Remission outcomes in severe eosinophilic asthma with mepolizumab therapy: Analysis of the REDES study

Clinical remission of mild-to-moderate asthma: Rates, contributing factors, and stability

Background

Although clinical remission (CR) of severe asthma has been extensively investigated, CR of mild-to-moderate asthma remains unexplored.

Objective

This study aimed to determine CR rates, contributing factors, and stability in patients with mild-to-moderate asthma.

Methods

We retrospectively analyzed 263 patients with asthma. Three-component CR was defined as no exacerbation, no daily oral corticosteroid receipt, and an Asthma Control Test score equivalent to that of the well control; 4-component CR included these parameters plus forced expiratory volume in 1 second of ≥80% predicted. CR during the 1 year and stability of CR over 10 years were retrospectively analyzed in patients with mild-to-moderate and severe asthma.

Results

The CR rates were significantly higher (4-component, 73.2%; 3-component, 81.0%) in patients with mild-to-moderate asthma compared with the CR rate in patients with severe asthma (4-component, 33.9%; and 3-component, 30.6%). A lower smoking index contributed to 3- and 4-component CR. Lower body mass index contributed to 3-component remission, and later onset and shorter asthma duration contributed to 4-component remission. In patients experiencing 4-component remission 10 years before, 80.3% maintained disease in remission; 89.1% of patients experiencing 3-component remission maintained disease in remission. In patients with disease that did not maintain 4-component CR after 10 years, predicted forced expiratory volume decreased, but no differences in inhaled corticosteroid and long-acting β-agonists/long-acting muscarinic antagonists receipt were detected between 10 years ago and the present. The current muscarinic antagonist receipt remained low, at 16.7%.

Conclusion

CR, including normalized forced expiratory volume, is obtainable and sustainable in most Japanese patients with mild-to-moderate asthma. Assessing CR in these patients may help avoid undertreatment and reduce future risks.

PI3K pathway activation in severe asthma is linked to steroid insensitivity and adverse outcomes

Background

Patients with severe asthma may demonstrate reduced sensitivity to steroid treatment. However, the implications of this reduced responsiveness for clinical outcomes and the underlying mechanisms remain unclear.

Objective

The aim of this study was to investigate whether steroid sensitivity in patients with asthma is related to severity and clinical outcomes and to elucidate the role of inflammatory pathways in reducing steroid sensitivity.

Methods

This observational study of 169 asthma patients, with 161 followed for 1 year, involved isolation of peripheral blood mononuclear cells. These cells were treated with dexamethasone, and the mRNA expression of FKBP5, which is a marker of steroid sensitivity, was measured. To explore the mechanism underlying the reduced steroid sensitivity, cells were exposed to PI3K and MAPK inhibitors in combination with dexamethasone.

Results

A total of 53 patients diagnosed with severe asthma exhibited markedly diminished sensitivity to steroids compared with those with nonsevere asthma. Reduced steroid sensitivity has emerged as a critical risk factor for failure to experience clinical remission and exacerbation. This relationship between reduced steroid sensitivity and disease severity and adverse outcomes was confirmed at the 1-year follow-up. Mechanistic investigations revealed that the degree of recovery from steroid sensitivity after PI3Kδ/γ inhibitor treatment was significantly greater in patients with severe asthma than in those with nonsevere asthma, a finding confirmed at the 1-year follow-up.

Conclusions

Patients with severe asthma demonstrate reduced steroid sensitivity, which results in unfavorable clinical outcomes. Conversely, inhibition of the PI3K pathway significantly improves steroid sensitivity.

Is it possible to achieve remission in severe asthma? Retrospective analysis of a four-year response in a real-life cohort treated with mepolizumab

Introduction and objective: Response to biologics in severe uncontrolled asthma (SUA) can be classified as super-responders, good responders, non-responders, and those achieving clinical remission. The aim of this study is to evaluate the long-term response to mepolizumab in patients with severe eosinophilic asthma and assesses the rate of asthma clinical remission over four years in a real-life setting.

Methods: This is a single-center, observational, retrospective study was conducted at La Paz University Hospital (Madrid, Spain) from 2017 to 2022. Patients with SUA treated with mepolizumab 100mg every four weeks for at least three years were included. Response to mepolizumab was classified into good responders, super-responders, non-responders, and patients achieving clinical remission after three and four years of treatment.

Results: 27 patients (67% women; mean age 37.7 years) were included. 58% of patients achieved remission after three years of treatment, increasing to 63% after four years. Similar trends were observed in super-responders and good responders. We found that a significant number of patients treated with mepolizumab in a real-life setting can achieve asthma remission, particularly when compared to other similar studies.

Conclusions: By distinguishing these different degrees of response, clinicians can better understand the patient's condition and make more informed decisions about whether to continue with the current biologic therapy or consider switching to a different treatment.

Challenges and Opportunities in Achieving Asthma Remission

Background: Asthma is a chronic inflammatory disorder in millions of individuals across the globe with high morbidity, mortality, and health care costs. Despite advances in asthma treatment, long-term remission is a challenging target to achieve. Objectives: This review will address the path to remission in asthma with focus on the role of biologic agents in severe asthma management and on the question as to whether long-term disease control and remission are a reality. Methods: A systematic literature review from 1971 to 2025 was conducted through databases such as PubMed, MEDLINE, Scopus, and Web of Science. Clinical trials, meta-analyses, and real-world evidence concerning biologic therapies, such as monoclonal antibodies targeting interleukin -5 (IL-5), IL-4/IL-13, immunoglobulin E, and thymic stromal lymphopoietin, were considered. Symptom control, exacerbation frequency, lung function, and oral corticosteroid (OCS) use were some of the outcomes considered. Results: Biologic treatments have yielded significant gains in asthma control and reduction of exacerbation. Complete remission-long-term resolution of symptoms, inflammation, and drug dependence-is still difficult to achieve. Early intervention with biologics may prevent irreversible airway remodeling, but long-term remission is not in sight. These drugs reduce OCS dependency, but sustainability of remission remains to be investigated. Conclusions: Biologic therapies have advanced asthma treatment, particularly in severe cases, by improving symptoms and reducing exacerbations. However, complete remission remains a distant goal. The development of standardized remission criteria, better patient stratification, and long-term clinical studies are necessary to help achieve sustained asthma control and remission.

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.

Response to IL-5/IL-5R Antagonists and Remission Rate in Patients With Severe Asthma Who Would Have Been Excluded From the Pivotal Clinical Trials

BACKGROUND

Randomized controlled trials (RCTs) assessing the efficacy of IL-5/IL-5R antagonists showed a significant reduction in asthma exacerbations as well as a corticosteroid-sparing effect in selected patients with severe eosinophilic asthma.

OBJECTIVE

To compare the response and remission rate after treatment with IL-5/IL-5R antagonists in patients with asthma who would or would not have met inclusion criteria of pivotal RCTs.

