and enhancement of smell. Treatment evaluation is recommended at 6 months with annual follow-up. Longer administration intervals, such as every four weeks, have also proven effective in well-controlled patients. Although specific guidelines for discontinuation or switching biologics remain lacking, clinical judgment is essential in determining when treatment should be stopped or adjusted. Additionally, regulatory updates support the use of biologics for CRSwNP, and novel agents such as tezepelumab (an anti-thymic stromal lymphopoietin monoclonal antibody) continue to show promise. Finally, in Korea, biologics for CRSwNP are not covered by national health insurance, leading to extended dosing intervals due to high costs. Despite this limitation, studies have shown that adjusted dosing can maintain subjective quality of life. Recent studies by Korean authors have also explored practical considerations such as dosing intervals and comparisons to surgery. Further research is needed to optimize treatment strategies, particularly regarding cost-effectiveness and prospective studies tailored to the Korean healthcare system.

An evaluation of mepolizumab as an add-on maintenance treatment for severe eosinophilic asthma

INTRODUCTION

Clinical experience with anti-interleukin (IL)-5 biologic therapies for severe asthma has been increasing, alongside deeper and broader research focusing on the role of IL-5 and the IL-5 targeted mepolizumab. This review aims to provide an update of the evidence on the role of IL-5 and mepolizumab, with discussions of the benefits of mepolizumab and its future potential, to promote the comprehension of the pathophysiology and therapeutic approaches to asthma.

AREAS COVERED

For this narrative review, we conducted a database search in PubMed and Embase using the keywords 'IL-5' and 'mepolizumab,' focusing on randomized controlled trials and real-world studies up to September 2024. An overview of the pathogenesis of severe asthma, new insights on the role of IL-5 and mepolizumab, and the evidence on the efficacy and safety of mepolizumab in the treatment of severe eosinophilic asthma is provided, and its benefits in clinical remission and future applications are also discussed.

EXPERT OPINION

Mepolizumab holds considerable promise in asthma treatment due to its mechanism of action and multiple potential benefits. In clinical practice, it may be worth considering the exploratory initiation of mepolizumab add-on treatment from the time of medium-dose inhaled glucocorticosteroid use.

[Severe eosinophilic granulomatosis with polyangiitis-related peripheral neuropathy after the cessation of mepolizumab. A case report]

A 78-years-old man was treated for asthma and pansinusitis for >5 years, and mepolizumab was initiated two years previously. Two months after the cessation of mepolizumab treatment, the asthma symptoms worsened and acute progressive muscle weakness and sensory disturbance developed. On day 8 after the onset of weakness and hypoesthesia, the patient presented with complete flaccid tetraplegia and diffuse hypoesthesia of all extremities, without paresthesia or pain, and was admitted to our hospital. Blood tests revealed eosinophilia without anti-neutrophil cytoplasmic antibody elevation. Nerve conduction studies revealed severe axonal polyneuropathy and multifocal absent F-waves. Cerebrospinal fluid was normal. Eosinophilic granulomatosis with polyangiitis (EGPA) and Guillain-Barré syndrome (GBS) were suspected, and high-dose methylprednisolone was administered, followed by oral prednisolone. Eosinophils rapidly disappeared; however, the neurological symptoms did not improve. On day 16, sural nerve biopsy revealed myelinated fiber loss in most of the fibers in every nerve bundle regardless of fiber size, while eosinophilic infiltration in the epineurium and findings suggestive of necrotizing vasculitis were not observed. The results did not fulfill the pathological criteria for EGPA but supported the changes in vasculitis; hence, EGPA was diagnosed. Intravenous immunoglobulin, azathioprine, and rituximab were administered, and the prednisolone dose was gradually reduced to 10 ‍mg/d. The eosinophil count increased to 50/μl without pneumonia recurrence or worsening asthma. Neuropathy in the upper limbs gradually improved over two years, whereas that in the lower limbs did not change. This is the first reported case of sequential exacerbation of asthma and onset of EGPA after mepolizumab discontinuation. Among patients with asthma, the cessation of mepolizumab treatment may lead to the development of EGPA with an atypical clinical course, such as rapidly progressive severe neuropathy mimicking GBS.

Biologics and airway remodeling in asthma: early, late, and potential preventive effects

Although airway remodeling in severe and/or fatal asthma is still considered irreversible, its individual components as a cause of clinical symptoms and/or lung function changes remain largely unknown. While inhaled glucocorticoids have not consistently been shown to affect airway remodeling, biologics targeting specific pathways of airway inflammation have been shown to improve lung function, mucus plugging, and airway structural changes that can exceed those seen with glucocorticoids. This superiority of biologic treatment, which cannot be solely explained by insufficient doses or limited durations of glucocorticoid therapies, needs to be further explored. For this field of research, we propose a novel classification of the potential effects of biologics on airway remodeling into three temporal effects: early effects (days to weeks, primarily modulating inflammatory processes), late effects (months to years, predominantly affecting structural changes), and potential preventive effects (outcomes of early treatment with biologics). For the identification of potential preventive effects of biologics, we call for studies exploring the impact of early biological treatment on airway remodeling in patients with moderate-to-severe asthma, which should be accompanied by a long-term evaluation of clinical parameters, biomarkers, treatment burden, and socioeconomic implications.

