Real-life effects of dupilumab in patients with severe type 2 asthma, according to atopic trait and presence of chronic rhinosinusitis with nasal polyps

Clinical response and remission in patients treated with dupilumab for severe asthma: Results from the nationwide Danish Severe Asthma Register

BACKGROUND

Randomized clinical trials have demonstrated that dupilumab reduces exacerbations and maintenance oral corticosteroids (mOCS) use in patients with uncontrolled and severe asthma. However, evidence in real-life settings is limited.

OBJECTIVE

This study aimed to evaluate the proportion of patients achieving a clinical response and remission after treatment with dupilumab and identify predictors of response.

METHODS

We conducted a prospective observational study involving 203 severe asthma patients from the nationwide Danish Severe Asthma Register treated with dupilumab for 12 months. Clinical response to treatment was defined as a 50% reduction in exacerbations and/or a 50% reduction in mOCS dose. Clinical remission required meeting all the following criteria: complete cessation of exacerbations, no mOCS use, an Asthma Control Questionnaire (ACQ-6) score <1.50 and forced expiratory volume in one second (FEV1) > 80% of the predicted value. Predictors of treatment response were identified in a multivariate logistic regression model.

RESULTS

After 12 months of dupilumab treatment, 91% of patients demonstrated a clinical response, and 30% achieved clinical remission. All patients experienced fewer exacerbations, while patients with a clinical response and those achieving remission also exhibited significant improvements in mOCS dose reduction, FEV1%, and ACQ-6 score. Predictors of remission included higher baseline fractional exhaled nitric oxide [OR=3.82 (95% CI: 0.90, 16.17)], lower body mass index [OR=0.82 (95% CI: 0.71, 0.93) for one unit increase], and the absence of allergic rhinitis [OR=0.30 (95% CI: 0.08, 1.11)].

CONCLUSION

In this real-life setting, involving over 200 patients treated with dupilumab for 12 months, 91% had a clinical response, and 30% of patients achieved clinical remission. These findings highlight dupilumab's potential in improving outcomes for severe asthma patients.

Eosinophil-targeted treatment strategies for long-term outcomes in severe eosinophilic asthma

BACKGROUND

Airway eosinophilic inflammation is a key pathobiologic trait of severe asthma, a complex chronic disease which affects about 5-10% of asthmatic patients worldwide. Therefore, an in-depth knowledge of the immunopathologic mechanisms underlying severe eosinophilic asthma (SEA) is essential to understand the beneficial effects of currently available, eosinophil-targeted anti-asthma treatments, as well as to develop new therapeutic strategies.

AREAS COVERED

This narrative review article aims to provide a concise coverage of the pathophysiology of severe eosinophilic asthma, followed by an updated overview of current and newly emerging therapeutic approaches capable of counteracting airway eosinophilic inflammation. All information reported comes from an extensive literature search conducted on PubMed.

EXPERT OPINION

The recent advances regarding our understanding of the proinflammatory pathways characterizing the various SEA endotypes are allowing to shape effective therapeutic options, driven by the accurate selection of relevant molecular targets. Such successful developments are at the basis of the sustained clinical remission of eosinophilic asthma, which today represents a realistic goal for many severe asthmatic patients.

Exploring factors associated with clinical remission in patients with severe asthma receiving anti-IL-4Rα, anti-IL-5/5R, or anti-IgE treatment

BACKGROUND

The optimal selection of biologics is critical for achieving clinical remission (CR) in patients with severe asthma. This real-world study examined baseline prebiologic factors associated with CR in patients with severe asthma receiving anti-IL-4Rα, anti-IL-5/5R, or anti-IgE treatment.

METHODS

This Japanese multicenter retrospective observational study included consecutive patients with severe asthma whose spirometry and asthma control test (ACT) data were available after at least 1 year of anti-IL-4Rα, anti-IL-5/5R, or anti-IgE treatment. The 3-domain CR was defined based on no maintenance oral corticosteroid (OCS) use, no exacerbation in the previous year, and ACT ≥23. The 4-domain CR was defined based on no OCS, no exacerbation, ACT ≥20, and percentage-predicted forced expiratory volume in 1 s ≥ 80 %.

RESULTS

A total of 236 patients with severe asthma were included (n = 81, 104, and 51 for the anti-IL-4Rα, anti-IL-5/5R, and anti-IgE treatment groups, respectively). The rates of 3- and 4-domain CR were 28-47 % and 22-36 %, respectively. In the multivariate models, the presence of chronic rhinosinusitis and higher FeNO levels were associated with 3-domain CR in patients receiving anti-IL-4Rα treatment but not in those receiving anti-IL-5/5R or anti-IgE treatment after adjusting for baseline OCS use, past-year exacerbation history, body mass index, sex, and disease duration. Moreover, higher FeNO levels were associated with 4-domain CR in patients receiving anti-IL-4Rα treatment after adjustment for the same variables.

CONCLUSION

Anti-IL-4Rα treatment may be effective for patients with severe asthma who have chronic rhinosinusitis or high FeNO levels at baseline.

Biological therapy in chronic rhinosinusitis with nasal polyps

INTRODUCTION

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a heterogeneous disease. High proportions of patients with CRSwNP characterized by type 2 inflammation fail to gain adequate control with conventional treatment. The application of biologics in clinics and assessments of novel biologics in clinical trials are blooming in expectations to fulfill the unmet medical needs of patients with CRSwNP with type 2 inflammation.

AREAS COVERED

After an extensive search of PubMed, Medline, and EMBASE for the most recent evidence, we thoroughly summarize current advances in biological therapies for treating patients with CRSwNP.

