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Chase NM, Littlejohn M, Holweg CTJ, Millette LA, Seetasith A, Steinke JW, Trzaskoma BL, Hanania NA, Casale TB. Effectiveness of omalizumab across different dosing regimens in patients with moderate-to-severe allergic asthma. Respir Med 2024; 223:107537. [PMID: 38253245 DOI: 10.1016/j.rmed.2024.107537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 01/18/2024] [Accepted: 01/19/2024] [Indexed: 01/24/2024]
Abstract
For patients with moderate-to-severe persistent allergic asthma, omalizumab is approved for subcutaneous administration according to a recommended dosing table based on weight and total immunoglobulin E (IgE) level. The aim of this analysis was to assess asthma outcomes including quality of life in patients with allergic asthma initiated on omalizumab in the PROSPERO trial; patients were stratified by where their IgE and body weight fell on the approved dosing table. Patient groups were defined as Inside Dosing Table: patients whose IgE and weight fell within the approved dosing table (n = 506); Insufficient Data to Recommend a Dose: patients who fell into the section of the approved dosing table where not enough clinical data were available to make dosing recommendations (n = 72); and Outside Dosing Table: patients who fell outside the approved dosing table due to baseline IgE and/or weight (n = 209). Overall, asthma and quality of life outcomes were improved after omalizumab initiation for both patients who fall within the recommended dosing table or those who fall outside the recommended dosing table. Our results suggest that omalizumab treatment may be effective in a wide range of patients with moderate-to-severe allergic asthma. ClinicalTrials.gov identifier NCT01922037.
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Affiliation(s)
| | | | | | | | | | | | | | - Nicola A Hanania
- Section of Pulmonary and Critical Care Medicine, Baylor College of Medicine, Houston, TX, USA.
| | - Thomas B Casale
- Division of Allergy and Immunology, University of South Florida, Tampa, FL, USA.
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2
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Venditto L, Morano S, Ferrante G, Piazza M, Tenero L, Piacentini G, Pecoraro L. The Evolution of Scientific Knowledge in Childhood Asthma over Time: A Surprising History. Children (Basel) 2024; 11:262. [PMID: 38397374 PMCID: PMC10887562 DOI: 10.3390/children11020262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 02/14/2024] [Accepted: 02/16/2024] [Indexed: 02/25/2024]
Abstract
Asthma is a disease that has been described since the times of Hammurabi. However, it is only since the 1960s that effective therapeutic strategies have been available. Pathogenic mechanisms underlying the disease have been deeply studied, contributing to creating a "patient-specific asthma" definition. Biological drugs have been approved over the last twenty years, improving disease management in patients with severe asthma via a "precision medicine-driven approach". This article aims to describe the evolution of scientific knowledge in childhood asthma, focusing on the most recent biological therapies and their indications for patients with severe asthma.
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Affiliation(s)
| | | | - Giuliana Ferrante
- Pediatric Clinic, Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, 37126 Verona, Italy; (L.V.); (S.M.); (M.P.)
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3
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Gaberino CL, Bacharier LB, Jackson DJ. Controversies in Allergy: Are Biologic Treatment Responses in Severe Asthma the Same in Adults and Children? J Allergy Clin Immunol Pract 2023; 11:2673-2682. [PMID: 37517797 DOI: 10.1016/j.jaip.2023.07.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Revised: 07/18/2023] [Accepted: 07/20/2023] [Indexed: 08/01/2023]
Abstract
The availability of biologic agents for patients with severe asthma has increased dramatically over the last several decades. The absence of direct head-to-head comparative data and relative lack of biomarkers to predict response can make it difficult to choose the right biologic medication for a given patient. Selecting a biologic agent for the pediatric population presents further challenges due to more limited approved biologic agents and fewer clinical trials in children. In addition, the outcome data that are currently available suggest that treatment responses for a given biologic may be different between adult and pediatric patients. To better understand this possible difference in treatment response, this review focuses on the available efficacy data for biologics evaluated in adult and pediatric patients with severe asthma in addition to other considerations when choosing a biologic agent. Finally, this review discusses how asthma phenotypes differ across age groups and their contributions to the responses to biologic treatment across age groups.