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

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

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

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

European biologic training course for type 2 inflammation by EUFOREA in 2024: key facts and lessons learned

The European Forum for Research and Education in Allergy and Airways diseases (EUFOREA) organized the first European Biologic Training Course (EBTC) in Brussels on 1st March 2024. The aim of this hybrid EBTC including both face-to-face and web-based participation was to address the educational needs of physicians dealing with asthma and Chronic Rhinosinusitis with Nasal Polyps (CRSwNP) on the clinically relevant aspects of diagnosing and treatment with biologics. EUFOREA is an international non-for-profit organization forming an alliance of all stakeholders dedicated to reducing the prevalence and burden of chronic respiratory diseases through the implementation of optimal patient care via educational, research, and advocacy activities. The inclusive and multidisciplinary approach of EUFOREA was reflected in faculty coming from the paediatric, allergology, pulmonology, and Ear, Nose and Throat (ENT) speciality and from different continents, with more than 250 participants from over 30 countries in the first EBTC. The current report provides a comprehensive overview of key statements made by the faculty of the EBTC 2024, especially focusing on patient selection for a biologic drug, the communication with patients, the onset of biological treatment and the follow-up in routine clinical practice.

Deconstructing inflammatory memory across tissue set points using cell circuit motifs

Tissue ecosystems are cellular communities that maintain set points through a network of intercellular interactions. We position health and chronic inflammatory disease as alternative stable set points that are (1) robust to perturbation and (2) capable of adaptation and memory. Inflammatory memory, which is the storage of prior experience to durably influence future responsiveness, is central to how tissue ecosystems may be pushed past tipping points that stabilize disease over health. Here, we develop a reductionist framework of circuit motifs that recur in tissue set points. In type 2 immunity, we distinctly find the emergence of 2-cell positive feedback motifs. In contrast, directional motif relays and 3-cell networks feature more prominently in type 1 and 17 responses. We propose that these differences guide the ecologic networks established after surpassing tipping points and associate closely with therapeutic responsiveness. We highlight opportunities to improve our current knowledge of how circuit motifs interact when building toward tissue-level networks across adaptation and memory. By developing new tools for circuit motif nomination and applying them to temporal profiling of tissue ecosystems, we hope to dissect the stability of the chronic inflammatory set point and open therapeutic avenues for rewriting memory to restore health.

Expert opinion on diagnosis and management of Severe Asthma in low and middle income countries (LMIC) with focus on India

OBJECTIVE

In this document, 9 Indian experts have evaluated the factors specific to LMICs when it came to Severe Asthma (SA) diagnosis, evaluation, biologic selection, non-biologic treatment options, and follow-up.

DATA SOURCES

A search was performed using 50 keywords, focusing on the Indian/LMICs perspective, in PubMed, Cochrane Library, and Google Scholar. The key areas of the search were focused on diagnosis, phenoendotyping, non-biological therapies, selecting a biologic, assessment of treatment response, and management of exacerbation.

STUDY SELECTIONS

The initial search revealed 1826 articles, from these case reports, observational studies, cohort studies, non-English language papers, etc., were excluded and we short-listed 20 articles for each area. Five relevant articles were selected by the experts for review.

RESULTS

In LMICs, SA patients may be referred to the specialist for evaluation a little late for Phenoendotyping of SA. While biologic therapy is now a standard of care, pulmonologists in LMICs may not have access to all the investigations to phenoendotype SA patients like fractional exhaled nitric oxide (FeNO), skin prick test (SPT), etc., but phenotyping of SA patients can also be done with simple blood investigations, eosinophil count and serum immunoglobulin E (IgE). Choosing a biologic in the overlapping phenotype of SA and ACO patients is also a challenge in the LMICs.

CONCLUSIONS

Given the limitations of LMIC, it is important to select the right patient and explain the potential benefits of biological therapy. Non-biologic add-on therapies can be attempted in a resource-limited setting where biological therapy is not available/feasible for patients.

Clinical remission and control in severe asthma: agreements and disagreements

Over the last two decades, we have witnessed great advancements in our understanding of the immunological pathways of asthma, leading to the development of targeted therapies, such as biologic drugs, that have radically and definitively changed the clinical outcomes of severe asthma. Despite the numerous therapeutic options available, ~4-10% of all people with asthma have severe or uncontrolled asthma, associated with an increased risk of developing chronic oral corticosteroid use, fixed airflow limitation, exacerbations, hospitalization and, finally, increased healthcare costs. The new concept of disease modification in asthma comes from the evolution of asthma management, which encompasses phenotyping patients with different inflammatory endotypes characterizing the disease, followed by the advent of more effective therapies capable of targeting the proximal factors of airway inflammation. This treat-to-target approach aims to achieve remission of the disease. Because the novel treatment paradigm for severe asthma with the advent of biologic therapies is no longer clinical control but rather clinical remission - a step closer to the concept of cure - a deeper and more accurate understanding of the critical causal mechanisms and endotypes of asthma is necessary to achieve the goal of clinical remission, which has the potential to generate real life-changing benefits for patients. This review aims to frame the evolution of the debated concept of clinical remission and provide clinicians with insights that may be helpful in achieving remission in the greatest number of patients.

Biomarkers and clinical outcomes after tezepelumab cessation: Extended follow-up from the 2-year DESTINATION study

BACKGROUND

Long-term tezepelumab treatment in the DESTINATION study (NCT03706079) resulted in reduced asthma exacerbations, reduced biomarker levels, and improved lung function and symptom control in patients with severe, uncontrolled asthma.

OBJECTIVE

To explore the time course of changes in biomarkers and clinical manifestations after treatment cessation after 2 years of tezepelumab treatment.

METHODS

DESTINATION was a 2-year, phase 3, multicenter, randomized, placebo-controlled, double-blind study of tezepelumab treatment in patients (12-80 years old) with severe asthma. Patients received their last treatment doses at week 100 and could enroll in an extended follow-up period from weeks 104 to 140. Change over time in key biomarkers and clinical outcomes were assessed in tezepelumab vs placebo recipients for 40 weeks after stopping treatment.

RESULTS

Of 569 patients enrolled in the extended follow-up period, 426 were included in the analysis (289 received tezepelumab and 137 placebo). In the 40-week period after the last tezepelumab dose, blood eosinophil counts, fractional exhaled nitric oxide levels, and Asthma Control Questionnaire-6 scores gradually increased from weeks 4 to 10, with a gradual reduction in pre-bronchodilator forced expiratory volume in 1 second such that blood eosinophil counts, fractional exhaled nitric oxide levels, and clinical outcomes returned to placebo levels; however, none of these outcomes returned to baseline levels. Total IgE levels increased later from week 28 and remained well below placebo and baseline levels during the 40-week period after the last tezepelumab dose.