EXPERT OPINION

In recent years, biological therapy has been in the spotlight in clinical studies on CRSwNP. Biologics have proven to be efficacious in reducing nasal polyp size, alleviating CRSwNP-related symptoms, improving quality of life, and reducing the need for systemic corticosteroids or endoscopic sinus surgery for nasal polyps. The considerable efficacy and safety profile of biologics has offered patients with refractory CRSwNP another treatment option. However, some concerns remain to be addressed. Aspects such as the position of biological therapy in the management of CRSwNP, traits of patients suitable for certain biologics, etc. necessitate efforts to elucidate these unknowns in order to provide patients with tailored therapy.

Real-world comparison of T2-biologics effectiveness in severe allergic asthma with nasal polyps

BACKGROUND

Patients with severe allergic asthma (SAA) and blood eosinophil count ≥0.3x109/L are eligible for multiple biologics. Several of them showed benefits on nasal polyps (NP), a frequent comorbidity of the severe asthma, but comparative studies on their effectiveness in the association SAA-NP are currently lacking. OUR OBJECTIVE: was to compare the effectiveness of anti-IgE, anti-IL5/R and anti-IL4R in patients with SAA-NP in real-world settings.

METHODS

A real-world multicentre observational study was realized including patients with SAA-NP treated by anti-IgE, anti-IL5/R or anti-IL4R for 6 months. We analyzed the nasal and respiratory symptoms, the number of asthma attacks and salbutamol use/week, acute sinusitis and severe exacerbation rates, the asthma control score, the lung function parameters, the NP endoscopic score, the sinus imaging, and the blood eosinophil count 6 months before and after treatment.

RESULTS

One hundred seven patients with SAA-NP were included: 35 treated by anti-IgE, 38 by anti-IL5/R and 34 by anti-IL4R. All the biologics showed similar effectiveness in improving asthma outcomes (symptoms, exacerbation rate, asthma control, lung function). Despite the amelioration of almost all rhinological parameters and sinus imaging in each group, greater benefits were found in the anti-IL4R group in terms of loss of smell (odds ratio OR 3.64[1.3-11.1], p = 0.017), nasal obstruction (OR12.00[2.00-23.10], p = 0.023), and NP endoscopic score (OR 18.10[4.43-24.50]).

CONCLUSION

All three biological classes improved asthma and sino-nasal outcomes in patients with SAA-NP. However, anti-IL4R was superior in improving the smell, nasal obstruction, and NP endoscopic size. Larger comparative studies are needed to confirm our results.

Profiling Blood Hypereosinophilia in Patients on Dupilumab Treatment for Respiratory Conditions: A Real-Life Snapshot

BACKGROUND

A transient and usually asymptomatic increase in blood eosinophil count (BEC) associated with dupilumab treatment has been described. Predicting factors related to the increase in BEC and the occurrence of symptoms are still poorly investigated.

OBJECTIVE

To investigate frequency, timing, duration, clinical relevance, and potential predictors of the increase in BEC in a real-life multicenter cohort of patients affected by asthma and/or chronic rhinosinusitis with nasal polyps (CRSwNP) treated with dupilumab.

METHODS

BEC and clinical conditions at baseline and every 3 months after the start of dupilumab treatment were assessed. Any adverse drug reaction was also recorded. Remission of dupilumab-associated eosinophilia was defined by follow-up BEC values <0.5 × 109 cells/L.

RESULTS

Overall, 108 of 195 (55%) patients experienced an increased BEC after dupilumab initiation, but only 29 of 195 (14.9%) showed hypereosinophilia. BEC peak occurred 6 months after the start of treatment and resolved after 9 months (median time). The probability of developing hypereosinophilia was 3.3 times higher in patients with the baseline BEC between 0.5 × 109 and 1.5 × 109 cells/L. The occurrence of symptoms during BEC peak was higher in patients with comorbidities and in patients showing any increase in BEC.

CONCLUSIONS

In a real-life setting, dupilumab treatment in patients with asthma and/or CRSwNP was often associated with a transient increase in BEC, but hypereosinophilia rarely occurred. Onset of symptoms co-occurring with BEC peak was observed in a minority of subjects. BEC should not preclude dupilumab initiation or continuation but should be monitored for at least 8 months after treatment begins, particularly in the case of baseline eosinophilia/hypereosinophilia and/or comorbidities.

Effect of Dupilumab in CRSwNP Sinonasal Outcomes from Real Life Studies: A Systematic Review with Meta-analysis

PURPOSE OF REVIEW

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a debilitating inflammatory condition that significantly impacts quality of life. Despite treatment advances, recurrence is common, prompting the exploration of novel therapies such as monoclonal antibodies targeting the type 2 immune response, notably dupilumab. This research aims to evaluate the real-world evidence (RWE) of dupilumab in treating severe CRSwNP, comparing sinonasal outcomes to those observed in randomized clinical trials.

RECENT FINDINGS

Significant improvements were noted, with the average SNOT-22 score reduction being 37.2 points post-dupilumab treatment. The nasal polyp size (NPS) showed an average decrease of 3.6 points. The analysis highlighted the practical effectiveness of dupilumab, emphasizing its benefit over conventional therapies in reducing NPS and improving nasal symptoms. The findings advocate for the integration of dupilumab into standard treatment protocols for severe CRSwNP, providing a robust alternative that could potentially reduce the high recurrence rates associated with current management strategies. This study underscores the utility of RWE in assessing the effectiveness of new medical treatments, suggesting that dupilumab offers substantial real-world benefits for patients suffering from this challenging condition.

Dupilumab induced ocular surface diseases: an analysis of FAERS database, literature review and disease-gene interaction networks

BACKGROUND

Adverse events (AE) in dupilumab-induced ocular surface diseases (DIOSD) have raised concerns regarding its safety. The objective of this study was to evaluate DIOSD by employing database analysis and clinical case review, along with mechanism analysis.

