Biologics in severe asthma: the role of real-world evidence from registries

Management of Chronic Asthma in Adults

Asthma is characterized by chronic inflammation and respiratory symptoms such as wheezing and coughing. In the United States, it affects 25 million people annually. Chronic smokers, poor adherence to medications, incorrect use of inhalers, and overall poor asthma control are known risk factors that lead to poorly controlled chronic asthmatics. Although asthma is traditionally categorized by severity, treatment by primary care providers is guided by the Global Initiative for Asthma or the National Asthma Education and Prevention Program. As more research is available, shared decision-making between health care providers and patients will lead to improved outcomes in managing chronic asthma.

Real-World Effectiveness of Biologics in Patients With Severe Asthma: Analysis of the KoSAR

PURPOSE

Severe asthma is associated with high morbidity and healthcare utilization; however, treatment options for these patients are limited. This study aimed to determine the therapeutic effects of biologics in clinical practice.

METHODS

This multicenter, retrospective cohort study included 136 patients who received biologics for at least 4 months between September 2017 and July 2022 at 25 medical centers affiliated with the Korean Severe Asthma Registry (KoSAR). The study evaluated the treatment effects, including acute exacerbation rates, maintenance of oral corticosteroid dosages, lung function, quality of life, blood eosinophil count, and fractional exhaled nitric oxide (FeNO) levels, by comparing measurements before and after 4 months of biologic treatment. Responses for each medication was evaluated based on the Global Evaluation of Treatment Effectiveness score, and any adverse reactions were summarized.

RESULTS

With the administration of biologics over the course of 4 months, there was a reduction in asthma acute exacerbations, a significant improvement in lung function, and a significant decrease in daily maintenance dose of oral steroid. Blood eosinophil counts decreased in the mepolizumab and reslizumab groups, while FeNO levels decreased only in the dupilumab group. The Asthma Control Test, Quality of Life Questionnaire for Adult Korean Asthmatics, and the EuroQol-visual analogue scale scores showed a significant improvement. Most patients (80.15%) responded to the biologic treatment. Meanwhile, non-responders often had chronic rhinosinusitis as a comorbidity, exhibited lower lung function, and required higher doses of oral steroids. No severe adverse events were reported.

CONCLUSIONS

Biologics are highly effective in Korean patients with Type 2 severe asthma, significantly reducing acute exacerbation rates and doses of oral corticosteroids, while also improving lung function. Therefore, it seems beneficial to administer biologics without any restrictions to patients exhibiting Type 2 severe asthma.

Severe asthma care trajectories: the French RAMSES cohort

Background

The French RAMSES study is an observational prospective multicentre real-life cohort including severe asthmatic subjects. The objective of the study was to compare the characteristics of patients, in terms of phenotype and asthma care trajectories, between those managed by tertiary referral centres (TRCs) or secondary care centres (SCCs).

Methods

Patients were prospectively recruited and enrolled for a 5-year follow-up. Patients' characteristics were analysed at inclusion and compared between TRCs and SCCs.

Results

52 centres (24 TRCs and 28 SCCs) included 2046 patients: 1502 (73.4%) were included by a TRC and 544 (26.6%) by a SCC. Patients were mainly women (62%), 53±15 years old, 67% with Asthma Control Test <20; at inclusion, 14% received oral corticosteroids (OCS) and 66% biologics. Compared with the SCC group, the TRC group had more frequent comorbidities and lower blood eosinophil counts (262 versus 340 mm-3; p=0.0036). OCS and biologics use did not differ between groups, but patients in the TRC group benefited more frequently from an educational programme (26% versus 18%; p=0.0008) and received more frequently two or more sequential lines of biologics (33% versus 24%; p=0.0105). In-depth investigations were more frequently performed in the TRC group (allergy tests: 74% versus 62%; p<0.0001; exhaled nitric oxide fraction: 56% versus 21%; p<0.0001; induced sputum: 6% versus 3%; p=0.0390).

Conclusions

Phenotypes and care trajectories differed in the RAMSES cohort between SCCs and TRCs, probably related to different levels of asthma severity and differences in medical resources and practices among centres. This highlights the need for standardisation of severe asthma care.