CONCLUSION

This analysis reveals the benefits of continued tezepelumab treatment in the management of patients with severe, uncontrolled asthma, compared with stopping treatment after 2 years.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03706079.

Long-term effects of mepolizumab in patients with severe eosinophilic asthma: a 6-year real-life experience

Background

Severe eosinophilic asthma (SEA) is often linked to a dysregulation in the Interleukin-(IL)-5 axis. Mepolizumab, a humanized monoclonal antibody, reduces eosinophils by directly binging to IL-5, potentially restoring homeostatic eosinophil biology, with a significant impact on quality of life, acute exacerbations and oral corticosteroids (OCS) elimination in SEA patients. While its short- and middle-term effects are well described, no study has so far investigated its long-lasting effects in SEA patients. The aim of our study was therefore to explore the effects of a long-term, six-year continuous treatment with mepolizumab on clinical control and clinical remission in a cohort of SEA patients.

Methods

We conducted a retrospective review of clinical records of patients who were prescribed mepolizumab between June 2017 and April 2018. We collected demographical, functional, and clinical data from visits performed at baseline and then at the specified timepoints and checked if patients had reached clinical remission after 6 years. We assessed asthma control test (ACT), exacerbation rate, and OCS elimination dose at 6 years. Clinical Remission (CR) was defined on the basis of the elimination of OCS and the contemporary presence of all the following: 1) stable lung function; 2) no exacerbation in the previous 12 months; 3) acceptable symptom control (ACT ≥ 20).

Results

Of 86 patients screened, 62 were included in the final analysis. Our study suggests that mepolizumab is effective and well tolerated after a six-year course of continuous treatment in patients with SEA. We reported a prevalence of 28 (46.8%) patients who reached complete CR at 72 months from the treatment start. 75% of patients eliminated the maintenance OCS already after 1 year of treatment; this proportion reached the 87% within the sixth year of treatment.

Conclusion

Mepolizumab proved to be effective in real-life after 6 years of treatment, inducing a complete clinical remission in the 46.8% of patients, with sustained improvements in quality of life, exacerbation rate, OCS intake and lung function.

Titration of anti-IL-5 biologics in severe asthma: an open-label randomised controlled trial (the OPTIMAL study)

BACKGROUND

Anti-interleukin (IL)-5 biologics effectively reduce exacerbations and the need for maintenance oral corticosteroids (mOCS) in severe eosinophilic asthma. However, it is unknown how long anti-IL-5 treatment should be continued. Data from clinical trials indicate a gradual but variable loss of control after treatment cessation. In this pilot study of titration, we evaluated a dose-titration algorithm in patients who had achieved clinical control on an anti-IL-5 biologic.

METHODS

In this open-label randomised controlled trial conducted over 52 weeks, patients with clinical control (no exacerbations or mOCS) on anti-IL-5 treatment were randomised to continue with unchanged intervals or have dosing intervals adjusted according to a titration algorithm that gradually extended dosing intervals and reduced them again at signs of loss of disease control. The OPTIMAL algorithm was designed to down-titrate dosing until signs of loss of control, to enable assessment of the longest dosing interval possible.

RESULTS

Among 73 patients enrolled, 37 patients were randomised to the OPTIMAL titration arm; 78% of patients tolerated down-titration of treatment. Compared to the control arm, the OPTIMAL arm tended to have more exacerbations during the study (32% versus 17%; p=0.13). There were no severe adverse events related to titration, and lung function and symptoms scores remained stable and comparable in both study arms throughout.

CONCLUSION

This study serves as a proof of concept for titration of anti-IL-5 biologics in patients with severe asthma with clinical control on treatment, and the OPTIMAL algorithm provides a potential framework for individualising dosing intervals in the future.

Safety, pharmacokinetics and pharmacodynamics of SHR-1703, an innovative long-acting anti-interleukin-5 monoclonal antibody, in healthy subjects: a randomized, double-blind, dose-escalation, placebo-controlled phase I study

OBJECTIVE

SHR-1703 is a novel humanized IgG1 monoclonal antibody with high IL-5 affinity and prolonged half-life, aiming to control eosinophil-related diseases. The study intended to evaluate pharmacokinetics, pharmacodynamics, immunogenicity, safety, and tolerability of SHR-1703 in healthy subjects.

METHODS

A single-center, randomized, double-blind, placebo-controlled, single-dose escalation phase I study was conducted. 42 subjects were allocated to sequentially receive single subcutaneous injection of 20, 75, 150, 300, and 400 mg SHR-1703 or placebo.

RESULTS

After administration, SHR-1703 was slowly absorbed with median Tmax ranging from 8.5 to 24.5 days. Mean t1/2 in 150 to 400 mg doses was 86 to 100 days. Cmax and AUC increased in nearly dose-proportional pattern over range of 75 to 400 mg SHR-1703. After receiving SHR-1703, peripheral blood eosinophils (EOS) greatly decreased from baseline, which showed no significant change from baseline in placebo group. Magnitude and duration of reduction of EOS rose with increased dosing of SHR-1703. In 400 mg dose, remarkable efficacy of reducing EOS maintained up to approximately 6 months post single administration. Moreover, SHR-1703 exhibited low immunogenicity (2.9%), favorable safety, and tolerability in healthy subjects.

CONCLUSION

Pharmacokinetics, pharmacodynamics, immunogenicity, safety, and tolerability of SHR-1703 support further clinical development of SHR-1703 in eosinophil-associated diseases.