RESEARCH DESIGN AND METHODS

Database AE data were extracted from FAERS from 2017 Quarter 1 (Q1) to 2023 Q1. Disproportionality analyses were performed to identify the risk signals associated with DIOSD. Case reports/case series reported on DIOSD from March 2017 to June 2023 were collected for a literature review. The mechanisms of DIOSD were investigated through disease-gene interaction network analysis.

RESULTS

A total of 85 signals related to DIOSD were detected from FAERS. The most reported AE was 'dry eye' (n = 3503, ROR 20.32, 95% CI: 19.53-21.14). There were 36 articles, including 201 cases showing the evidence of DIOSD, with an average age of 43 years. About 64.18% patients suffered from severe atopic dermatitis, and 48.26% were reported with a previous ocular history. The mechanisms study suggested that tumor necrosis factor plays an important role in DIOSD.

CONCLUSIONS

Our findings support that dupilumab use is associated with exacerbation or new-onset OSD. Particular attention should be focused on eye symptoms during dupilumab use.

Clinical remission attainment, definitions, and correlates among patients with severe asthma treated with biologics: a systematic review and meta-analysis

BACKGROUND

Clinical remission has emerged as an important treatment goal in severe asthma; however, studies have reported variable attainment due to differences in study populations, definitions, and methods. We aimed to perform a systematic review and meta-analysis of clinical remission attainment, definitions, and correlates among patients with severe asthma who have been treated with biologics.

METHODS

In this systematic review and meta-analysis, we searched Web of Science, Embase, and MEDLINE, using the keywords "asthma" and "remission", for studies published between database inception and June 13, 2024, that reported clinical remission among patients with severe asthma treated with biologics. Studies were eligible for inclusion in both the systematic review and meta-analysis if they were published in English language peer-reviewed journals and reported rates of clinical remission for patients treated with biologics for severe asthma. There were no limitations by study design. Two reviewers independently screened identified papers (AS and CR), with disagreements resolved through consensus or referral to a third reviewer (JB). Study-level data on study characteristics, clinical remission definitions, clinical remission attainment, and the potential correlates of clinical remission were extracted independently by two reviewers (AS and CR) using Covidence. We defined a three-component definition of clinical remission, which included use of maintenance oral corticosteroids, exacerbations, and asthma symptom burden, and a four-component definition, which additionally included lung function. We meta-analysed the rate of attainment of clinical remission and assessed the correlates of clinical remission using DerSimonian-Laird random-effects models. Statistical heterogeneity was assessed using the I2 statistic. This study was registered with PROSPERO, CRD42024507233.

FINDINGS

Our search identified 3014 potentially eligible studies, of which 1812 were screened. 25 studies were included, which reported 28 analyses of clinical remission attainment. 68 definitions of clinical remission were identified, of which 48 were unique. Little consensus was found between studies in terms of the clinical remission definition, particularly for symptoms and lung function. Eight analyses used the three-component definition of clinical remission and 25 used the four-component definition. The pooled proportion of patients who attained clinical remission was 38% (95% CI 29-47; I2=93%) for the three-component definition and 30% (27-34; I2=83%) for the four-component definition. Several pulmonary factors were associated with lower clinical remission rates, including worse FEV1 (odds ratio 0·09 [95% CI 0·01-0·92]; I2=87%), worse asthma symptoms (0·23 [0·17-0·33]; I2=0%), longer asthma duration (0·49 [0·32-0·76]; I2=22%), and use of maintenance oral corticosteroids (0·57 [0·40-0·79]; I2=49%). The presence of comorbidities, in particular depression (0·38 [0·23-0·61]; I2=6%) and obesity (0·41 [0·31-0·54]; I2=0%), were important non-pulmonary barriers to clinical remission.

INTERPRETATION

Clinical remission is an achievable goal for a minority of patients with severe asthma treated with biologics. Definitions of clinical remission varied substantially between studies, and materially affected attainment, suggesting an urgent need for further consensus-driven definitions. Longer disease duration, higher asthma severity, and the presence of comorbidities were identified as important barriers to clinical remission, suggesting that earlier intervention with effective treatments and a broader treatable traits approach might improve outcomes.

FUNDING

Health Data Research UK, Inflammation and Immunity driver project.

Identifying super-responders: A review of the road to asthma remission

Asthma is a chronic respiratory disease marked by heterogeneity and variable clinical outcomes. Recent therapeutic advances have highlighted patients achieving optimal outcomes, termed "remission" or "super-response." This review evaluates the various definitions of these terms and explores how disease burden impedes the attainment of remission. We assessed multiple studies, including a recent systematic review and meta-analysis, on biologic treatments for asthma remission. Our review highlights that type 2 inflammation may be the strongest predictor of biologic response. Key comorbidities (eg, obesity and mood disorders) and behavioral factors (eg, poor adherence, improper inhalation technique, and smoking) were identified as dominant traits limiting remission. In addition, asthma burden and longer disease duration significantly restrict the potential for remission in patients with severe asthma under the current treatment paradigm. We review the potential for a "predict-and-prevent" approach, which focuses on early identification of high-risk patients with type 2 inflammation and aggressive treatment to improve long-term asthma outcomes. In conclusion, this scoping review highlights the following unmet needs in asthma remission: (1) a harmonized global definition, with better defined lung function parameters; (2) integration of nonbiologic therapies into remission strategies; and (3) a clinical trial of early biologic intervention in patients with remission-prone, very type 2-high, moderately severe asthma with clinical remission as a predefined primary end point.