METHODS

This was a retrospective cohort study of patients with severe eosinophilic asthma aged 18 and older treated with IL-5/IL-5R antagonists between 2012 and 2020 in a tertiary outpatient asthma clinic. Patients aged 75 years or younger, with a smoking history of less than 10 pack-years and a reversible FEV1 less than 80% predicted in the previous year were considered to fulfill the pivotal RCT inclusion criteria. Response to treatment and clinical remission of asthma were assessed in those who did or did not fulfill pivotal RCT inclusion criteria.

RESULTS

A total of 108 subjects were included. Only 22 patients (20.4%) met all pivotal RCT inclusion criteria. There was no significant difference in response to treatment of these patients compared with those who did not fulfill inclusion criteria (odds ratio [95% CI] = 0.66 [0.15-2.85]). However, RCT eligibility was associated with a higher likelihood of achieving clinical remission (odds ratio [95% CI] = 4.09 [1.02-16.45]).

CONCLUSION

IL-5/IL-5R antagonists seem to be as effective in subjects who would have been excluded from pivotal RCTs as in those who met the RCT inclusion criteria, but RCT eligibility increases the likelihood of achieving clinical remission of asthma.

Is Disease Stability an Attainable Chronic Obstructive Pulmonary Disease Treatment Goal?

Chronic obstructive pulmonary disease (COPD) is a heterogeneous lung condition characterized by progressive airflow obstruction. Despite advancements in diagnosis and treatment, the disease burden remains high; although clinical trials have shown improvements in outcomes such as exacerbations, quality of life, and lung function, improvement may not be attainable for many patients. For patients who do experience improvement, it is challenging to set management goals given the progressive nature of COPD. We therefore propose disease stability as an appropriate and attainable treatment goal. Other disease areas have developed definitions of no disease activity or remission, which provide relevant information for defining and achieving stability for patients with COPD. Disease stability builds on related concepts already defined in COPD, such as clinical control and clinically important deterioration. Current components that could form part of a disease stability definition include exacerbations, health status (including quality of life and symptoms), and lung function. Considerations should be given to intervals over which stability is defined and assessed, appropriate thresholds, and defining a composite. Ensuring a holistic approach, objective measurements, and harmonious, clear communication between patients and physicians can further support establishing disease stability. Here we propose a preliminary definition of disease stability, informed by existing research in COPD. Further research will be needed to validate the framework for use in clinical and research settings. Exploring disease stability as a goal, however, is an opportunity to develop and validate an attainable treatment target to advance the standard of care for patients with COPD.

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.

Cluster Analysis Identifies Patients With Severe Eosinophilic Asthma Who Achieve Super-Response and Remission With Mepolizumab

This study identifies two distinct subgroups of patients with severe eosinophilic asthma who respond differently to mepolizumab. Cluster analysis reveals that patients with a family history of asthma, positive skin prick tests and higher baseline lung function have better treatment outcomes, highlighting the value of personalised treatment strategies.

Roads to remission: evolving treatment concepts in type 2 inflammatory diseases

Non-communicable diseases (NCDs) characterised by type 2 inflammation, including asthma, allergic rhinitis, chronic rhinosinusitis with nasal polyps, atopic dermatitis, food allergies and eosinophilic esophagitis, are increasing in prevalence worldwide. Currently, there is a major paradigm shift in the management of these diseases, towards the concept of disease modification and the treatment goal remission, regardless of severity and age. Remission as a treatment goal in chronic inflammatory NCDs was first introduced in rheumatoid arthritis, and then adopted in other non-type 2 inflammatory diseases. Among diseases with type 2 Inflammation, this concept is novel and currently most advanced in asthma. This new paradigm has been developed based on a better understanding of the pathophysiology of type 2 inflammation and the advent of highly effective drugs selectively interfering with type 2 pathways. Here, we review the evolution of the new remission concepts in type 2 inflammatory diseases and discuss associated challenges and future research needs.

Funding

None.

On-treatment clinical remission of severe asthma with real-world longer-term biologic use

Background

There are limited real-world data describing the proportion of patients with severe asthma (SA) who achieve on-treatment clinical remission with long-term biologic treatment.

Objective

Our aim was to examine the proportion and characteristics of adults with SA who achieved clinical remission with biologic therapy.

Methods

CHRONICLE is an observational study of US subspecialist-treated adults with SA. Sites reported exacerbations and biologic use from 12 months before enrollment forward. Monthly Asthma Control Test scores and 6-monthly specialist assessments of asthma control were collected. Patients who enrolled from February 2018 to February 2023, began taking a biologic during the study observation period, and continued use of that biologic for at least 12 months were evaluated. Incident on-treatment clinical remission was defined in a 12-month interval as the absence of exacerbations and systemic corticosteroid use, a 50% or greater improvement in Asthma Control Test scores of least 20 points in the latest 6 months, and specialist report of asthma control.

Results

Among the evaluable patients (n = 611), the median duration of biologic use was 39.6 months. In at least one 12-month interval during the study, 79.9% of patients had no exacerbations or systemic corticosteroid use and 46.0% met the definition of clinical remission at any point. The point prevalence of clinical remission increased from 22.3% at 12 to 13 months of biologic use to 34.3% at 47 to 48 months of biologic use.

Conclusions

In a real-world cohort of patients with SA with longer-term biologic treatment, almost one-half achieved on-treatment clinical remission. With at least 1 year of biologic therapy, clinical remission is a feasible treatment goal in SA.

A RESPONSE to antiIL-5 therapy in comorbid patients with chronic rhinosinusitis with nasal polyps and severe asthma: Study protocol

Background

Chronic rhinosinusitis with nasal polyps (CRSwNP) and severe asthma (SA) are 2 frequently coexisting conditions that are, in most cases, associated with eosinophilic inflammation. The concurrence of both diseases has a negative synergistic impact on disease severity and patients' health-related quality of life. Thus, a holistic, collaborative management of these patients is a critical unmet need. Mepolizumab, a systemic anti-IL-5 therapy, has been shown to be effective as an add-on treatment in both SA and CRSwNP, with more literature available on asthma outcomes than on CRSwNP.

Objectives

The primary objective of the study is to evaluate the real-world effectiveness of mepolizumab in improving the health-related quality of life of comorbid patients at 12 months using the SNOT-22 questionnaire. Secondary objectives include safety and efficacy outcomes of mepolizumab treatment in the 2 populations, which are expected to have variable severity of the respective comorbid conditions.

Methods

RESPONSE is a European real-world prospective cohort study designed to assess the effectiveness of mepolizumab in 2 cohorts of adult patients: one with SA as primary diagnosis with (secondary diagnosis) comorbid CRSwNP, and another with CRSwNP as primary diagnosis with (secondary diagnosis) comorbid asthma. Up to 350 patients receiving newly prescribed mepolizumab will be followed up for 12 months as per the investigators' standard of care.