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Affiliation(s)
- Courtney L Gaberino
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Leonard B Bacharier
- Department of Pediatrics, Monroe Carrel Jr Children's Hospital at Vanderbilt University Medical Center, Nashville, Tenn
| | - Daniel J Jackson
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wis.
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4
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Schleich F, Bougard N, Moermans C, Sabbe M, Louis R. Cytokine-targeted therapies for asthma and COPD. Eur Respir Rev 2023; 32:32/168/220193. [PMID: 37076177 PMCID: PMC10113955 DOI: 10.1183/16000617.0193-2022] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 01/23/2023] [Indexed: 04/21/2023] Open
Abstract
Asthma affects over 300 million people worldwide and its prevalence is increasing. COPD is the third leading cause of death globally. Asthma and COPD are complex inflammatory diseases of the airways in which impaired host defences lead to increased susceptibility to pathogens, pollutants and allergens. There is a constant interplay between host and the environment. Environmental exposures can alter the lung microbiome and influence the development of sensitisation by disrupting normal immunoregulation. The underlying airway inflammation in severe asthma is heterogeneous, with upregulation of type 2 cytokines in most cases but increased neutrophilic inflammation and activated T-helper 17 mediated immunity in others. COPD may also comprise several different phentoypes that are driven by different molecular mechanisms or endotypes. This disease heterogeneity is affected by comorbidities, treatments and environmental exposures. Recent intervention trials have shed light on the pathways beyond type 2 inflammation that can lead to beneficial outcomes versus potentially deleterious effects. We have made a great deal of progress over the last 10 years in terms of immunology and the pathophysiology of asthma and this has led to the development of novel treatments and major improvements in severe asthma outcomes. In COPD, however, no targeted treatments have demonstrated great improvements. This article reviews the mechanism of action and efficacy of the available biologics in asthma and COPD.
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Affiliation(s)
- Florence Schleich
- Respiratory Medicine, CHU of Liege, Belgium
- GIGA I3, University of Liege, Belgium
| | | | | | - Mare Sabbe
- Respiratory Medicine, CHU of Liege, Belgium
| | - Renaud Louis
- Respiratory Medicine, CHU of Liege, Belgium
- GIGA I3, University of Liege, Belgium
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5
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Menzella F, Just J, Sauerbeck IS, Mailaender C, Saccheri F, Thonnelier C, Jaumont X, Mala L. Omalizumab for the treatment of patients with severe allergic asthma with immunoglobulin E levels above >1500 IU/mL. World Allergy Organ J 2023; 16:100787. [PMID: 37332525 PMCID: PMC10276275 DOI: 10.1016/j.waojou.2023.100787] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 04/24/2023] [Accepted: 05/16/2023] [Indexed: 06/20/2023] Open
Abstract
Immunoglobulin E (IgE) plays a critical role in the allergen-initiated inflammatory pathway and thus serves as a viable therapeutic target in allergic or IgE-mediated diseases such as asthma. Omalizumab, an anti-IgE biologic, has been approved in the United States (US, 2003) and in the European Union (EU, 2005) as an add-on therapy in patients with moderate-to-severe persistent asthma and severe allergic asthma (SAA) aged 6 years and older. The dose and frequency of omalizumab are adjusted based on the patient's body weight and baseline IgE levels, as recommended by its dosing tables. Currently, these dosing recommendations are limited to patients with baseline IgE levels of up to 1500 IU/mL in the European Union and 700 IU/mL in the United States. However, many patients with SAA have IgE levels >1500 IU/mL, highlighting an unmet need. This review presents the current evidence on the treatment benefits of omalizumab in patients with IgE levels >1500 IU/mL. The findings from the reviewed studies which included >3000 patients support the efficacy and effectiveness of omalizumab in reducing exacerbations, and improving asthma control, lung function, and quality of life in patients with severe asthma having IgE levels beyond the current dosing range. Omalizumab was well-tolerated in these patients, with no new safety signals. In addition, high IgE levels (>1500 IU/mL) are also reported in several comorbidities of asthma (allergic rhinitis, atopic dermatitis, allergic bronchopulmonary aspergillosis [ABPA], food allergy, and nasal polyposis) and omalizumab has demonstrated efficacy and safety in these indications. These data suggest that omalizumab may be considered for administration in SAA patients, with high IgE levels outside the current dosing tables. A detailed assessment of patients with high IgE levels is needed before deciding on the optimal treatment approach. A management algorithm for SAA patients with IgE >1500 IU/mL is proposed in this review and a suggestion to follow the Delphi consensus is advised.