Efficacy of dupilumab and risk factors for dupilumab-induced hypereosinophilia in severe asthma: a preliminary study from China

OBJECTIVE

Dupilumab has been approved for the treatment of severe asthma with type 2 inflammation by inhibiting interleukin (IL)-4 and IL-13 signaling. However, dupilumab-induced hypereosinophilia (HE) has been reported and should not be ignored. The aim of this study was to investigate the efficacy of dupilumab in Chinese patients with severe asthma, whether HE affects its efficacy, and the possible risk factors for HE.

METHODS

20 patients with severe asthma who received dupilumab treatment for at least 12 months in the First Affiliated Hospital of Guangzhou Medical University from 2019 to 2022 were included. We compared clinical data and laboratory tests results before dupilumab treatment and at 4 and 12 months after treatment. Based on whether dupilumab treatment triggers HE defined as blood eosinophil count (BEC) ≥ 1.5 × 109 cells/L, the patients were allocated into non-HE and HE groups.

RESULTS

The patients showed a significant increase in asthma control test (ACT) scores, a decrease in the number of exacerbations, a decrease in the proportion of patients taking an oral corticosteroid (OCS) and in the dose, and a significant improvement in the pulmonary function parameters FEV1/FVC (%) and FEV1 (% predicted) after 4 and 12 months of treatment with dupilumab. For type 2 inflammatory biomarkers, the levels of fractional concentration of exhaled nitric oxide (FeNO), sputum eosinophil count percentage (SEC%) and total immunoglobulin E (TIgE) decreased significantly, whereas BEC were higher after 4 months of treatment, but returned to baseline levels after 12 months. 8 patients (40%) developed asymptomatic HE after dupilumab, and the efficacy was not significantly different between the HE and non-HE groups. The earliest BEC elevation appeared at 1 month after treatment, but most of them declined after 6 months, and basically returned to the baseline level around 12 months of treatment. In addition, we further found that when patients had FeNO ≥ 60 ppb, food allergens positive and combined eosinophilic otitis media (EOM), their BEC increased significantly more than that of the control group after 4 months as well as 12 months of treatment.

CONCLUSIONS

This study demonstrated that dupilumab was efficacious in Chinese patients with severe asthma, and some patients developed asymptomatic, self-limited HE, which did not affect its efficacy. Additionally, FeNO ≥60 ppb, food allergens positive, and co-morbidities with EOM may be the risk factors for developing HE.

Dupilumab responder types and predicting factors in patients with type 2 severe asthma: A real-world cohort study

BACKGROUND

Severe asthma (SA) presents a considerable healthcare challenge despite optimal standard treatment. Dupilumab, which is effective in type 2 (T2) SA patients, demonstrates variable responses, categorizing patients as non-responders, partial responders, or those achieving clinical remission. However, real-world response rates remain underexplored. Additionally, understanding the characteristics of patients achieving clinical remission is crucial for predicting favourable responses to dupilumab.

OBJECTIVE

To investigate responder types and identify predictors of clinical remission and non-response induced by dupilumab in a real-world cohort of SA patients.

METHODS

We analyzed retrospective data from SA patients undergoing dupilumab treatment in a study conducted at Franciscus Gasthuis & Vlietland hospital. Data were collected at baseline and at a 12 to 24-months follow-up (T = 12). Response rates were evaluated at T = 12. Predictors of non-response and clinical remission were investigated using multivariate logistic regression analysis with a stepwise forward variable selection approach.

RESULTS

Among the 175 patients screened, 136 met the inclusion criteria. At T = 12, 31.6 % achieved clinical remission, 47.1 % were partial responders and 21.3 % were non-responders. Predictors associated with clinical remission included high baseline blood eosinophil counts (BEC) and male sex. Conversely, younger age at baseline, low baseline total immunoglobin E (IgE) and low baseline fractional exhaled nitric oxide (FeNO) levels were identified as predictors of non-response.

CONCLUSIONS

Dupilumab results in clinical disease remission in one-third of the treated patients. Clinical remission is predicted by high BEC and male sex, whereas low total IgE, low FeNO and younger age indicate a lower likelihood of response.

Exploring potential roles of long non-coding RNAs in cancer immunotherapy: a comprehensive review

Cancer treatment has long been fraught with challenges, including drug resistance, metastasis, and recurrence, making it one of the most difficult diseases to treat effectively. Traditional therapeutic approaches often fall short due to their inability to target cancer stem cells and the complex genetic and epigenetic landscape of tumors. In recent years, cancer immunotherapy has revolutionized the field, offering new hope and viable alternatives to conventional treatments. A particularly promising area of research focuses on non-coding RNAs (ncRNAs), especially long non-coding RNAs (lncRNAs), and their role in cancer resistance and the modulation of signaling pathways. To address these challenges, we performed a comprehensive review of recent studies on lncRNAs and their impact on cancer immunotherapy. Our review highlights the crucial roles that lncRNAs play in affecting both innate and adaptive immunity, thereby influencing the outcomes of cancer treatments. Key observations from our review indicate that lncRNAs can modify the tumor immune microenvironment, enhance immune cell infiltration, and regulate cytokine production, all of which contribute to tumor growth and resistance to therapies. These insights suggest that lncRNAs could serve as potential targets for precision medicine, opening up new avenues for developing more effective cancer immunotherapies. By compiling recent research on lncRNAs across various cancers, this review aims to shed light on their mechanisms within the tumor immune microenvironment.

Type 2 severe asthma: pathophysiology and treatment with biologics

INTRODUCTION

The hallmark of most patients with severe asthma is type 2 inflammation, driven by innate and adaptive immune responses leading to either allergic or non-allergic eosinophilic infiltration of airways. The cellular and molecular pathways underlying severe type 2 asthma can be successfully targeted by specific monoclonal antibodies.