Conclusion

This study will report the effects of anti-IL-5 therapy in both diseases investigated and the respective comorbidity, as well as the consequence of treating milder forms of asthma and CRSwNP with mepolizumab, supporting the emerging evidence on early treatment optimization.

Early Treatment Response to Mepolizumab Predicts Clinical Remission in Severe Eosinophilic Asthma

BACKGROUND

Mepolizumab can induce an early response and clinical remission in people with severe eosinophilic asthma (SEA).

OBJECTIVE

To find whether early response to mepolizumab (100 mg) could predict future asthma remission and to identify the best predictor of treatment response to mepolizumab for achieving remission.

METHODS

The Australian Mepolizumab Registry was used to investigate the early response to mepolizumab at 3 and 6 months and relate this to clinical remission at 12 months. Treatment response was assessed using the 5-item Asthma Control Questionnaire (ACQ-5), oral corticosteroid (OCS) dose, exacerbation frequency, and postbronchodilator FEV1. Clinical remission, assessed at 12 months, was defined as an ACQ-5 score less than or equal to 1.0 at 12 months, no exacerbations in the previous 6 months, and no OCS use for asthma in the previous 6 months. We estimated the optimism-corrected area under the curve for internal validation.

RESULTS

We analyzed 255 participants with SEA. Seventy-eight (30.6%) participants achieved clinical remission at 12 months. A prediction model including ACQ-5 score, exacerbation frequency, OCS dose, and postbronchodilator FEV1 at 6 months was more predictive of achieving remission than measures at 3 months. The ACQ-5 score at 6 months had the highest optimism-corrected area under the curve of 0.778 (95% CI, 0.719-0.833). An ACQ-5 score less than 1.5 at 6 months had a sensitivity of 85.9% for achieving clinical remission, whereas an ACQ-5 score less than 0.75 had a specificity of 84.7%.

CONCLUSIONS

The ACQ-5 score at 6 months was the best predictor of achieving clinical remission at 12 months in people with SEA treated with mepolizumab. These results can be used to design a treat-to-target paradigm for asthma, in which treatment response is assessed at 6 months to predict clinical remission.

Regional challenges to optimize the management of patients with severe asthma type 2 inflammation: a Delphi consensus in seven countries

Objective:Severe asthma burdens patients and presents clinical management challenges for healthcare professionals. Biologics are crucial interventions for severe type two (T2) patients with high eosinophil counts. We conducted a Delphi consensus in seven developing or typically underrepresented countries to understand expert agreement on managing severe asthma with type two (T2) inflammation.

Methods:The study comprised two online survey rounds and a participant meeting, involving 21 and 20 respiratory experts in the first and second survey, respectively. We developed a 70-statement questionnaire after literature review. Responses were recorded on a Likert scale (0-9) with 75% consensus threshold.

Results:Consensus was reached on 37/60 closed-ended questions, including subtypes, in survey-1 and 20/47 closed-ended questions in survey-2. 95% of participants agreed on biomarker use for biologic treatment selection. 100% agreed timely biologic treatment leads to improvement in patients with severe asthma and an eosinophilic phenotype. 90% agreed to avoid maintenance oral corticosteroids (OCS) and start biologic therapy directly. Experts defined clinical remission on treatment as no exacerbations, no OCS use, Asthma Control Questionnaire (ACQ)-5 score < 1.5, and lung function optimization (forced expiratory volume in one second [FEV1] ≥ 80% of predicted or pre-bronchodilator FEV1 increase ≥ 100 mL from baseline). In survey-1, 81% agreed these outcomes are achievable in practice. All referral statements achieved consensus.

Conclusions:This Delphi study focused on understanding patients with severe asthma and T2 inflammation in developing/underrepresented countries. Appropriately utilizing biomarkers, timely treatment interventions for best outcomes, expert consensus on clinical remission, and referral are crucial for improving patient management.

Poor Agreement Among Asthma Specialists on the Choice and Timing of Initiation of a Biologic Treatment for Severe Asthma Patients

BACKGROUND

Because the number of monoclonal antibodies available for severe asthma is growing, specialists currently choose without clear guidelines. Despite increasing knowledge on treatment response to these monoclonal antibodies, making the optimal choice for each individual patient remains a challenge. However, evidence of this daily challenge is lacking.

OBJECTIVE

To evaluate interobserver agreement on the choice of biologic therapy in severe asthma patients among severe asthma specialists, based on clinical cases.

METHODS

This 2-phase study included a pilot local study and an international validation study. Asthma specialists were presented 7 real-life asthma cases managed with a monoclonal antibody. Based on the clinical information provided in the cases, they were asked whether they would have initiated a monoclonal antibody and, if so, their treatment of choice between (1) omalizumab, (2) mepolizumab, (3) reslizumab, (4) benralizumab, and (5) dupilumab. Interobserver agreement for each question was assessed using Gwet agreement coefficient (AC1).

RESULTS

Sixteen physicians from the Province of Quebec (Canada) completed the pilot survey, and 70 physicians from 26 countries completed the international survey. The Gwet AC1 for the decision to initiate a biological therapy was 0.48 in the pilot survey and 0.33 in the international survey. For the choice of therapy, agreement was 0.33 and 0.26, respectively.

CONCLUSIONS

The interobserver agreement among asthma specialists in both the decision to initiate a biological treatment in patients with severe asthma and the selection of treatment is weak. These results highlight the need for studies seeking reliable predictors for optimal response to biological therapies.

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.

Clinical remission in patients with severe eosinophilic asthma treated with mepolizumab: A post-hoc analysis of RELIght study

Background: Remission of asthma can occur as part of the natural history of the disease; however, the use of biologics can result in disease remission in some patients. Objective: In this post hoc analysis of the RELIght study, we aimed to evaluate clinical remission in real life among patients treated with mepolizumab, to detect possible differences between "remitters" and "nonremitters," and to evaluate possible predictors of remission. Methods: Clinical remission was defined as the absence of asthma exacerbations, discontinuation of oral corticosteroids (OCS), achievement of asthma control (Asthma Control Test [ACT] ≥ 20), and stable or improved lung function. Results: A total of 146 patients were evaluated; remission was achieved in 40 (27.4%) and 29 (22%) after 12 and 24 months, respectively. At 12 months, the patients in remission had a better baseline ACT score (17.0 [14.0-19.0] versus 15.0 [12.0-17.0]; p = 0.027), were more rarely using OCS (35% versus 62.2%; p = 0.004), and required a lower baseline dose of OCS (5.0 mg/day [5.0-10.0 mg/day] versus 10.0 mg/day [5.0-15.0 mg/day]; p = 0.042) at baseline, whereas, at 24 months, they less frequently carried a baseline diagnosis of gastroesophageal reflux disease (GERD) (10.3% versus 32%; p = 0.031) and used lower doses of OCS at baseline (5.0 [1.0-5.0] versus 10.0 [5.0-15.0]; p = ≤0.001) versus nonremitters; 52.5% of patients had sustained remission, whereas 42.5% experienced relapse. These patients more frequently had GERD versus patients with sustained remission (52.9% versus 4.8%; p = 0.002). Finally, regression analysis has shown that GERD was the only predictor of relapse. Conclusion: Remitters had better asthma control and needed lower doses or no maintenance OCS at baseline, whereas GERD seems to be an important factor that affects remission and relapse.Clinical trial NCT04084613, www.clinical trials.gov.