CLINICAL TRIAL REGISTRATION

The study was registered on the ClinicalTrials.gov (identifier: NCT04480762).

Big Data Research on Severe Asthma

The continuously increasing prevalence of severe asthma has imposed an increasing burden worldwide. Despite the emergence of novel therapeutic agents, management of severe asthma remains challenging. Insights garnered from big data may be helpful in the effort to determine the complex nature of severe asthma. In the field of asthma research, a vast amount of big data from various sources, including electronic health records, national claims data, and international cohorts, is now available. However, understanding of the strengths and limitations is required for proper utilization of specific datasets. Use of big data, along with advancements in artificial intelligence techniques, could potentially facilitate the practice of precision medicine in management of severe asthma.

[Advances in the management of asthma]

Asthma is a heterogeneous inflammatory airway disease that causes relevant morbidity across individuals of all age cohorts. In recent years, advances in the understanding of asthma pathophysiology have led to the development of treatments tailored to specific pheno- and endotypes of the disease. This has significantly changed asthma management, especially for patients with severe disease. These new treatment options offer individuals with asthma access to personalized and disease-modifying therapies. The present paper is a comprehensive overview of recent clinical studies and of German and international guideline updates on asthma management.

CDC167 exhibits potential as a biomarker for airway inflammation in asthma

Current asthma treatments have been discovered to decrease the risk of disease progression. Herein, we aimed to characterize novel potential therapeutic targets for asthma. Differentially expressed genes (DEGs) for GSE64913 and GSE137268 datasets were characterized. Weighted correlation network analysis (WGCNA) was used to identify trait-related module genes within the GSE67472 dataset. The intersection of the module genes of interest, as well as the DEGs, comprised the key module genes that underwent additional candidate gene screening using machine learning. In addition, a bioinformatics-based approach was used to analyze the relative expression levels, diagnostic values, and reverently enriched pathways of the screened candidate genes. Furthermore, the candidate genes were silenced in asthmatic mice, and the inflammation and lung injury in the mice were validated. A total of 1710 DEGs were characterized in GSE64913 and GSE137268 for asthma patients. WGCNA identified 2367 asthma module genes, of which 285 overlapped with 1710 DEGs. Four candidate genes, CDC167, POSTN, SEC14L1, and SERPINB2, were validated using the intersection genes of three machine learning algorithms, including Least Absolute Shrinkage and Selection Operator, Random Forest, and Support Vector Machine. All the candidate genes were significantly upregulated in asthma patients and demonstrated diagnostic utility for asthma. Furthermore, silencing CDC167 reduced the levels of inflammatory cytokines significantly and alleviated lung injury in ovalbumin (OVA)-induced asthmatic mice. Our study demonstrated that CDC167 exhibits potential as diagnostic markers and therapeutic targets for asthma patients.

The clinical effectiveness of mepolizumab treatment in severe eosinophilic asthma; outcomes from four years cohort evaluation

BACKGROUND

Clinical trials and real world studies demonstrated benefit of mepolizumab treatment in severe asthma but data on its effectiveness beyond 2 years remain limited. Herein, we provide mepolizumab treatment evaluation up to 4 years.

METHODS

we studied all patients initiated on mepolizumab in our center from June 2017 to August 2018. Clinical outcomes data were retrieved from the local dendrite systems registry. Comparison analyses and logistic regression were conducted to explore longevity and predictors of response to mepolizumab treatment.

RESULTS

a total of 66 patients initiated on mepolizumab with a median follow-up of 45.8 (42.4,48.1) months were included in the study [mean age 50.3 years (range 18-79), females 50 (73%) ]. At 20.7 months of treatment, 42 patients (63.6%) had positive response, 13 (19.7%) negative response, and 11 (16.7%) discontinued due to other factors. At 45.8 months, 35 (53%) patients were still on mepolizumab, 21 (31.8%) switched to a different biologic, and 10 (15.2%) discontinued biologics. Two deaths were recorded during the study period.The median blood eosinophil was reduced from 0.43x109/L (0.27, 0.75) to 0.04 (0.0, 0.1) (p < 0.00001)]. The median annual exacerbations were reduced from 6.0 (4,8) to 1.0 (0.0,3.0) (p < 0.00001), and mOCS use was reduced from59% to 29%, p = 0.001. The mean asthma control questionnaire-6 (ACQ6) improved from 3.1 ± 1.7 to 2.1 ± 1.3 (p < 0.00001).

CONCLUSIONS

mepolizumab clinical benefit was sustained over 4 years. However, approximately half of the cohort discontinued the treatment prompting the need for further research into the treatment response longevity.

A tailored approach to refractory severe Mepolizumab-associated headache: a case study

INTRODUCTION

Biologic drugs have been shown to reduce asthma exacerbations, improve lung function and quality of life, reduce oral corticosteroid use in appropriately selected patients. Mepolizumab has been demonstrated to have a safety profile that is similar to placebo, however, when present side effects may lead to treatment discontinuation. Among these, headache is one of the most common.

CASE STUDY

We hereby describe the case of a never-smoking male patient with an eosinophilic corticosteroid-dependent severe asthma. He displayed well controlled comorbidities and good adherence to the inhaled therapy. Mepolizumab was started in 2017 with an initial remarkable clinical improvement. After three doses of biologic therapy, he reported a severe orthostatic headache associated with vomiting, unresponsive to analgesic drugs, that required hospitalization. No other cause than treatment with Mepolizumab was found to be plausibly associated with this new-onset headache. The therapeutic regimen was modified by administering Mepolizumab for two consecutive months alternated with a one-month break.

RESULTS

The patient did not experience any further episodes of headache, while maintaining a good and stable control of his asthma. We were able to taper oral corticosteroids, and no flares-ups occurred in the following 5 years.

CONCLUSION

Our experience indicates that a tailored strategy for managing severe asthmatic patients, who have experienced side effects from biologic drugs, can be effective in maintaining drug efficacy while minimizing side effects. Further studies on a larger number of patients are required to demonstrate whether the positive outcomes here described are replicable on a larger scale.