AREAS COVERED

This review article provides a concise overview of the pathophysiology of type 2 asthma, followed by an updated appraisal of the mechanisms of action and therapeutic efficacy of currently available biologic treatments used for management of severe type 2 asthma. Therefore, all reported information arises from a wide literature search performed on PubMed.

EXPERT OPINION

The main result of the recent advances in the field of anti-asthma biologic therapies is the implementation of a personalized medicine approach, aimed to achieve clinical remission of severe asthma. Today this accomplishment is made possible by the right choice of the most beneficial biologic drug for the pathologic traits characterizing each patient, including type 2 severe asthma and its comorbidities.

Type-2 severe asthma comorbidities in the era of biologics: time to rethink clinical response?

INTRODUCTION

The use of monoclonal antibodies in patients with severe asthma has led clinicians to explore new levels of clinical improvement, as testified by the growing interest on clinical remission achievement. In this context, a major role is played by asthma-related comorbidities, which can influence asthma pathophysiology and treatment response.

AREAS COVERED

In this special report, we highlighted how asthma-related comorbidities could deeply affect monoclonal antibody response as well as clinical remission achievement. As examples, we provided data from clinical trials and real-life experiences involving patients with severe asthma and chronic rhinosinusitis with nasal polyps (CRSwNP), eosinophilic granulomatosis with polyangiitis (EGPA) or bronchiectasis.

EXPERT OPINION

Comorbidities associated with severe asthma development should be carefully assessed in everyday clinical practice, even with the help of new diagnostic technologies, artificial intelligence and multidisciplinary teams. Future studies should address the role of comorbidities in remission achievement, describing how these diseases could generate new trajectories of clinical and functional response in patient treated with monoclonal antibodies.

Targeting Asthma Remission as the Next Therapeutic Step Toward Improving Disease Control

The long-term goal of asthma management is to achieve disease control, comprising the assessment of 2 main domains: (1) symptom control and (2) future risk of adverse outcomes. Decades of progress in asthma management have correlated with increasingly ambitious disease control targets. Moreover, the introduction of precision medicines, such as biologics, has further expanded the limits of what can be achieved in terms of disease control. It is now believed that clinical remission, a term rarely associated with asthma, may be an achievable treatment goal. An expert framework published in 2020 took the first step toward developing a commonly accepted definition of clinical remission in asthma. However, there remains a widespread discussion about the clinical parameters and thresholds that should be included in a standardized definition of clinical remission. This review aims to discuss on-treatment clinical remission as an aspirational outcome in asthma management, drawing on experiences from other chronic diseases where remission has long been a goal. We also highlight the integral role of shared decision-making between patients and health care professionals and the need for a common understanding of the individual patient journey to remission as foundational elements in reducing disease burden and improving outcomes for patients with asthma.

Difficult-To-Treat and Severe Asthma: Can Real-World Studies On Effectiveness of Biological Treatments Change the Lives of Patients?

Many different phenotypes that characterize severe asthma are supported by intricate pathomechanisms called endotypes. The latter are driven by molecular interactions, mediated by intercellular networks. With regard to the biological treatments of either allergic or non-allergic eosinophilic type 2 asthma, real-world studies have confirmed the positive effects of currently available antibodies directed against immunoglobulins E (IgE), interleukin-5 (IL-5) and its receptor, as well as the receptors of interleukins-4 (IL-4) and 13 (IL-13). The best way to treat severe asthma should be chosen based on the peculiar phenotypic and endotypic traits of each patient. This will lead to relevant improvements in both clinical and functional outcomes. In particular, biological therapies can change the lives of asthma patients with a strong impact on quality of life. Unfortunately, patients with severe non-type-2 asthma, who continue to have pertinent unmet needs, are not receiving satisfactory advances within the context of biological treatments. It is also hopeful that in the next future new therapeutic strategies will be specifically implemented for these people, perhaps offering them the opportunity to improve their current, mostly inadequate asthma management.

Dupilumab Efficacy on Asthma Functional, Inflammatory, and Patient-Reported Outcomes across Different Disease Phenotypes and Severity: A Real-Life Perspective

Dupilumab is currently approved for the treatment of Type 2 severe asthma and chronic rhinosinusitis with nasal polyps (CRSwNP). Few studies have specifically reported on dupilumab efficacy on asthma outcomes as a primary objective in a real-life setting, in patients with and without CRSwNP. Our study aimed to explore the efficacy of dupilumab on functional, inflammatory, and patient-reported outcomes in asthma patients across different disease phenotypes and severity, including mild-to-moderate asthma coexisting with CRSwNP. Data from 3, 6, and 12 months follow-up were analyzed. Asthma (FEV1%, Tiffeneau%, ACT, FeNO, oral steroid use, exacerbation rate, and blood eosinophilia) and polyposis (SNOT22, VAS, NPS) outcomes showed a rapid (3 months) and sustained (6 and 12 months) significant change from baseline, despite most of the patients achieving oral steroid withdrawal. According to the sensitivity analysis, the improvement was not conditioned by either the presence of polyposis or severity of asthma at baseline. Of note, even in the case of milder asthma forms, a significant further improvement was recorded during dupilumab treatment course. Our report provides short-, medium-, and long-term follow-up data on asthma outcomes across different diseases phenotypes and severity, contributing to the real-world evidence related to dupilumab efficacy on upper and lower airways T2 inflammation.

Comparison of clinical remission criteria for severe asthma patients receiving biologic therapy

BACKGROUND

The concept of remission on biological treatment has been suggested as a therapeutic target for patients with severe asthma, composed of 1. no chronic use of systemic steroids, 2. no exacerbations, 3. minimal symptoms, and 4. optimized lung function, for a significant time. However, the criteria for remission are not clearly defined.