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Affiliation(s)
- Francesco Menzella
- Head, Pulmonology Unit, S. Valentino Hospital, AULSS 2 Marca Trevigiana, Italy
| | - Jocelyne Just
- Allergology Department, Trousseau Hospital, AP-HP Paris, France
- Allergology Department, Université Paris Sorbonne, AP-HP Paris, France
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Bacharier LB, Jackson DJ. Biologics in the treatment of asthma in children and adolescents. J Allergy Clin Immunol 2023; 151:581-589. [PMID: 36702649 DOI: 10.1016/j.jaci.2023.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Revised: 01/02/2023] [Accepted: 01/03/2023] [Indexed: 01/26/2023]
Abstract
Severe asthma in childhood confers substantial patient- and society-level burdens. Although biologics have been available for the management in adults and adolescents for nearly 20 years, research on the efficacy and safety of biologics in children and adolescents has lagged. Fortunately, more recent research specifically in children has provided an evidence base for biologic use in this age group. Most children with severe asthma demonstrate a type 2 inflammatory phenotype, the primary target of currently approved biologics. Three biologics, omalizumab, mepolizumab, and duplilumab, are Food and Drug Administration-approved for children as young as 6 years, whereas benralizumab and tezepelumab are approved for adolescents older than 12 years. All these agents reduce the rates of severe asthma exacerbations, whereas their effects on pulmonary function vary across agents. Safety profiles are reassuring, although additional long-term safety data in children are still needed. The choice of a biologic agent follows a careful assessment of other factors that contribute to uncontrolled asthma and includes biomarkers of blood eosinophils, fractional exhaled nitric oxide, allergic sensitization, and IgE levels. This review focuses on the underlying pathophysiology of childhood asthma, an approach to phenotyping patients, and the efficacy, safety, and use of biologics in children and adolescents with severe asthma.
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Affiliation(s)
- Leonard B Bacharier
- Department of Pediatrics, Monroe Carell Jr Children's Hospital at Vanderbilt University Medical Center, Nashville, Tenn.
| | - Daniel J Jackson
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wis
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Atkinson CE, Schworer SA, Matthews K, Mills K, Neighbors K, Burbank AJ, Hernandez ML. Omalizumab is associated with improved asthma outcomes in children and adolescents with serum immunoglobulin E above dosing guidelines. J Allergy Clin Immunol Pract 2022; 10:2756-2757.e1. [PMID: 35803538 PMCID: PMC10519372 DOI: 10.1016/j.jaip.2022.06.041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 06/07/2022] [Accepted: 06/21/2022] [Indexed: 06/15/2023]
Affiliation(s)
- Claire E Atkinson
- Division of Allergy & Immunology, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Stephen A Schworer
- Division of Allergy & Immunology, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Kate Matthews
- Division of Infectious Disease, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Katherine Mills
- Children's Research Institute, Department of Pediatrics, University of North Carolina, Chapel Hill, NC
| | | | - Allison J Burbank
- Division of Allergy & Immunology, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, NC.