Long-term safety, durability of response, cessation and switching of biologics

PURPOSE OF REVIEW

Severe asthma patients suffer from decreased quality of life, and increased asthma symptoms, exacerbations, hospitalizations, and risk of death. Biologics have revolutionized treatment for severe asthma. However, with multiple biologic agents now available, clinicians must consider initial selection the long-term effectiveness of biologics. Additionally, patients have overlapping eligibilities and clinicians may consider switching between biologics for improved response. Finally, careful assessment of biologics cessation is needed for severe asthma patients who depend on these add-on therapies for asthma control.

RECENT FINDINGS

Evidence for long-term durability and safety varies by biologic agent. In general, initial benefits noted from these agents (ex. exacerbation reduction) is, at minimum, sustained with long term use. Rates of adverse events and serious adverse events, including those requiring cessation of a biologics are low with long term use. Further studies are needed to understand the development of antidrug antibodies but currently their prevalence rates are low. Adverse events and insufficient efficacy are common reasons for biologic cessation or switching. Discontinuation maybe associated with waning of benefits but can be considered in certain situations. Biologic switching can be associated with improved asthma control.

SUMMARY

Biologics are safe and effective long-term therapies for the management of asthma. Discontinuation must be carefully considered and if possible avoided. Reasons for insufficient efficacy must be evaluated and if needed, biologic switching should be considered.

Biologic therapies for severe asthma with persistent type 2 inflammation

Asthma is a chronic inflammatory airways disease with reversible airflow obstruction, characterised in the majority by type 2 airway inflammation. Type 2 inflammation results in secretion of interleukin-4, -5 and -13 in the airways, recruitment of inflammatory cells (especially eosinophils and mast cells), and airway changes such as mucus hypersecretion and increased airway reactivity. Approximately 5 to 10% of people with asthma, despite optimal therapy and adherence to treatment with inhaled corticosteroids and long-acting beta2 agonists, are unable to obtain good symptom control and continue to experience exacerbations requiring oral corticosteroids; this is known as 'severe asthma'. In many cases, this is associated with persistent type 2 inflammation, indicated by the persistent elevation of blood eosinophils or fractional exhaled nitric oxide. In people with severe asthma and persistent type 2 inflammation, biologic (monoclonal antibody) therapy is indicated. Biologic therapies currently available in Australia for asthma are benralizumab, dupilumab, mepolizumab and omalizumab. They are administered subcutaneously and are generally well tolerated. Biologic asthma therapies are very effective in improving symptoms, and reducing the rate of exacerbations and use of oral corticosteroids, in people with severe asthma and persistent type 2 inflammation. Inhaled corticosteroid treatment should be continued in people using a biologic therapy.

Advancements in biologic therapy in eosinophilic asthma

INTRODUCTION

Asthma encompasses a spectrum of phenotypes often categorized into two groups- type 2 high (T2 high) and type 2 low (T2 low). T2 high includes atopic and eosinophilic presentations whereas T2 low is non-atopic, non-eosinophilic, and oft associated with neutrophilic inflammation. Eosinophilic asthma is often driven by IgE, IL-4, IL-5, and IL-13 and TSLP. This can lead to eosinophilic inflammatory response in the airways which in turn can be used as target for treatment.

AREAS COVERED

The article will focus on biologic therapy that is currently being used in eosinophilic asthma management in mainly the adult population including clinical trials and co-morbidities that can be treated using the same biologics. A review on asthma biologics for pediatric population has been reviewed elsewhere.

EXPERT OPINION

Biological therapy for asthma targeting the IgE, IL-4, IL-5, IL-13, and TSLP pathways are shown to have benefit for the treatment of eosinophilic asthma, as exemplified in real-world studies. When choosing the right biological agent factors such as phenotype, comorbidities, and cost-effectiveness of the biologic agent must be taken into consideration.

Adverse events of anti-IL-5 drugs in patients with eosinophilic asthma: a meta-analysis of randomized controlled trials and real-world evidence-based assessments

BACKGROUND

We aimed to clarify comprehensively the safety profiles of anti-IL-5 drugs and pinpoint potential safety concerns that may arise in their post-marketing phase.

METHODS

Two researchers conducted comprehensive searches of PubMed, EMBASE, Web of Science, and the Cochrane Library from inception to September 2022. Additionally, we investigated the FDA AE Reporting System for post-marketing adverse event (AE) reports related to anti-IL-5 drugs. The outcomes fulfilled the proportional reporting rate criteria and the Bayesian confidence propagation neural network.

RESULTS

We included 24 published studies in our analysis. The anti-IL-5 treatment group showed an incidence of AEs comparable to the placebo group, and it exhibited a significantly lower frequency of serious AEs. Common AEs were asthma, nasopharyngitis, headache, upper respiratory tract infection (URTI), and bronchitis. The post-marketing data included 28,478 case reports associated with the suspect drugs and 75 suspect safety observations affecting 16 system organ classes. New suspect observations included incomplete therapeutic product effect, URTIs, and pulmonary mass in reports related to mepolizumab. Reports associated with mepolizumab and benralizumab also indicated issues with incorrect technique in device usage and product issues.

CONCLUSIONS

Individual anti-IL-5 drugs' safety profiles largely matched their product inserts. We identified issues like improper device usage, product issue, and URTIs as potential concerns for mepolizumab and benralizumab. Additionally, all anti-IL-5 drugs showed signs of incomplete therapeutic effects.