Distinct trajectories of treatment response to mepolizumab toward remission in patients with severe eosinophilic asthma

BACKGROUND

Patients with severe eosinophilic asthma, characterised by a high disease burden, benefit from mepolizumab, which improves symptoms and reduces exacerbations, potentially leading to clinical remission in a subgroup. This study aimed to identify treatment response trajectories to mepolizumab for severe eosinophilic asthma and to assess the achievement of clinical remission.

METHODS

Data from the Australian Mepolizumab Registry were used to assess treatment responses at 3, 6 and 12 months. The treatment response trajectories were identified using a group-based trajectory model. The proportions achieving clinical remission at 12 months, which was defined as well-controlled symptoms, no exacerbations and no oral corticosteroid (OCS) use for asthma management, were compared between trajectories, and baseline predictors of the trajectories were identified using logistic regression analysis.

RESULTS

We identified three trajectory groups: Group 1, "Responsive asthma with less OCS use" (n=170); Group 2, "Responsive late-onset asthma" (n=58); and Group 3, "Obstructed and less responsive asthma" (n=70). Groups 1 and 2 demonstrated higher proportions achieving clinical remission at 36.5% and 25.9%, respectively, compared to Group 3 with 5.7% (p<0.001). Baseline predictors for assigned groups included lower OCS dose in Group 1; greater forced expiratory volume in 1 s percentage predicted, higher Asthma Quality of Life Questionnaire score, higher OCS dose and nasal polyps in Group 2; with Group 3 as the reference.

CONCLUSIONS

Treatment response to mepolizumab in severe eosinophilic asthma follows three trajectories with varying proportions achieving clinical remission and differing baseline characteristics. Treatment response variability may influence the achievement of clinical remission with mepolizumab therapy.

A real-world study to evaluate effectiveness of mepolizumab in treating severe asthma in Taiwan (REMIT)

BACKGROUND

REMIT is the first real-world study of mepolizumab effectiveness in patients with severe asthma (SA) in Taiwan.

OBJECTIVES

The primary objective evaluated changes in clinically significant exacerbations (CSEs; defined as use of oral corticosteroids (OCS) or emergency department (ED) visits and/or hospitalizations) in the 12 months pre- and post-mepolizumab treatment. Secondary objectives assessed changes in the number of CSEs requiring ED visits/hospitalizations and daily maintenance OCS (mOCS) dosage 12 months pre- and post-mepolizumab treatment. Three- and four-component clinical remissions were analyzed based on OCS-free, exacerbation-free, and asthma control (± stability in lung function).

DESIGN

REMIT was a retrospective, observational, self-controlled study analyzing patients in Taiwan with SA who were newly prescribed subcutaneous mepolizumab 100 mg Q4W.

METHODS

Data were extracted from records of 15 medical centers in Taiwan for patients indexed between November 1, 2018 and October 31, 2020.

RESULTS

A total of 170 patients were included: mean age at index date, 58.7 years; 53.5% female; 100% Chinese; 7.1% with chronic rhinosinusitis with nasal polyps, 1.8% with eosinophilic granulomatosis with polyangiitis, 1.2% with hypereosinophilic syndrome; and 55.7% with blood eosinophil count >300/µL. Pre-treatment, 71.2% had ⩾2 exacerbations, and 28.7% were on mOCS; 75.3% had no prior biologic treatment, and 24.7% had switched from other biologics. Most patients (80.0%) completed ⩾10 mepolizumab doses. Following the first mepolizumab administration (index date), CSEs reduced by 46.0% (rate ratio (RR): 0.545, 95% confidence interval (CI): 0.418-0.710; p < 0.0001) in the 12 months post-index. Exacerbations requiring ED visits/hospitalization reduced by 46.9% (RR: 0.531, 95% CI: 0.349-0.808; p = 0.0031). Median mOCS dose reduced by 100% by end of study and 81.8% of patients discontinued mOCS post-treatment. After 1 year of mepolizumab treatment, 28% and 23% patients achieved three- and four-component clinical remission, respectively.

CONCLUSION

Mepolizumab use in a patient population in Taiwan with SA significantly reduced CSEs and mOCS use in routine clinical practice.

The role of biologics in inducing remission in asthma

Asthma remissions have been identified as a new treatment outcome and as based on experience with biologics. Remissions are defined as no symptoms, no exacerbations, no use of systemic corticosteroids, and stabilization (optimization) of lung functions; all these criteria need to be sustained for at least 1 year. This study discussed the evolution of remissions, the evolving criteria, and experiences in achieving remission after treatment with biologics. In severe, uncontrolled asthma, treatment with biologics has led to remissions in 20% to 35% of the subjects treated. It is proposed that remissions will become a new and important treatment outcome for asthma.

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.

Time is lung: higher preservation of lung function in severe asthma patients after earlier mepolizumab treatment

Introduction

Severe asthma involves a persistent inflammation of the airways that is associated with a greater risk of exacerbations. Exacerbations are associated with a higher lung function decline over time. The prevention of lung function decline could become a strategy for disease modification, and this could be more likely to happen in patients with an earlier therapeutic approach. Thus, this study means to analyse the effect of asthma duration in clinical outcomes such as lung function in patients from the REDES study. REDES was an observational real-world study that assessed the effectiveness and safety of mepolizumab 100 mg s.c. every 4 weeks for 12 months in 318 patients with severe asthma in Spain.

Methods

This post hoc analysis evaluated how disease duration affected the study results through a stratification according to quartiles on their disease progression. Continuous analyses were also performed to assess the impact of confounder variables on forced expiratory volume in 1 s (FEV1) (%).

Results

At baseline, patients with shorter time of disease had a significantly higher lung function than patients with longer asthma duration. At 12 months, pre-bronchodilator (BD) FEV1 values and the proportion of patients with ≥80% pre-BD FEV1 were higher according to a shorter disease persistence (Q1>Q2>Q3>Q4).

Conclusion

These results support that time of disease persistence contributes to the lung function decline of patients with severe asthma, uncontrolled while on previous treatment, and that an earlier approach with mepolizumab may imply a higher preservation of their lung function.