OBJECTIVE

Our objective was to compare different criteria for remission in subjects receiving biologicals for severe asthma.

METHODS

A cross-sectional study of adult subjects who receive a stable regimen of a biological for severe asthma for at least 6-months. We compared the proportion of subjects who fulfilled different specific criteria in the four domains, as well as those who achieved different composite outcome measures of clinical remission.

RESULTS

Of 39 subjects, 28 were females (71.8%), mean age 60.4. Twelve were current or past smokers (30.8%). Twelve had prior different biological treatment (30.8%), and 3/39 had more than one previous treatment (7.7%). Current biological included mepolizumab 12/39 (30.8%), dupilumab 11/39 (28.2%), benralizumab 10/39 (25.6%), omalizumab 5/39 (12.8%), reslizumab 1/39 (2.6%). Different specific criteria were achieved in 39-80% of subjects, being highest for no chronic steroid use and lowest for symptoms control and lung function. Overall remission was obtained by 20-41%, depending on definition, with significant variability in agreement between different sets of remission criteria (Cohen's kappa 0.33-0.89).

CONCLUSION

Clinical remission is achievable in real-world severe asthmatics on biological therapies. The core criteria for remission should be better defined.

A case of recurrent chronic eosinophilic pneumonia after switching from benralizumab to dupilumab

Dupilumab inhibits interleukin-4Rα and suppresses type 2 inflammation. Careful administration of dupilumab is required because it increases the blood eosinophil count secondary to a decrease in local eosinophil counts, sometimes resulting in eosinophilic complications. We herein report a case of recurrent chronic eosinophilic pneumonia after switching from benralizumab to dupilumab. A 54-year-old man with a history of eosinophilic pneumonia presented to our hospital with symptoms of cough, fever, and phlegm production six months after beginning dupilumab administration for recurrent chronic rhinosinusitis. When using dupilumab, it is essential to carefully monitor patients' eosinophil trends and pulmonary symptoms.

Safety of dupilumab in T2 airways conditions: focus on eosinophilia across trials and real-life evidence

INTRODUCTION

Dupilumab, a monoclonal antibody targeting the IL-4 receptor alpha subunit, effectively blocks both IL-4 and IL-13 mediated pathways. Its introduction has represented a significant advancement in the treatment of severe asthma and other Type 2 (T2) conditions, including nasal polyps, atopic dermatitis, and eosinophilic esophagitis. To date, Dupilumab has demonstrated optimal efficacy and safety profile.

AREAS COVERED

The safety profile of dupilumab has been extensively studied, especially for its effects on blood eosinophil count. Transient eosinophil increase during treatment is typically insignificant from a clinical point of view and related to its mechanism of action. Rare cases of hyper-eosinophilia associated with clinical conditions like eosinophilic granulomatosis with polyangiitis (EGPA) and hypereosinophilic syndrome (HES) have been reported. Those cases are often related to the drug's steroid-sparing effect or the natural trajectory of the underlying disease rather than a direct cause-effect relationship with dupilumab.

EXPERT OPINION

The management of hyper-eosinophilia during dupilumab treatment requires comprehensive diagnostic work-up and strict follow-up monitoring for early detection of systemic disease progression in order to avoid unnecessary discontinuation of an effective treatment. This approach highlights the importance of a personalized treatment.

Real-World Characteristics of Patients with Severe Asthma prior to Starting Dupilumab: The ProVENT Study

INTRODUCTION

Dupilumab is approved for the treatment of severe type 2 (T2) asthma; however, the characteristics of patients receiving dupilumab in routine clinical practice are incompletely understood. This study describes the characteristics of patients with severe asthma before dupilumab treatment in a real-world setting.

METHODS

This interim analysis of an ongoing real-life study of dupilumab assessed baseline characteristics of the first patient cohort enrolled in the ProVENT study.

RESULTS

A total of 99 patients (59% females) were analyzed (17% received another biologic before dupilumab treatment and 15% were on maintenance oral corticosteroid treatment). Adult-onset asthma (>18 years) and an allergic phenotype were documented in 58% and 48% of patients, respectively. Median (interquartile range) age was 54 (40-61) years; the median number of exacerbations in the last 24 months was 1 (0-3); median fractional exhaled nitric oxide (FeNO) value was 38 (23-64) ppb; and median blood eosinophils (bEOS) count was 184 (8-505) cells/µL. According to the United Kingdom Severe Asthma Registry classification, 53% of patients had T2 intermediate asthma (bEOS ≥150 cells/µL or FeNO ≥25 ppb), 17% had T2 high asthma (bEOS ≥150 cells/µL and FeNO ≥25 ppb), and 4% had T2 low asthma (bEOS <150 cells/µL and FeNO <25 ppb). At least one GINA criterion for T2 airway inflammation was documented in 70% of patients. T2 comorbidities were observed in 64% of patients.

CONCLUSIONS

This analysis suggests that patients eligible for dupilumab treatment display various clinical and biochemical characteristics rather than one clear-cut phenotype.

Severe asthma clinical remission after biologic treatment with anti-IL4/IL13: A real-life experience

INTRODUCTION

Dupilumab, a fully human anti-interleukin-4/interleukin-13 monoclonal antibody, has shown efficacy in many aspects of Type-2 severe asthma management. Currently, we lack real-life studies addressing the achievment of clinical remission in patients treated with this biologic.

MATERIALS AND METHODS

We performed a prospective study enrolling 18 patients with severe asthma treated with Dupilumab. We assessed main clinical, functional and biological severe asthma features at baseline (T0) and after a 1-year course of treatment (T12). Clinical remission was defined at T12 in patients without asthma exacerbations, no oral corticosteroid (OCS) use, ACT ≥ 20 and FEV1 improvement ≥ 100 ml from baseline.