Mitogen-activated protein kinase-guided drug discovery for post-viral and related types of lung disease

Respiratory viral infections are a major public health problem, with much of their morbidity and mortality due to post-viral lung diseases that progress and persist after the active infection is cleared. This paradigm is implicated in the most common forms of chronic lung disease, such as asthma and COPD, as well as other virus-linked diseases including progressive and long-term coronavirus disease 2019. Despite the impact of these diseases, there is a lack of small-molecule drugs available that can precisely modify this type of disease process. Here we will review current progress in understanding the pathogenesis of post-viral and related lung disease with characteristic remodelling phenotypes. We will also develop how this data leads to mitogen-activated protein kinase (MAPK) in general and MAPK13 in particular as key druggable targets in this pathway. We will also explore recent advances and predict the future breakthroughs in structure-based drug design that will provide new MAPK inhibitors as drug candidates for clinical applications. Each of these developments point to a more effective approach to treating the distinct epithelial and immune cell based mechanisms, which better account for the morbidity and mortality of post-viral and related types of lung disease. This progress is vital given the growing prevalence of respiratory viruses and other inhaled agents that trigger stereotyped progression to acute illness and chronic disease.

Articular manifestations related to anti-interleukin-5 therapies in severe asthma: a case series

Articular manifestations should be screened before and during anti-IL-5/5R biologic treatment in severe asthma. Rigorous multidisciplinary team discussion should be carried out to assess the risk-benefit balance of withholding effective treatment. https://bit.ly/3vfPn4k.

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

OBJECTIVE

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

DATA SOURCES

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

STUDY SELECTIONS

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

RESULTS

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

SUMMARY

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

Sustained efficacy of mepolizumab in patients with severe chronic rhinosinusitis with nasal polyps: SYNAPSE 24-week treatment-free follow-up

BACKGROUND

In the 52-week Phase III SYNAPSE study, mepolizumab given every 4 weeks (100 mg subcutaneously) reduced nasal polyp (NP) size, improved symptoms and quality of life (QoL), and reduced corticosteroid use and number of sinus surgeries in patients with severe chronic rhinosinusitis with nasal polyps (CRSwNP), versus placebo. Because the durability of mepolizumab's efficacy after discontinuation is poorly understood in CRSwNP, the efficacy of mepolizumab after discontinuation was analyzed in severe CRSwNP, over a 24-week follow-up.

METHODS

Changes from SYNAPSE baseline to end of treatment (week 52) and end of follow-up (week 76) were assessed for total endoscopic NP score, nasal obstruction and overall symptoms visual analog scale scores, and 22-item Sino-Nasal Outcome Test score. Time to first sinus surgery, time to first corticosteroid use, and geometric mean blood eosinophil counts (BECs) were also assessed.

RESULTS

Among 134 follow-up patients, clinical improvements observed with mepolizumab versus placebo were partially evident 24 weeks after discontinuation despite BEC returning to baseline. The mean (95% confidence interval [CI]) change from baseline in NP score (week 52: -1.3 [1.8 to -0.9] vs. -0.3 [-0.6 to 0.1]; week 76: -1.2 [-1.6 to -0.7] vs. -0.1 [-0.5 to 0.3]) and the proportion of patients having sinus surgery (week 52: 4% vs. 25%; week 76: 9% vs. 31%) remained substantially improved with mepolizumab versus placebo. Mepolizumab-associated improvements in overall symptoms, quality of life, and corticosteroid use versus placebo were partially sustained at week 76.

CONCLUSION

Fifty-two weeks of mepolizumab treatment is associated with sustained clinical benefits up to 24 weeks after discontinuation in patients with severe CRSwNP, which should be considered by physicians when making treatment decisions.

Efficacy and Safety of Mepolizumab in the Management of Severe Eosinophilic Asthma: A Systematic Review

Severe eosinophilic asthma (SEA) is characterized by persistent airway inflammation and frequent exacerbations despite standard treatments. Mepolizumab, a monoclonal antibody that reduces eosinophil levels by targeting interleukin-5, has emerged as an add-on therapy for patients with SEA. This systematic review evaluated mepolizumab's efficacy and safety for treating SEA. A comprehensive literature search was conducted across major databases. Thirty-two studies with over 6,000 patients were included, comprising randomized controlled trials, open-label extensions, and real-world observational analyses. Study quality and risk of bias were assessed using standard tools. Meta-analysis was deemed inappropriate due to heterogeneity. Instead, a narrative synthesis was performed. Mepolizumab significantly reduced exacerbation rates by around 50% and improved symptoms and lung function compared to placebo in pivotal trials. Long-term open-label studies showed sustained reductions in exacerbations and stable lung function for up to 4.5 years. Real-world data demonstrated consistent 50%-90% exacerbation decreases across diverse patient populations over 6-24 months. Mepolizumab exhibited an acceptable safety profile, with mild injection site reactions and headaches as most common adverse events. While specific subgroups may show enhanced responses, mepolizumab displayed broad efficacy regardless of patient demographics or phenotypes. The extensive evidence provides robust support for mepolizumab as an efficacious and safe add-on treatment option for patients with severe, refractory eosinophilic asthma. Further high-quality comparative effectiveness research is warranted to optimize patient selection and positioning among emerging biologics.

The association of varying treatment thresholds of mepolizumab on asthma exacerbations in adults

Background: Asthma has a high healthcare burden globally, with up to 10% of the asthma population suffering from severe disease. Biologic agents are a newer class of asthma treatments for severe asthma, with good evidence for efficacy in clinical trials. Nevertheless, real-world studies of its impact on clinical outcomes are limited.Methods: This is an observational cohort study using administrative claims data. The study population consisted of patients aged ≥18 years who had a diagnosis of asthma and initiated mepolizumab after November 4, 2015 and had continuous medical and drug coverage in both the 365 days prior to and following mepolizumab initiation. In patients treated with mepolizumab, we described clinically significant asthma exacerbations by minimum continuous treatment thresholds following initiation of mepolizumab, medication switching patterns and chronic oral corticosteroid (≥28 days) use.Results: We identified 2,536 adults with asthma who initiated mepolizumab. There was an association toward reduction in severe asthma-related events over the first one year of exposure. We observed associations with reduced dispensings of oral corticosteroids over the first year after mepolizumab initiation. Very few patients switched to other biologics during the study period.Conclusions: Treatment with mepolizumab may be associated with fewer asthma-related events in the first year. Over the first one year after initiating mepolizumab, we found associations with decreased concomitant dispensings of oral corticosteroids and medium to high dose ICS/LABA. Additionally, most patients who initiated mepolizumab did not switch to other biologics.