| | - Michelle L Hernandez
- Division of Allergy & Immunology, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, NC
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Abstract
BACKGROUND This is the second update of previously published reviews in the Cochrane Library (2015, first update 2017). Interleukin-5 (IL-5) is the main cytokine involved in the proliferation, maturation, activation and survival of eosinophils, which cause airway inflammation and are a classic feature of asthma. Studies of monoclonal antibodies targeting IL-5 or its receptor (IL-5R) suggest they reduce asthma exacerbations, improve health-related quality of life (HRQoL) and lung function in appropriately selected patients, justifying their inclusion in the latest guidelines. OBJECTIVES To compare the effects of therapies targeting IL-5 signalling (anti-IL-5 or anti-IL-5Rα) with placebo on exacerbations, health-related quality-of-life (HRQoL) measures and lung function in adults and children with chronic asthma, and specifically in those with eosinophilic asthma refractory to existing treatments. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, and two trials registers, manufacturers' websites, and reference lists of included studies. The most recent search was 7 February 2022. SELECTION CRITERIA We included randomised controlled trials comparing mepolizumab, reslizumab and benralizumab versus placebo in adults and children with asthma. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and analysed outcomes using a random-effects model. We used standard methods expected by Cochrane. MAIN RESULTS Seventeen studies on about 7600 participants met the inclusion criteria. Six used mepolizumab, five used reslizumab, and six used benralizumab. One study using benralizumab was terminated early due to sponsor decision and contributed no data. The studies were predominantly on people with severe eosinophilic asthma, which was similarly but variably defined. One was in children aged 6 to 17 years; nine others included children over 12 years but did not report results by age group separately. We deemed the overall risk of bias to be low, with all studies contributing data of robust methodology. We considered the certainty of the evidence for all comparisons to be high overall using the GRADE scheme, except for intravenous (IV) mepolizumab and subcutaneous (SC) reslizumab because these are not currently licensed delivery routes. The anti-IL-5 treatments assessed reduced rates of 'clinically significant' asthma exacerbation (defined by treatment with systemic corticosteroids for three days or more) by approximately half in participants with severe eosinophilic asthma on standard care (at least medium-dose inhaled corticosteroids (ICS)) with poorly controlled disease (either two or more exacerbations in the preceding year or Asthma Control Questionnaire (ACQ) score of 1.5 or more), except for reslizumab SC. The rate ratios for these effects were 0.45 (95% confidence interval (CI) 0.36 to 0.55; high-certainty evidence) for mepolizumab SC, 0.53 (95% CI 0.44 to 0.64; moderate-certainty evidence) for mepolizumab IV, 0.43 (95% CI 0.33 to 0.55; high-certainty evidence) for reslizumab IV, and 0.59 (95% CI 0.52 to 0.66; high-certainty evidence) for benralizumab SC. Non-eosinophilic participants treated with benralizumab also showed a significant reduction in exacerbation rates, an effect not seen with reslizumab IV, albeit in only one study. No data were available for non-eosinophilic participants treated with mepolizumab. There were improvements in validated HRQoL scores with all anti-IL-5 agents in severe eosinophilic asthma. This met the minimum clinically important difference (MCID) for the broader St. George's Respiratory Questionnaire (SGRQ; 4-point change) for benralizumab only, but the improvement in the ACQ and Asthma Quality of Life Questionnaire (AQLQ), which focus on asthma symptoms, fell short of the MCID (0.5 point change for both ACQ and AQLQ) for all of the interventions. The evidence for an improvement in HRQoL scores in non-eosinophilic participants