Molecular mechanisms and clinical impact of biologic therapies in severe asthma

Severe asthma is a critical condition for patients with asthma, characterized by frequent exacerbations, decreased pulmonary function, and unstable symptoms related to asthma. Consequently, the administration of systemic corticosteroids, which cause secondary damage because of their adverse effects, is considered. Recently, several types of molecular-targeted biological therapies have become available for patients with severe asthma, and they have a capacity to improve the pathophysiology of severe asthma. However, several clinical reports indicate that the effects differ depending on the biological targets of asthma in individual patients. In this review, the molecular mechanisms and clinical impact of biologic therapies in severe asthma are described. In addition, molecules targeted by possible future biologics are also addressed. Better understanding of the mechanistic basis for the role of biologics in severe asthma could lead to new therapeutic options for these patients.

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.

SANI clinical remission definition: a useful tool in severe asthma management

In the field of severe asthma, the concept of disease control has recently been integrated by the one of clinical remission. With this new concept, we move on to analyze the efficacy of therapy on multiple parameters simultaneously, starting with the mandatory discontinuation of the systemic glucocorticoids, to which is added the effect on exacerbations, respiratory function, and symptoms control. The Italian severe asthma registry SANI (Severe Asthma Network Italy) drafted criteria for the definition of disease remission, allowing patients to be classified into two groups, partial and complete remission. The greater dynamism of the definition, provided by SANI, allows us to hypothesize its practical use, concerning therapy management of severe asthma patients, starting from the level of remission, with the aim to facilitate the clinical decision on replacement, continuation or modulation of patients' therapy.

Long-Term Clinical and Sustained REMIssion in Severe Eosinophilic Asthma Treated With Mepolizumab: The REMI-M Study

BACKGROUND

Biological therapies, such as mepolizumab, have transformed the treatment of severe eosinophilic asthma. Although mepolizumab's short-term effectiveness is established, there is limited evidence on its ability to achieve long-term clinical remission.

OBJECTIVE

To evaluate the long-term effectiveness and safety of mepolizumab, explore its potential to induce clinical and sustained remission, and identify baseline factors associated with the likelihood of achieving remission over 24 months.

METHODS

The REMIssion in Severe Eosinophilic Asthma Treated with Mepolizumab (REMI-M) is a retrospective, real-world, multicenter study that analyzed 303 patients with severe eosinophilic asthma who received mepolizumab. Clinical, demographic, and safety data were collected at baseline, 3, 6, 12, and 24 months. The most commonly used definitions of clinical remission, which included no exacerbations, no oral corticosteroid (OCS) use, and good asthma control with or without assessment of lung function parameters, were assessed. Sustained remission was defined as reaching clinical remission at 12 months and maintaining it until the end of the 24-month period.

RESULTS

Clinical remission rates ranged from 28.6% to 43.2% after 12 months and from 26.8% to 52.9% after 24 months based on the different remission definitions. The proportion of patients achieving sustained remission varied between 14.6% and 29%. Factors associated with the likelihood of achieving clinical remission included the presence of aspirin-exacerbated respiratory disease, better lung function at baseline, male sex, absence of anxiety/depression, gastroesophageal reflux disease, bronchiectasis, and reduced OCS consumption. Adverse events were infrequent.

CONCLUSIONS

This study demonstrates the real-world effectiveness of mepolizumab in achieving clinical remission and sustained remission in severe eosinophilic asthma over 24 months. The identification of distinct factors associated with the likelihood of achieving clinical remission emphasizes the importance of comprehensive management of comorbidities and timely identification of patients who may benefit from biologics.

Evaluation of multiple-flows exhaled nitric oxide and its clinical significance in severe asthmatic patients treated with biologics: a prospective real-life study

BACKGROUND

Specific biomarkers, such as eosinophilia in peripheral blood or fractional exhaled nitric oxide (FeNO), can guide us in the choice of biologic therapy, allowing a more personalized approach. Although there are multiple evidences in the literature about the role of FeNO as a predictor of response to different biologic treatments, there are no data on the relationship between FeNO changes and clinical response to the four biologic drugs currently in use.

OBJECTIVE

To evaluate and to compare the expression of multiple-flows FeNO parameters in a cohort of patients with severe asthma (SA) before and during the treatment with biologics to evaluate the performance of these biomarkers in predicting the achievement of clinical remission.

METHODS

We prospectively enrolled 50 patients with severe asthma eligible for biologic therapy. Patients underwent clinical and functional monitoring at baseline (T0) and after 1, 6, and 12 months of treatment (T1, T6, T12), including multiple flows FeNO assessment.

RESULTS

A statistically significant reduction of FeNO50 values and J'awNO was observed only in benralizumab and dupilumab subgroups. Among biomarkers, the reduction of FeNO 50 values at T1 was associated with a higher probability of achieving clinical remission at T12 (p = 0.003), which was also confirmed by ROC curve analysis (AUC 0.758, p = 0.002; sensitivity 60% and specificity 74% for a reduction of 16 ppb).

CONCLUSION

These data confirm the potential of this biomarker in predicting clinical response to biologic treatment in patients with severe asthma in order to guide clinical decisions and evaluate a shift to other biologic therapy.

Clinical response and on-treatment clinical remission with tezepelumab in a broad population of patients with severe, uncontrolled asthma: results over 2 years from the NAVIGATOR and DESTINATION studies

BACKGROUND

In asthma, clinical response is characterised by disease improvement with treatment, whereas clinical remission is characterised by long-term disease stabilisation with or without ongoing treatment. The proportions of patients receiving tezepelumab who responded to treatment and who achieved on-treatment clinical remission were assessed in the NAVIGATOR (ClinicalTrials.gov identifier NCT03347279) and DESTINATION (ClinicalTrials.gov identifier NCT03706079) studies of severe, uncontrolled asthma.

METHODS

NAVIGATOR and DESTINATION were phase 3, randomised, double-blind, placebo-controlled studies; DESTINATION was an extension of NAVIGATOR. Complete clinical response was defined as achieving all of the following: ≥50% reduction in exacerbations versus the previous year, improvements in pre-bronchodilator (BD) forced expiratory volume in 1 s (FEV1) of ≥100 mL or ≥5%, improvements in Asthma Control Questionnaire (ACQ)-6 score of ≥0.5 and physician's assessment of asthma improvement. On-treatment clinical remission was defined as an ACQ-6 total score ≤1.5, stable lung function (pre-BD FEV1 >95% of baseline) and no exacerbations or use of oral corticosteroids during the time periods assessed.