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.

Mepolizumab in chronic rhinosinusitis with nasal polyposis

Chronic rhinosinusitis with nasal polyposis (CRSwNP) is a heterogeneous upper airway disease that is prevalent globally. Recent research into the molecular basis of the disease has led to the development of biologics as a new therapeutic option for severe and recalcitrant forms of CRSwNP. Mepolizumab is a monoclonal antibody targeting IL-5, one of the signature cytokines of the type 2 immune response and which plays an important role in the pathogenesis of CRSwNP. Here we present the latest evidence behind mepolizumab, examining disease pathophysiology and pharmacology, as well as data from clinical trials, real-life studies and meta-analyses. As we welcome this promising step forward into precision medicine, we discuss practical issues and future perspectives on mepolizumab and biologics for CRSwNP.

[Biologics in severe childhood asthma]

INTRODUCTION

Severe asthma in children remains relatively rare. It is no longer considered as a single disease but rather as a syndrome corresponding to different phenotypes and distinct pathophysiological pathways. Various biomarkers can contribute to phenotyping, essentially specific IgE test results, blood eosinophil counts, the exhaled fraction of NO (FeNO) assay, as well as deep lung biomarkers from induced sputum, bronchoalveolar lavage or bronchial biopsy.

STATE OF KNOWLEDGE

In children, the biologics currently approved for severe asthma are omalizumab, mepolizumab and dupilumab from the age of 6, and tezepelumab from the age of 12.

PERSPECTIVES

Benralizumab and tezepelumab offer promising perspectives and a pediatric extension could be of interest in future treatment of severe pediatric asthma.

CONCLUSIONS

Based on physiopathological mechanisms, biologics represent a new and promising approach in the treatment of asthma. That said, the long-term efficacy and impact of these treatments on the natural history of the disease require further investigation. It is of paramount importance to take into account the specificities of pediatric asthma and, more particularly, to conduct clinical trials in younger patients.

[Advances in the management of asthma]

Asthma is a heterogeneous inflammatory airway disease that causes relevant morbidity across individuals of all age cohorts. In recent years, advances in the understanding of asthma pathophysiology have led to the development of treatments tailored to specific pheno- and endotypes of the disease. This has significantly changed asthma management, especially for patients with severe disease. These new treatment options offer individuals with asthma access to personalized and disease-modifying therapies. The present paper is a comprehensive overview of recent clinical studies and of German and international guideline updates on asthma management.

Long-Term Efficacy of Mepolizumab at 3 Years in Patients with Severe Asthma: Comparison with Clinical Trials and Super Responders

The efficacy mepolizumab in severe asthmatic patients is proven in the literature. Primarily to study the effect of mepolizumab on exacerbations, steroid dependence, and the continuation of efficacy in the long term. Secondarily to evaluate the effect of the drug on nasal polyps. Analyzing data from SANI (Severe Asthma Network Italy) clinics, we observed severe asthmatic patients treated with mepolizumab 100 mg/4 weeks, for a period of 3 years. 157 patients were observed. Exacerbations were reduced from the first year (-84.6%) and progressively to 90 and 95% in the second and third ones. Steroid-dependent patients decreased from 54% to 21% and subsequently to 11% in the second year and 6% in the third year. Patients with concomitant nasal polyps, assessed by SNOT-22, showed a 49% reduction in value from baseline to the third year. The study demonstrated the long-term efficacy of mepolizumab in a real-life setting.

Immunoregulation of asthma by type 2 cytokine therapies: Treatments for all ages?

Asthma is classically considered to be a disease of type 2 immune dysfunction, since many patients exhibit the consequences of excess secretion of cytokines such as IL-4, IL-5, and IL-13 concomitant with inflammation typified by eosinophils. Mouse and human disease models have determined that many of the canonical pathophysiologic features of asthma may be caused by these disordered type 2 immune pathways. As such considerable efforts have been made to develop specific drugs targeting key cytokines. There are currently available multiple biologic agents that successfully reduce the functions of IL-4, IL-5, and IL-13 in patients, and many improve the course of severe asthma. However, none are curative and do not always minimize the key features of disease, such as airway hyperresponsiveness. Here, we review the current therapeutic landscape targeting type 2 immune cytokines and discuss evidence of efficacy and limitations of their use in adults and children with asthma.

Priority index for asthma (PIA): In silico discovery of shared and distinct drug targets for adult- and childhood-onset disease

Asthma is a chronic disease that is caused by a combination of genetic risks and environmental triggers and can affect both adults and children. Genome-wide association studies have revealed partly distinct genetic architectures for its two age-of-onset subtypes (namely, adult-onset and childhood-onset). We reason that identifying shared and distinct drug targets between these subtypes may inform the development of subtype-specific therapeutic strategies. In attempting this, we here introduce Priority Index for Asthma or PIA, a genetics-led and network-driven drug target prioritisation tool for asthma. We demonstrate the validity of the tool in improving drug target prioritisation for asthma compared to the status quo methods, as well as in capturing the underlying etiology and existing therapeutics for the disease. We also illustrate how PIA can be used to prioritise drug targets for adult- and childhood-onset asthma, as well as to identify shared and distinct pathway crosstalk genes. Shared crosstalk genes are mostly involved in JAK-STAT signaling, with clinical evidence supporting that targeting this pathway may be a promising drug repurposing opportunity for both subtypes. Crosstalk genes specific to childhood-onset asthma are enriched for PI3K-AKT-mTOR signaling, and we identify genes that are already targeted by licensed medications as repurposed drug candidates for this subtype. We make all our results accessible and reproducible at http://www.genetictargets.com/PIA. Collectively, our study has significant implications for asthma computational medicine research and can guide the future development of subtype-specific therapeutic strategies for the disease.