treated with benralizumab and reslizumab was weak, but the tests for subgroup difference were negative. All anti-IL-5 treatments produced small improvements in mean pre-bronchodilator forced expiratory flow in one second (FEV1) of between 0.08 L and 0.15 L in eosinophilic participants, which may not be sufficient to be detected by patients. There were no excess serious adverse events with any anti-IL-5 treatment; in fact, there was a reduction in such events with benralizumab, likely arising from fewer asthma-related hospital admissions. There was no difference compared to placebo in adverse events leading to discontinuation with mepolizumab or reslizumab, but significantly more discontinued benralizumab than placebo, although the absolute numbers were small (42/2026 (2.1%) benralizumab versus 11/1227 (0.9%) placebo). The implications for efficacy or adverse events are unclear. AUTHORS' CONCLUSIONS Overall this analysis supports the use of anti-IL-5 treatments as an adjunct to standard care in people with severe eosinophilic asthma and poor symptom control. These treatments roughly halve the rate of asthma exacerbations in this population. There is limited evidence for improved HRQoL scores and lung function, which may not meet clinically detectable levels. The studies did not report safety concerns for mepolizumab or reslizumab, or any excess serious adverse events with benralizumab, although there remains a question over adverse events significant enough to prompt discontinuation. Further research is needed on biomarkers for assessing treatment response, optimal duration and long-term effects of treatment, risk of relapse on withdrawal, non-eosinophilic patients, children (particularly under 12 years), comparing anti-IL-5 treatments to each other and, in patients meeting relevant eligibility criteria, to other biological (monoclonal antibody) therapies. For benralizumab, future studies should closely monitor rates of adverse events prompting discontinuation.
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Affiliation(s)
| | - Amanda Wilson
- School of Nursing and Midwifery, University of Technology Sydney, Sydney, Australia
| | - Stephen Milan
- Health Innovation Campus and Centre for Health Futures, Lancaster University, Lancaster, UK
| | | | - Freda Yang
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Colin Ve Powell
- Department of Emergency Medicine, Sidra Medciine, Doha, Qatar
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Bakakos A, Rovina N, Loukides S, Bakakos P. Biologics in severe asthma: Outcomes in clinical trials-Similarities and differences. Expert Opin Biol Ther 2022; 22:855-870. [PMID: 35712995 DOI: 10.1080/14712598.2022.2091409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Severe asthma is a heterogenous disease characterized by multiple phenotypes. Targeted biologic therapies have revolutionarily changed the management of severe asthma by affecting various clinical outcomes, mainly by reducing exacerbations and the use of maintenance corticosteroids, but also by improving lung function and patient quality of life. AREAS COVERED Randomized controlled trials have convincingly demonstrated the efficacy of different biologics in improving the above outcomes. However, no head-to-head studies exist to compare their efficacy and many patients with severe asthma are eligible for more than one biologic agent. In this review, we present the effect of various biologics in the various outcomes as shown in randomized controlled trials and discuss their similarities and differences. EXPERT OPINION Both the initial choice of a biologic as well as the option of switching to another give the clinician an interesting but also difficult decision when choosing a biologic therapy for patients with severe asthma. This decision is mainly based on the individual characteristics of the patient, especially rate of exacerbations and use of systemic corticosteroids, but is also influenced by the presence of comorbidities and lung function impairment. No safety concerns have been raised around the use of these biologics.