Real-life studies and registries of severe asthma: The advent of digital technology

Severe asthma is a chronic and heterogeneous disease that negatively affects the quality of life of our patients and health care utilization. Given the remaining burden of uncontrolled disease in many of these patients, better understanding of its epidemiology, disease mechanisms, effectiveness of novel therapies such as biologics are still highly needed. Asthma treatment guidelines are largely informed by randomized controlled trials (RCTs) and meta analyses of RCTs, however inclusion criteria of many efficacy RCTs of asthma treatments often exclude a high number of patients with asthma in the community. Data from real-life studies and registries of severe asthma can complement efficacy studies by not only providing evidence on how a treatment performs in everyday clinical practice, post marketing safety information, data to support subsequent clinical trial design, but also helping to delineate the natural history of a disease and supporting important translational research endeavors. In the current review, we summarise available national and international collaborative studies and registries, the variables studies and the novel data and insights they provide. The key source of information for most asthma registries are real-life data from patient's electronic health records. Advent of digital technology in collecting data and their analysis is obvious and we draw attention to generation of new knowledge from registries of severe asthma to improve current diagnostic and therapeutic guidelines and asthma control.

Adult Severe Asthma Registries: A Global and Growing Inventory

Aim

The International Severe Asthma Registry (ISAR; http://isaregistries.org/) uses standardised variables to enable multi-country and adequately powered research in severe asthma. This study aims to look at the data countries within ISAR and non-ISAR countries reported collecting that enable global research that support individual country interests.

Methods

Registries were identified by online searches and approaching severe asthma experts. Participating registries provided data collection specifications or confirmed variables collected. Core variables (results from ISAR's Delphi study), steroid-related comorbidity variables, biologic safety variables (serious infection, anaphylaxis, and cancer), COVID-19 variables and additional variables (not belonging to the aforementioned categories) that registries reported collecting were summarised.

Results

Of the 37 registries identified, 26 were ISAR affiliates and 11 non-ISAR affiliates. Twenty-five ISAR-registries and 4 non-ISAR registries reported collecting >90% of the 65 core variables. Twenty-three registries reported collecting all optional steroid-related comorbidity variables. Twenty-nine registries reported collecting all optional safety variables. Ten registries reported collecting COVID-19 variables. Twenty-four registries reported collecting additional variables including data from asthma questionnaires (10 Asthma Control Questionnaire, 20 Asthma Control Test, 11 Asthma Quality of Life Questionnaire, and 4 EuroQol 5-dimension 5-level Questionnaire). Eight registries are linked to databases such as electronic medical records and national claims or disease databases.

Conclusion

Standardised data collection has enabled individual severe asthma registries to collect unified data and increase statistical power for severe asthma research irrespective of ISAR affiliations.

Management of Chronic Asthma in Adults

Asthma is characterized by chronic inflammation and respiratory symptoms such as wheezing and coughing. In the United States, it affects 25 million people annually. Chronic smokers, poor adherence to medications, incorrect use of inhalers, and overall poor asthma control are known risk factors that lead to poorly controlled chronic asthmatics. Although asthma is traditionally categorized by severity, treatment by primary care providers is guided by the Global Initiative for Asthma or the National Asthma Education and Prevention Program. As more research is available, shared decision-making between health care providers and patients will lead to improved outcomes in managing chronic asthma.

Montelukast as a potential treatment for COVID-19

INTRODUCTION

Montelukast is a leukotriene inhibitor that is widely used to treat chronic asthma and allergic rhinitis. The drug interferes with molecular signaling pathways produced by leukotrienes in a variety of cells and tissues throughout the human body that lead to tightening of airway muscles, production of aberrant pulmonary fluid (airway edema), and in some cases, pulmonary inflammation.

AREAS COVERED

Montelukast has also been noted to have anti-inflammatory properties, suggesting it may have a role in the treatment of coronavirus disease 2019 (COVID-19), the disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which has been noted to induce misfiring of the immune system in some patients. A literature search of PubMed was performed to identify all relevant studies of montelukast and SARS-CoV-2 through 27 January 2023.

EXPERT OPINION

Montelukast has been the subject of small studies of SARS-CoV-2 and will be included in a large, randomized, double-blind, placebo-controlled study of outpatients with COVID-19 sponsored by the United States National Institutes of Health known as Accelerating COVID-19 Therapeutic Interventions and Vaccines-6. This paper reviews what is known about montelukast, an inexpensive, well-tolerated, and widely available medication, and examines the rationale for using this drug to potentially treat patients with COVID-19.