RESULTS

Higher proportions of tezepelumab than placebo recipients achieved complete clinical response over weeks 0-52 (46% versus 24%; OR 2.83, 95% CI 2.10-3.82) and on-treatment clinical remission over weeks 0-52 (28.5% versus 21.9%; OR 1.44, 95% CI 0.95-2.19) and weeks >52-104 (33.5% versus 26.7%; OR 1.44, 95% CI 0.97-2.14). Tezepelumab recipients who achieved on-treatment clinical remission versus complete clinical response at week 52 had better preserved lung function and lower inflammatory biomarker levels at baseline, and fewer exacerbations in the 12 months before the study.

CONCLUSIONS

Among patients with severe, uncontrolled asthma, tezepelumab treatment was associated with an increased likelihood of achieving complete clinical response and on-treatment clinical remission compared with placebo. Both are clinically important outcomes, but may be driven by different patient characteristics.

Biologics in Asthma: Potential to Achieve Clinical Remission

Establishing a universal definition for asthma remission has the potential to improve asthma outcomes and advance research. However, there is still no consensus definition despite broad multidisciplinary efforts to achieve this goal. This study explores the evolving concept of asthma remission, emphasizing the potential of biologics to achieve this state. We will discuss various proposed definitions of asthma remission, international guidelines, and studies evaluating the effectiveness of biologics at achieving clinical remission. We highlight the need for a consensus definition of asthma remission to standardize treatment goals and improve patient outcomes.

Targeting the IL-5 pathway in eosinophilic asthma: A comparison of anti-IL-5 versus anti-IL-5 receptor agents

Eosinophilic asthma is characterized by frequent exacerbations, poor symptom control and accelerated lung function decline. It is now recognized that the immune response underlying eosinophilic asthma involves a complex network of interconnected pathways from both the adaptive and innate immune systems. Within this response, interleukin-5 (IL-5) plays a central role in eosinophil differentiation, activation and survival and has emerged as a key target for therapies treating severe asthma. The monoclonal antibodies mepolizumab and reslizumab target the ligand IL-5, preventing its interaction with eosinophils; in contrast, benralizumab binds to the IL-5 receptor (IL-5R), preventing IL-5 from binding and leading to substantially greater eosinophil reduction by enhanced antibody-dependent cell-mediated cytotoxicity. Although no direct head-to-head clinical trials of asthma have been published to formally evaluate the clinical significance of these different therapeutic approaches, the potential benefits of partial versus complete eosinophil depletion continue to remain an important area of study and debate. Here, we review the existing real-world and clinical study data of anti-IL-5/anti-IL-5R therapies in severe eosinophilic asthma.

Clinical remission maintained and improved over time in patients with severe asthma treated with omalizumab

BACKGROUND

Clinical remission has recently been proposed as a possible treatment goal even in severe asthma. In this real-world study, we aimed to assess the achievement rate and predictive factors of clinical remission using omalizumab in patients with severe asthma.

METHODS

This retrospective observational study included patients with severe asthma initiated with omalizumab therapy and recruited from the asthma clinic of the Akdeniz University Hospital, Turkey. Clinical remission was defined as patients who received no oral corticosteroid (OCS) therapy; showed no exacerbations; showed an asthma control questionnaire score of ≤ 1, asthma control test (ACT) of ≥ 20, or both and, FEV1 of ≥ 80% predicted.

RESULTS

A total of 58 patients were included in the study, with an average age of 56.4 ± 13.6 years. The mean duration of asthma was 23.5 ± 11.8 years and the mean duration of omalizumab treatment was 80.05 ± 35.04 months. Clinical remission rates were 25.9% in the first and second year, 34.0% in the third year, 34.1% in the fourth year and 47.4% in the fifth year. Pre-omalizumab ACT, FEV1 (%) and OCS use were significantly higher in patients with clinical remission at 1 year. Logistic regression analyses showed that none of the factors predicted clinical remission.

CONCLUSION

Omalizumab has the potential to induce disease remission in a significant proportion of people with severe asthma, and this is maintained and improved over time.

Exploring Definitions and Predictors of Severe Asthma Clinical Remission after Biologic Treatment in Adults

Rationale: There is no consensus on criteria to include in an asthma remission definition in real life. Factors associated with achieving remission after biologic initiation remain poorly understood. Objectives: To quantify the proportion of adults with severe asthma achieving multidomain-defined remission after biologic initiation and identify prebiologic characteristics associated with achieving remission that may be used to predict it. Methods: This was a longitudinal cohort study using data from 23 countries from the International Severe Asthma Registry. Four asthma outcome domains were assessed in the 1 year before and after biologic initiation. A priori-defined remission cutoffs were: 0 exacerbations/yr, no long-term oral corticosteroid (LTOCS), partly/well-controlled asthma, and percent predicted FEV1 ⩾ 80%. Remission was defined using two (exacerbations + LTOCS), three (+control or +lung function), and four of these domains. The association between prebiologic characteristics and postbiologic remission was assessed by multivariable analysis. Measurements and Main Results: A total of 50.2%, 33.5%, 25.8%, and 20.3% of patients met criteria for two-, three- (+control), three- (+lung function), and four-domain remission, respectively. The odds of achieving four-domain remission decreased by 15% for every additional 10 years of asthma duration (odds ratio, 0.85; 95% confidence interval, 0.73-1.00). The odds of remission increased in those with fewer exacerbations per year, lower LTOCS daily dose, better control, and better lung function before biologic initiation. Conclusions: One in five patients achieved four-domain remission within 1 year of biologic initiation. Patients with less severe impairment and shorter asthma duration at initiation had a greater chance of achieving remission after biologic treatment, indicating that biologic treatment should not be delayed if remission is the goal.

Real-world clinical remission of severe asthma with benralizumab in Spanish adults with severe asthma

OBJECTIVE

Patients with severe eosinophilic asthma experience high risk of exacerbations and reduced quality of life. Benralizumab, a monoclonal antibody binding to IL-5 receptor α subunit, is an approved drug for its treatment. The objective was to describe clinical remission after benralizumab prescription in routine clinical practice.

METHODS

Retrospective multicenter study with data from four hospitals in Valencian Community (Spain) with asthma units between 2019 and 2020. Data was gathered at baseline and after 12 months. We considered clinical remission after 1 year if the patient remained without exacerbations and use of systemic corticosteroids and with good clinical control and normal lung function.

RESULTS

Data from 139 patients was gathered. At the 12-month follow-up, 44.1% were in clinical remission, since 84.0%, 77.5%, 51.0% and 95.5% of patients did not experience exacerbations, had total asthma control test score of ≥20, prebronchodilator FEV1 of ≥80% and did not use systemic corticosteroids. A significant reduction of long-acting muscarinic antagonists (p = 0.0001), leukotriene receptor antagonists (p = 0.0326), oral corticosteroids (p < 0.0001) and short-acting beta agonists (p = 0.0499) was observed. Baseline factors with greatest individual influence on clinical remission were employment situation, tobacco use, comorbidity number, eosinophil value, number of exacerbations, FEV1, emergency visit number, and ACT, MiniAQLQ and TAI scores. Final analysis of multiple logistic regression indicated that having baseline FEV1 value below 80% increases remission chance 9.7 times a year compared to FEV1 >80%.