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Affiliation(s)
- Agamemnon Bakakos
- 1st University Department of Respiratory Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Nikoletta Rovina
- 1st University Department of Respiratory Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Stelios Loukides
- 2nd University Department of Respiratory Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Petros Bakakos
- 1st University Department of Respiratory Medicine, National and Kapodistrian University of Athens, Athens, Greece
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Choi Y, Byun JM, Kim I, Park JH, Kim KH, Kim JS, Choi IS, Yang MS, Park H. Successful management of severe allergic reactions to platelet transfusion with omalizumab: A case report. Medicine (Baltimore) 2021; 100:e27724. [PMID: 34871268 PMCID: PMC8568427 DOI: 10.1097/md.0000000000027724] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Accepted: 10/22/2021] [Indexed: 01/05/2023] Open
Abstract
RATIONALE An allergic transfusion reaction is a common side effect of transfusions of red blood cells. Using washed red blood cells is the most effective method for preventing such a reaction. However, the availability of other washed transfusion components, including platelets, is limited. PATIENT CONCERNS A 69-year-old patient with acute myeloid leukemia progressed from myelodysplastic syndrome and was treated with azacitidine. She experienced a minor reaction to platelet transfusion that initially responded to the administration of corticosteroids and antihistamines. However, she worsened even after subsequent preventive treatments and was referred to the emergency department due to anaphylaxis. The patient developed hypotension, chest pain, and dyspnea 10 minutes after the initiation of platelet transfusion. DIAGNOSES She was diagnosed with platelet-induced anaphylaxis. INTERVENTIONS In an attempt to prevent anaphylaxis, 150 mg of omalizumab was prescribed 1 week prior to transfusion. However, she experienced anaphylaxis again and was administered intramuscular epinephrine. For the following transfusion, we treated her with a 300 mg dose of omalizumab 24 hours before the transfusion. OUTCOMES She tolerated well and continued to receive further chemotherapy and platelet transfusion with premedication. LESSONS This case suggests that omalizumab is a good candidate for the management of severe allergic transfusion reactions.
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Affiliation(s)
- Yeonjoo Choi
- Department of Hematology and Oncology, The Catholic University of Korea, St. Mary Incheon Hospital, Incheon, Republic of Korea
| | - Ja Min Byun
- Department of Hematology and Oncology, Seoul National University Hospital, Seoul, Republic of Korea
| | - Inho Kim
- Department of Hematology and Oncology, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jin Hyun Park
- Department of Hematology and Oncology, Seoul National University Boramae Medical Center, Seoul, Republic of Korea
| | - Ki Hwan Kim
- Department of Hematology and Oncology, Seoul National University Boramae Medical Center, Seoul, Republic of Korea
| | - Jin-Soo Kim
- Department of Hematology and Oncology, Seoul National University Boramae Medical Center, Seoul, Republic of Korea
| | - In Sil Choi
- Department of Hematology and Oncology, Seoul National University Boramae Medical Center, Seoul, Republic of Korea
| | - Min-Suk Yang
- Department of Allergy and Clinical Immunology, Seoul National University Boramae Medical Center, Seoul, Republic of Korea
| | - Hyunkyung Park
- Department of Hematology and Oncology, Seoul National University Boramae Medical Center, Seoul, Republic of Korea
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Trevor J, Lugogo N, Carr W, Moore WC, Soong W, Panettieri RA, Desai P, Trudo F, Ambrose CS. Exacerbations in US Severe Asthma: Incidence, Characteristics, Predictors, and Effects of Biologic Treatments. Ann Allergy Asthma Immunol 2021; 127:579-587.e1. [PMID: 34273485 DOI: 10.1016/j.anai.2021.07.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 07/06/2021] [Accepted: 07/12/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND Patients with severe asthma (SA) have a heightened risk of exacerbations, including hospitalization. The real-world, specialist-verified incidence and characteristics of exacerbations among patients with SA in the United States (US) have not been described. OBJECTIVE To describe the real-world incidence, characteristics, and predictors of exacerbations among patients with SA in the US. METHODS CHRONICLE is an ongoing observational study of specialist-treated US adults with SA receiving biologic treatment or maintenance systemic corticosteroids (SCS), or uncontrolled by high-dosage inhaled corticosteroids with additional controllers. For patients enrolled February 2018 to February 2020, annualized rates and characteristics of exacerbation-related events were summarized by treatment category for 12 months before enrollment and after enrollment through the latest data collection. Results were further analyzed for subgroups of interest. RESULTS Among 1884 enrolled patients, 53.5% and 12.3% experienced an exacerbation and asthma hospitalization, respectively (0.81 and 0.14 per person-year). Of all exacerbations, 36%, 9%, and 15% required an unscheduled healthcare provider visit, emergency department visit without hospitalization, and hospitalization, respectively. Among patients not receiving biologics or SCS, higher blood eosinophil count, higher fractional exhaled nitric oxide, and lower total immunoglobulin E level were associated with higher exacerbation rates. Exacerbation rates decreased after starting or switching biologics (n = 1299). Multivariate analyses of enrolled patients showed prior-year exacerbations/hospitalizations, lack of asthma control, and geographic region also predicted event risk. CONCLUSION In this real-world cohort of specialist-treated US adults with SA, there was a substantial burden of exacerbations and associated healthcare resource utilization. Patients receiving biologics had a lower exacerbation burden.