RESULTS

Among total population, 38.9% of patients achieved clinical remission at T12. Anti IL-4/IL-13 treatment significantly reduced asthma exacerbations and OCS use in the overall cohort, with a more pronounced ACT improvement in the remission group. Patients achieving clinical remission went through a step down of the inhalation therapy, suspending long-acting anti-muscarinics administration at T12.

CONCLUSIONS

Treatment with anti-IL4/IL13 can induce clinical remission in patients with T2 severe asthma.

Personalized Medicine in Asthma: Current Approach and Future Perspectives

Asthma is one of the most common chronic respiratory diseases, affecting over 300 million people worldwide [...].

Dupilumab's Impact on Blood Parameters in Nasal Polyposis: 18-Month Follow-Up in Real Life

Background

Dupilumab represents the first approved biological for severe uncontrolled chronic rhinosinusitis with nasal polyps (CRSwNP).

Objective

Aim of this paper is to provide a multicentric real-life study about treatment with dupilumab for CRSwNP with a special focus on blood parameters and IgE, IgG, and IgA.

Method

A retrospective data collection was jointly conducted at the Otolaryngology departments of San Camillo Forlanini Hospital and University of Rome "La Sapienza" from December 2020 to January 2023.

Results

A total of 130 patients were included in the study. Monitoring our patients for 18 months, we observed a reduction in nasal polyposis and an improvement in symptoms and their impact on quality of life. Regarding blood tests, a transient increase in blood eosinophils was found in most cases. Total IgE showed a gradual decrease in values. IgG and IgA also showed a slight reduction of values, while remaining within normal ranges.

Conclusion

To the best of our knowledge, this is the first study to evaluate the impact of dupilumab on several blood parameters in patients receiving treatment for CRswNP. Further studies are needed to confirm our results and to understand the underlying immunological mechanisms.

Asthma improvement in patients treated with dupilumab for severe atopic dermatitis

Introduction

Atopic dermatitis (AD) is considered a systemic type 2 immune driven disease, and it is associated to many atopic comorbidities including asthma. The aim of our study was to prospectively evaluate the respiratory outcomes in patients with persistent allergic asthma treated with dupilumab due to severe AD (sAD).

Methods

We enrolled eligible patients with sAD for dupilumab treatment from September 2018 to December 2020. We then selected the subgroup of patients sensitized to perennial allergens. Dupilumab's efficacy and safety on AD and comorbid asthma were assessed at baseline, one month, four months, and then every 4 months up to one year.

Results

A total of 437 patients with sAD were enrolled for dupilumab treatment due to sAD, and 273 reached 48 weeks of therapy. Respiratory outcomes were evaluated in the 85 asthmatic patients with positivity only to perennial allergens. Our patients showed statistically and clinically significant improvement in asthma control (Asthma Control Test and Asthma Control Questionnaire) and airway obstruction parameters (FEV1), in addition to the expected AD-related skin outcomes. Specifically, a significant improvement was achieved at the fourth month of dupilumab therapy, and this trend was maintained up to twelve months, regardless of asthma severity.

Conclusions

Our results showed the overall improvement of the clinical picture that dupilumab offers for patients with severe AD and persistent allergic asthma of any severity, highlighting the importance of a global multidisciplinary approach of type 2 driven disease.

Changes in Peripheral Blood Eosinophil Counts and Risk of Eosinophilic Granulomatosis with Polyangiitis Onset after Initiation of Dupilumab Administration in Adult Patients with Asthma

BACKGROUND

The purpose of this study is to clarify the changes in peripheral blood eosinophil (PBE) counts and eosinophilic granulomatosis with polyangiitis (EGPA) onset in patients with asthma who were treated with dupilumab in clinical practice.

METHODS

The primary outcome of this study is to determine the onset of EGPA in patients whose PBE counts continued to rise within 6 months of dupilumab initiation (rising group) and in patients whose PBE counts peaked and subsequently declined within 6 months (peaked and declined group). As a secondary outcome, the incidence of developing EGPA in patients with PBE counts greater than 1500 cells/μL at 3 or 6 months after dupilumab administration is investigated.

RESULTS

A total of 37 individual were enrolled (male/female = 14/23, median age = 57.0 years old). The development of EGPA was significantly more frequent in the rising group compared with the peaked and declined group (p = 0.042, effect size = 0.455, moderate association). Patients with PBE counts greater than 1500 cells/μL showed a significantly higher risk of developing EGPA (p = 0.017, effect size = 0.678, strong association).

CONCLUSIONS

Physicians should check for the onset of EGPA by monitoring the elevation of eosinophils within 6 months after dupilumab administration, especially in patients with PBE counts greater than 1500 cells/μL at 3 months.

Dupilumab in a patient with severe asthma and glucocorticoid hypersensitivity: a case report

Recently, several biologics have been approved for the treatment of severe asthma. Dupilumab, a biologic used to treat severe asthma, is a monoclonal antibody targeting interleukin-4 and interleukin-13. In the present case, inhaled corticosteroid-induced glucocorticoid hypersensitivity was suspected, and the administration of omalizumab and mepolizumab had no beneficial effects. Subsequently, we switched to dupilumab therapy, which produced better effectiveness. Therefore, when a biologic agent proves ineffective, changing to another suitable biologic agent should be considered.