CONCLUSION

Clinical remission after treatment with benralizumab is achievable in a high percentage of patients with severe asthma eosinophilia not controlled in real life.

Interleukin-5 as a pleiotropic cytokine orchestrating airway type 2 inflammation: Effects on and beyond eosinophils

Interleukin (IL)-5 is the key cytokine in the maturation, activation, proliferation, migration and survival of eosinophils, which are key effector cells in many upper and lower airway diseases. Through its effects on eosinophils, IL-5 indirectly contributes to various pathophysiological processes including tissue damage, repair and remodelling. Understanding the importance of IL-5 in eosinophil-associated diseases led to the development of anti-IL-5 therapies, which provide clinical benefits across a range of conditions. However, recent evidence suggests that eosinophil-depletion alone may not account for all of the therapeutic effects of anti-IL-5 therapy and that IL-5 may also contribute to disease independently of its effects on eosinophils. Indeed, evidence from ex vivo studies and targeted therapy in vivo demonstrates that IL-5 and its inhibition affects a much broader range of cells beyond eosinophils, including epithelial cells, plasma cells, mast cells, basophils, neutrophils, type 2 innate lymphoid cells, T regulatory cells and fibroblasts. This review will provide an update on the evidence supporting the breadth of IL-5 biology relevant to disease pathogenesis beyond eosinophil-associated inflammation, where there is a need for additional insight, and the clinical implications of a more central role of IL-5 in type 2 inflammation.

Sustained remission induced by 2 years of treatment with benralizumab in patients with severe eosinophilic asthma and nasal polyposis

BACKGROUND AND OBJECTIVE

Several randomized controlled trials (RCTs) have shown that benralizumab is characterized by a good profile of efficacy and safety, thereby being potentially able to elicit clinical remission on-treatment of severe eosinophilic asthma (SEA). The main goal of this multicentre observational study was to verify the effectiveness of benralizumab in inducing a sustained remission on-treatment of SEA in patients with or without comorbid chronic rhinosinusitis with nasal polyps (CRSwNP).

METHODS

Throughout 2 years of treatment with benralizumab, a four-component evaluation of sustained remission of SEA was performed, including the assessment of SEA exacerbations, use of oral corticosteroids (OCSs), symptom control and lung function.

RESULTS

The present study recruited 164 patients suffering from SEA. After 24 months of add-on biological therapy with benralizumab, 69 (42.1%) achieved the important target of sustained remission on-treatment (exacerbation rate = 0, OCS dose = 0, pre-bronchodilator FEV1 ≥80% pred., ACT score ≥ 20). During the same period, a persistent improvement of CRSwNP (SNOT-22 < 30, NP recurrence = 0) was observed in 33 (40.2%) out of 82 subjects with concomitant NP. The latter comorbidity and post-bronchodilator reversibility of airflow limitation were two independent predictors of sustained remission on-treatment (OR = 2.32, p < 0.05 and OR = 5.59, p < 0.01, respectively).

CONCLUSION

Taken together, the results of this real-life clinical investigation indicate that benralizumab can induce a sustained remission on-treatment of SEA, especially in those patients with comorbid CRSwNP and reversible airflow limitation.

Exploring Clinical Remission in Moderate Asthma - Perspectives from Asia, the Middle East, and South America

INTRODUCTION

Clinical remission is a relatively new concept in asthma but recent research initiatives suggest it could be an ambitious and achievable therapeutic target for patients with asthma.

METHODS

In this modified Delphi study (comprising two online surveys, completed either side of a virtual scientific workshop), the opinions of a panel of respiratory physicians were evaluated to summarize perspective statements on key therapeutic outcomes and criteria for on-treatment clinical remission in patients with moderate asthma. An agreement threshold was pre-defined as agreement by ≥ 75% of participants.

RESULTS

Surveys 1 and 2 were completed by 20 and 18 participants, respectively. Most participants (95%) agreed with the concept of clinical remission in moderate asthma and that this should be a desirable treatment goal (90%). Based on a composite measure of 4-6 desirable therapeutic outcomes, current understanding of clinical remission was considered as 12 months with no exacerbations, no oral corticosteroids, no daytime or night-time asthma symptoms (Asthma Control Test score ≥ 20 or Asthma Control Questionnaire score ≤ 0.75), stable lung function, and no treatment-related adverse events. No agreement was reached on the role of relievers in defining therapeutic outcomes or on the wider use of biomarkers and airway hyperresponsiveness for defining asthma remission in clinical practice.

CONCLUSIONS

In line with recent consensus statements from the United States and Europe, there was a high level of agreement on the elements of clinical remission among a panel of respiratory physicians from Asia, the Middle East, and South America. Extension of the concept of clinical remission to patients with moderate asthma was considered aligned with the potential of clinical remission as a goal of therapy.

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.

Clinical remission in severe asthma: lights and shadows on an ambitious goal

PURPOSE OF REVIEW

The aim of this study was Describe the latest evidence related to the concept of clinical remission in patients with severe asthma, focusing on the lights and shadows of this concept.

RECENT FINDINGS

The idea of clinical remission in severe asthma patients brings about a significant shift in the way asthma is treated and managed. Although there has yet to be unanimous agreement among various scientific societies on the precise definition, this concept can be extremely useful in advancing the treatment of the disease.

SUMMARY

Asthma is a common respiratory condition that affects more than 300 million people globally. It has variable symptoms and severity levels, with about 10% of patients experiencing severe asthma. While there have been advancements in treatment, severe asthma poses significant challenges. Recent approaches have focused on achieving clinical remission, which goes beyond symptom control to address underlying inflammation and biological processes. Clinical remission criteria include the absence of symptoms, reduced medication usage, and normalized inflammatory markers. Various biologic therapies show promise, with some patients achieving remission. However, remission's definition varies globally, hindering standardization and a valid comparison. Standardizing remission criteria and refining predictive factors are crucial for effective asthma management. Overall, achieving clinical remission offers hope for improved long-term outcomes in severe asthma patients.

Effect of Azithromycin on Asthma Remission in Adults With Persistent Uncontrolled Asthma: A Secondary Analysis of a Randomized, Double-Anonymized, Placebo-Controlled Trial

BACKGROUND

Asthma remission is a potential treatment goal.

RESEARCH QUESTION

Does adding azithromycin to standard therapy in patients with persistent uncontrolled asthma induce remission compared with placebo?