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Affiliation(s)
| | | | - Warner Carr
- Allergy & Asthma Associates of Southern California, Mission Viejo, California
| | - Wendy C Moore
- Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Weily Soong
- University of Alabama at Birmingham, Birmingham, Alabama
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12
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Abstract
Asthma is the most common chronic pediatric lung disease that has traditionally been defined as a syndrome of airway inflammation characterized by clinical symptoms of cough and wheeze. Highlighting the complex and heterogeneous nature of asthma, this review summarizes recent advances in asthma classification that are based on pathobiology, and thereby directly addresses limitations of existent definitions of asthma. By reviewing and contrasting clinical and mechanistic features of adult and childhood asthma, the review summarizes key biomarkers that distinguish childhood asthma subtypes. While atopy and its severity are important features of childhood asthma, there is evidence to support the existence of a childhood asthma endotype distinct from the atopic endotype. Although biomarkers of non-atopic asthma are an area of future research, we summarize a clinical approach that includes existing measures of airway-specific and systemic measures of atopy, co-existing morbidities, and disease severity and control, in the definition of childhood asthma, to empower health care providers to better characterize asthma disease burden in children. Identification of biomarkers of non-atopic asthma and the contribution of genetics and epigenetics to pediatric asthma burden remains a research need, which can potentially allow delivery of precision medicine to pediatric asthma. IMPACT: This review highlights asthma as a complex and heterogeneous disease and discusses recent advances in the understanding of the pathobiology of asthma to demonstrate the need for a more nuanced definitions of asthma. We review current knowledge of asthma phenotypes and endotypes and put forth an approach to endotyping asthma that may be useful for defining asthma for clinical care as well as for future research studies in the realm of personalized medicine for asthma.
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13
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Votto M, De Filippo M, Licari A, Marseglia A, De Amici M, Marseglia GL. Biological Therapies in Children and Adolescents with Severe Uncontrolled Asthma: A Practical Review. Biologics 2021; 15:133-142. [PMID: 33981139 PMCID: PMC8107006 DOI: 10.2147/btt.s252574] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 04/19/2021] [Indexed: 12/29/2022]
Abstract
Severe uncontrolled asthma is a complex and heterogeneous disease. A multidisciplinary assessment is required to correctly identify and manage children and adolescents with severe asthma because they may require strict monitoring and additional treatment with advanced targeted therapies. Recent research efforts have focused on identifying epidemiologic, clinical, and molecular mechanisms that underlie severe asthma, leading to the recognition of different phenotypes and endotypes and identifying biomarkers able to predict the response to biologic therapies. Additional progress has occurred by introducing biological therapies that have revolutionized the care of chronic allergic diseases in the adult and pediatric population. In this review, we briefly summarized the current literature on biological therapies to treat severe asthma in children and adolescents.