Preclinical immunological characterization of rademikibart (CBP-201), a next-generation human monoclonal antibody targeting IL-4Rα, for the treatment of Th2 inflammatory diseases

Rademikibart (CBP-201) is a next-generation human monoclonal antibody targeting IL-4Rα, undergoing evaluation in Phase 2 clinical trials for the treatment of moderate-to-severe Th2 inflammatory diseases. We report the immunological characterization of rademikibart. Rademikibart and dupilumab were associated with K_D of 20.7 pM and 45.8 pM, respectively, when binding to distinct human IL-4Rα epitopes. Rademikibart did not bind to IL-4Rα from other species. Rademikibart inhibited IL-4 and IL-13-mediated STAT6 signaling (mean ± SD IC₅₀: 7.0 ± 2.5 and 6.6 ± 1.5 ng/mL, respectively), TF-1 cell proliferation (IC₅₀: 8.0 ± 1.6 and 9.7 ± 0.8 ng/mL, respectively) and TARC production in PBMCs (IC₅₀: 59.2 ± 3.9 and 13.5 ± 0.2 ng/mL, respectively). Rademikibart versus dupilumab was more potent in the STAT6 assays (IL-4, p < 0.01; IL-13, p = 0.03), with non-significant trends towards greater potency in the TF-1 cell assays (IL-4, p = 0.09; IL-13, p = 0.20), and similar potency in the TARC assays. In experiments with mice expressing human IL-4Rα and IL-4, rademikibart and dupilumab demonstrated similar potency; both monoclonal antibodies eliminated IL-4 (p < 0.0001) and IL-13 (p < 0.05) mediated B cell activation in vitro and ovalbumin-induced IgE (p < 0.01) and eosinophilic lung infiltration (p < 0.0001) in vivo. In Th2-stimulated human skin explants, rademikibart rapidly downregulated IL-4, IL-13, and TARC gene expression, with greater effectiveness than dupilumab for IL-4 (p < 0.01) and a non-significant trend towards superiority for IL-13. In summary, rademikibart bound to a distinct IL-4Rα epitope with high affinity and demonstrated reductions in Th2 inflammatory biomarkers with at least similar and potentially superior potency to dupilumab.

Comorbid asthma in patients with chronic rhinosinusitis with nasal polyps: did dupilumab make a difference?

BACKGROUND

The clinical heterogeneity of chronic rhinosinusitis (CRS) and bronchial asthma is attributable to different underlying inflammatory profiles. However, the similarity between CRS with nasal polyps (CRSwNP) and type-2 asthma pathophysiology speculates that one biological therapy could affect both comorbidities. Despite dupilumab, a monoclonal antibody that targets IL-4α and IL-13 receptors, being used in patients with nasal polyps and severe asthma, real-life data about its efficacy in improving the quality of life and patient symptoms is still lacking. This study's primary objective was to evaluate dupilumab treatment's effect on the frequency of olfactory symptoms and health-related quality of life tests as measured by the Sino-nasal outcome test (SNOT-22) in patients with NP. The secondary objective was the effect of dupilumab on asthma symptom control as measured by the asthma control test (ACT).

METHODS

A prospective study was conducted of 166 patients with CRSwNP, with or without asthma. The following variables were collected at baseline and after at least six months of continuous dupilumab therapy; SNOT-22, olfactory symptoms frequency, and ACT score.

RESULTS

Asthma prevalence in patients with CRSwNP was high (59.63%), and being female with a history of frequent use of oral corticosteroid (OCS) courses and repeated unsuccessful nasal and para-nasal surgeries for polyposis increased the likelihood of having underlying asthma by 2, 1 and 4 times more, respectively. Additionally, being asthmatic required a longer duration of dupilumab treatment. However, both the health-related quality of life and olfactory symptoms improved equally in both groups.

CONCLUSION

Even with associated comorbid asthma in patients with CRSwNP, treatment with dupilumab could improve the quality of life, olfactory symptoms, and asthma symptom control.

Pathobiology of Type 2 Inflammation in Asthma and Nasal Polyposis

Asthma and nasal polyposis often coexist and are frequently intertwined by tight pathogenic links, mainly consisting of the cellular and molecular pathways underpinning type 2 airway inflammation. The latter is characterized by a structural and functional impairment of the epithelial barrier, associated with the eosinophilic infiltration of both the lower and upper airways, which can be driven by either allergic or non-allergic mechanisms. Type 2 inflammatory changes are predominantly due to the biological actions exerted by interleukins 4 (IL-4), 13 (IL-13), and 5 (IL-5), produced by T helper 2 (Th2) lymphocytes and group 2 innate lymphoid cells (ILC2). In addition to the above cytokines, other proinflammatory mediators involved in the pathobiology of asthma and nasal polyposis include prostaglandin D₂ and cysteinyl leukotrienes. Within this context of 'united airway diseases', nasal polyposis encompasses several nosological entities such as chronic rhinosinusitis with nasal polyps (CRSwNP) and aspirin-exacerbated respiratory disease (AERD). Because of the common pathogenic origins of asthma and nasal polyposis, it is not surprising that the more severe forms of both these disorders can be successfully treated by the same biologic drugs, targeting many molecular components (IgE, IL-5 and its receptor, IL-4/IL-13 receptors) of the type 2 inflammatory trait.

Progress in diagnosis and treatment of difficult-to-treat asthma in children

At present, medications containing inhaled corticosteroids (ICS-containing) are the keystones of asthma treatment. The majority of asthmatic children can significantly improve clinical outcomes with little worsening by standardized inhaled glucocorticoid treatment, but there is still a small proportion of children who are unable to achieve good symptom control even after the maximum standardized treatment, known as 'children with difficult-to-treat asthma (DA)'. The high heterogeneity of DA makes therapy challenging and expensive, which poses a serious risk to children's health and makes it extremely difficult for clinical physicians to accurately identify and treat children with DA. This article reviews the definition, evaluation, and treatment of this asthma in order to provide a reference for optimal clinical decision-making.