STUDY DESIGN AND METHODS

This secondary analysis used data from the Asthma and Macrolides: the Azithromycin Efficacy and Safety (AMAZES) clinical trial-a double-anonymized placebo-controlled trial that evaluated the safety and efficacy of azithromycin on asthma exacerbations. The primary remission definition (referred to as clinical remission) was zero exacerbations and zero oral corticosteroids during the previous 6 months evaluated at 12 months and a 5-item Asthma Control Questionnaire score ≤ 1 at 12 months. Secondary remission definitions included clinical remission plus lung function criteria (postbronchodilator FEV1 ≥ 80% or postbronchodilator FEV1 ≤ 5% decline from baseline) and complete remission (sputum eosinophil count < 3% plus the aforementioned criteria). Sensitivity analyses explored the robustness of primary and secondary remission definitions. The predictors of clinical remission were identified.

RESULTS

A total of 335 participants (41.5% male; median age, 61.01 years; quartile 1-3, 51.03-68.73) who completed the 12-month treatment period were included in the analysis. Twelve months of treatment with azithromycin induced asthma remission in a subgroup of patients, and a significantly higher proportion in the azithromycin arm achieved both clinical remission (50.6% vs 38.9%; P = .032) and clinical remission plus lung function criteria (50.8% vs 37.1%; P = .029) compared with placebo, respectively. In addition, a higher proportion of the azithromycin group achieved complete remission (23% vs 13.7%; P = .058). Sensitivity analyses supported these findings. Baseline factors (eg, better asthma-related quality of life, absence of oral corticosteroid burst in the previous year) predicted the odds of achieving clinical remission. Azithromycin induced remission in both eosinophilic and noneosinophilic asthma.

INTERPRETATION

In this study, adults with persistent symptomatic asthma achieved a higher remission rate when treated with azithromycin. Remission on treatment may be an achievable treatment target in moderate/severe asthma, and future studies should consider remission as an outcome measure.

Spanish Consensus on Remission in Asthma (REMAS)

The concept of "remission" in asthma has been around for a long time and it has been a controversial topic. Despite the attempts of some studies to characterize this entity, the discussion continues. In the case of asthma there is still no clear definition, either in terms of its meaning or the parameters that should be included or whether it should be divided into clinical or complete remission. To help defining these controversial concepts, SEPAR has advocated the multidisciplinary working group REMAS (REMission in ASthma). Following the Delphi methodology and with the involvement of more than 120 specialists in asthma management, this group has arrived at a consensus on the definitions of remission in asthma and establishing the criteria and characteristics that will be of use in future studies evaluating the efficacy or effectiveness of treatments.

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.

Clinical Remission Criteria and Serum Levels of Type 2 Inflammation Mediators during 24 Weeks of Treatment with the Anti-IL-5 Drug Mepolizumab in Patients with T2-High Severe Asthma

Anti-interleukin (IL) 5 is an effective treatment modality for inhibiting eosinophilic inflammation in patients with T2-high severe asthma. The aim of this study was to determine the clinical efficacy and serum levels of type 2 inflammatory mediators during 24 weeks of mepolizumab treatment in patients with T2-high severe asthma. Eighteen patients with T2-high severe asthma were enrolled in this study. All patients received 100 mg of mepolizumab subcutaneously every 4 weeks and were retested at 4, 12, and 24 weeks. A clinical examination, asthma control test (ACT), and spirometry were performed; fractional exhaled nitric oxide (FeNO) levels were evaluated; and blood samples were drawn at every visit. Type 2 inflammation mediator levels were measured using enzyme-linked immunosorbent assay (ELISA). The blood eosinophil level significantly decreased, the ACT score and FEV1 increased after 4 weeks of mepolizumab treatment with the same tendency after 12 and 24 weeks (p < 0.05), and the FeNO level did not change (p > 0.05). A total of 27.8% of patients reached clinical remission criteria after 24 weeks of mepolizumab treatment. IL-33 and eotaxin significantly increased (p < 0.05) while IL-5, IL-13, thymic stromal lymphopoietin (TSLP), soluble IL-5 receptor subunit alpha (sIL-5Rα), and soluble high-affinity immunoglobulin E receptor (sFcεRI) decreased, with the same tendency after 12 and 24 weeks (p < 0.05). The serum levels of immunoglobulin (Ig) E and IL-4 and IL-25 levels did not change during mepolizumab treatment compared to baseline (p > 0.05). In conclusion, treatment with mepolizumab over 24 weeks improved lung function and asthma control in T2-high severe asthma patients, with nearly one-third achieving clinical remission criteria, and affected the balance of type 2 inflammatory mediators.

Remission in asthma

PURPOSE OF REVIEW

To review the current concepts of remission in asthma.

RECENT FINDINGS

Until 2023, asthma guidelines have been promoting the concept of disease control, recommending the step-wise addition of drugs until the best possible disease control is achieved. With the advent of highly effective, anti-inflammatory disease-modifying antiasthmatic drugs (DMAADs), treatment goals of asthma have changed. Several national guidelines have now announced remission as a general treatment goal in asthma. Currently, all guidelines agree that asthma remission is defined by the presence of at least three characteristics over a period of at least one 1 year: absence of exacerbations, no systemic corticosteroid use for the treatment of asthma and minimal asthma-related symptoms. In the future, a generally accepted, evidence-based and easy-to-use definition of remission will be needed for daily clinical practice. It is clear, however, that precise phenotyping (including measurement of biomarkers) is an essential prerequisite to achieve clinical remission in each individual patient.

SUMMARY

Remission has been included as the treatment goal in asthma in several national guidelines, reflecting the paradigm shift in asthma, from short-term symptom control to long-term symptom prevention. An international consensus on the criteria for asthma remission is expected in the near future.

Evaluation of Clinical Remission in Best-Performing Severe Asthmatic Patients Treated for Three Years with Mepolizumab

BACKGROUND

In its severe form, where possible, asthma is treated using biological drugs in order to reduce, as much as possible, the use of systemic steroids. Mepolizumab is effective for severe asthma based on key outcomes such as exacerbation and steroid dependence. Its efficacy in terms of the criteria for clinical remission in the short and long term has become of interest.

OBJECTIVE

We aimed to evaluate the effect of mepolizumab in the achievement of clinical remission after 3 years of administration.

METHODS

In this study, 71 patients who continued mepolizumab for 3 years were assessed for clinical remission according to six different published sets of remission criteria.

RESULTS

According to the criteria, 39-52% of patients experienced complete remission in the first year, increasing to 51-73% at 3 years. By classifying patients according to partial and complete remission criteria, proposed by the SANI, we observe 22% of patients in partial remission at one year, achieving complete remission after three years. The baseline factors associated with earlier remission were a higher FEV1, if we consider classifications requiring an FEV1 ≥ 80%, a low OCS dose, and low FeNO levels, in the patients requiring FEV1 stabilization.

CONCLUSIONS

Clinical remission is possible for patients treated with mepolizumab. The observations at three years compared with the first year indicated that the factors negatively affecting remission delayed rather than prevented it. Earlier treatment could increase the chances of remission.

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.