Severe asthma remaining well-controlled after mepolizumab discontinuation: A case report and literature review

Mepolizumab, a humanized anti-IL-5 monoclonal antibody used for severe asthma, results in a reduced rate of asthma exacerbation, improved lung function, reduced oral corticosteroid use, and improved quality of life. A 62-year-old man using high-dose inhaled corticosteroid visited our hospital because of poorly-controlled asthma. He had eosinophilia in peripheral blood and sputum, and high levels of fraction of exhaled nitric oxide. Therefore, he was treated with mepolizumab for severe asthma. Mepolizumab treatment resulted in significantly improved pulmonary function and reduced frequencies of asthma exacerbations. Because of his good asthma control, mepolizumab treatment was discontinued after 3 years. Since discontinuing mepolizumab, his asthma control has remained without exacerbation. Previous studies suggest that mepolizumab should be continued to sustain clinical benefits. However, cases of long-term controlled asthma have not been reported after mepolizumab withdrawal, and our case may be instructive.

Biological therapy management from the initial selection of biologics to switching between biologics in severe asthma

The aim of this review is to elaborate the management of biologic therapy from initial selection to switching biologics in severe asthma. A nonsystematic review was performed for biological therapy management in severe asthma. Depending on clinical characteristics and biomarkers, selecting the preferred biologic based on super-responder criteria from previous studies may result in adequate clinical efficacy in most patients. On the other hand, no matter how carefully the choice is made, in some patients, it may be necessary to discontinue the drug due to suboptimal clinical response or even no response. This may result in the need to switch to a different biological therapy. How long the biological treatment of patients whose asthma is controlled with biologics will be continued and according to which criteria they will be terminated remains unclear. It has been shown that in patients with a long history of good response to biologics, asthma control may be impaired when biologics are discontinued, while it may persist in others. Therefore, discontinuation of biologics may be a viable strategy in a particular patient group. Clinicians should make the best use of all predictive factors to identify patients who will most benefit from each biologic. Patients who do not meet a predefined response criterion after sufficient time for response evaluation and who are eligible for one or more alternative biological agents should be offered the opportunity to switch to another biologic. There is no consensus on when the biologics used in severe asthma that produce favorable results should be discontinued. In our opinion, treatment should continue for at least five years, as premature termination may potentially deteriorate asthma control.

Mapping knowledge structure and research of the biologic treatment of asthma: A bibliometric study

Background

Bronchial asthma (asthma) is a chronic inflammatory disease of the airways, involving a variety of cells and cellular components, that manifests clinically as recurrent episodes of wheezing, shortness of breath, with or without chest tightness or cough, airway hyperresponsiveness, and variable airflow limitation. The number of people with asthma has reached 358 million worldwide and asthma causes huge economic loss. However, there is a subset of patients who are not sensitive to existing drugs and the existing drugs have many adverse effects. Therefore, it's important to find new drugs for asthma patients.

Methods

Publications related to biologics in asthma published from 2000 to 2022 were retrieved from Web of Science Core Collection. The search strategies were as follows: topic: TS=(biologic* OR "biologic* product*" OR "biologic* therap*" OR biotherapy* OR "biologic* agent*" OR Benralizumab OR "MEDI-563" OR Fasenra OR "BIW-8405" OR Dupilumab OR SAR231893 OR "SAR-231893" OR Dupixent OR REGN668 OR "REGN-668" OR Mepolizumab OR Bosatria OR "SB-240563" OR SB240563 OR Nucala OR Omalizumab OR Xolair OR Reslizumab OR "SCH-55700" OR SCH55700 OR "CEP-38072" OR CEP38072 OR Cinqair OR "DCP-835" OR DCP835 OR Tezspire OR "tezepelumab-ekko" OR "AMG-157" OR tezspire OR "MEDI-9929" OR "MEDI-19929" OR MEDI9929 OR Itepekimab OR "REGN-3500"OR REGN3500 OR "SAR-440340"OR SAR440340 OR Tralokinumab OR "CAT-354" OR Anrukinzumab OR "IMA-638" OR Lebrikizumab OR "RO-5490255"OR "RG-3637"OR "TNX-650"OR "MILR1444A"OR "MILR-1444A"OR"PRO301444"OR "PRO-301444"OR Pitrakinra OR altrakincept OR "AMG-317"OR"AMG317" OR Etokimab OR Pascolizumab OR "IMA-026"OR Enokizumab OR "MEDI-528"OR "7F3COM-2H2" OR 7F3COM2H2 OR Brodalumab OR "KHK-4827" OR "KHK4827"OR "AMG-827"OR Siliq OR Ligelizumab OR "QGE-031" OR QGE031 OR Quilizumab OR Talizumab OR "TNX-901" OR TNX901 OR Infliximab OR Etanercept OR "PRS-060") AND TS=asthma*. The document type was set to articles and review articles and the language restriction was set to English. Three different analysis tools including one online platform, VOS viewer1.6.18, and CiteSpace V 6.1.R1 software were used to conduct this bibliometric study.

Results

This bibliometric study included 1,267 English papers published in 244 journals from 2,012 institutions in 69 countries/regions. Omalizumab, benralizumab, mepolizumab, and tezepelumab in relation to asthma were the research hotspots in the field.

Conclusion

This study systematically uncovers a holistic picture of existing literature related to the biologic treatment of asthma over the past 20 years. We consulted scholars in order to understand key information in this field from the perspective of bibliometrics, which we believe may greatly facilitate future research in this field.