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Affiliation(s)
- Martina Votto
- Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.,Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Maria De Filippo
- Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.,Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Amelia Licari
- Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.,Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Alessia Marseglia
- Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Mara De Amici
- Immuno-Allergology Laboratory, Clinical Chemistry Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Gian Luigi Marseglia
- Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.,Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
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14
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Shah SN, Grunwell JR, Mohammad AF, Stephenson ST, Lee GB, Vickery BP, Fitzpatrick AM. Performance of Eosinophil Cationic Protein as a Biomarker in Asthmatic Children. J Allergy Clin Immunol Pract 2021; 9:2761-2769.e2. [PMID: 33781764 DOI: 10.1016/j.jaip.2021.02.053] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 02/07/2021] [Accepted: 02/25/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Although blood eosinophils are a frequently used marker of type 2 inflammation in children with asthma, their sensitivity is relatively poor. Additional markers of type 2 inflammation are needed. OBJECTIVE We hypothesized that plasma concentrations of eosinophil cationic protein (ECP), a marker of eosinophil activation, would be useful for detection of type 2 inflammation and would predict poorer asthma outcomes over 1 year. METHODS Children and adolescents 6 through 17 years (N = 256) with confirmed asthma completed a baseline visit and a follow-up visit at 12 months. A subset also underwent systemic corticosteroid responsiveness testing with intramuscular triamcinolone. Outcome measures at 12 months included uncontrolled asthma, lung function, and asthma exacerbations treated with systemic corticosteroids. RESULTS Plasma ECP concentrations ranged from 0.03 to 413.61 ng/mL (median, 6.95 ng/mL) and were consistently associated with other markers of type 2 inflammation. At baseline, children in the highest ECP tertile had poorer asthma control, more airflow limitation, and more exacerbations, but also had greater symptom improvement with intramuscular triamcinolone. At 12 months, associations between the highest ECP tertile and exacerbations, but not lung function or asthma control, persisted after covariate adjustment. However, the sensitivity of ECP was modest and was not markedly different from that of blood eosinophil counts. CONCLUSION Plasma ECP concentrations may be a useful marker of type 2 inflammation in children and may help identify those children at highest risk for recurrent exacerbations who could benefit from corticosteroid treatment. However, additional markers may be needed to improve sensitivity for outcome detection.
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Affiliation(s)
- Sheel N Shah
- Department of Pediatrics, Emory University, Atlanta, Ga; Center for Cystic Fibrosis and Airways Disease Research, Children's Healthcare of Atlanta, Atlanta, Ga
| | - Jocelyn R Grunwell
- Department of Pediatrics, Emory University, Atlanta, Ga; Center for Cystic Fibrosis and Airways Disease Research, Children's Healthcare of Atlanta, Atlanta, Ga
| | | | | | - Gerald B Lee
- Department of Pediatrics, Emory University, Atlanta, Ga; Center for Cystic Fibrosis and Airways Disease Research, Children's Healthcare of Atlanta, Atlanta, Ga
| | - Brian P Vickery
- Department of Pediatrics, Emory University, Atlanta, Ga; Center for Cystic Fibrosis and Airways Disease Research, Children's Healthcare of Atlanta, Atlanta, Ga
| | - Anne M Fitzpatrick
- Department of Pediatrics, Emory University, Atlanta, Ga; Center for Cystic Fibrosis and Airways Disease Research, Children's Healthcare of Atlanta, Atlanta, Ga.
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15
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Sheehan WJ, Krouse RZ, Calatroni A, Gergen PJ, Gern JE, Gill MA, Gruchalla RS, Khurana Hershey GK, Kattan M, Kercsmar CM, Lamm CI, Little FF, Makhija MM, Searing DA, Zoratti E, Busse WW, Teach SJ. Aeroallergen Sensitization, Serum IgE, and Eosinophilia as Predictors of Response to Omalizumab Therapy During the Fall Season Among Children with Persistent Asthma. J Allergy Clin Immunol Pract 2020; 8:3021-3028.e2. [PMID: 32376491 PMCID: PMC8775809 DOI: 10.1016/j.jaip.2020.03.051] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 03/27/2020] [Accepted: 03/27/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Perennial aeroallergen sensitization is associated with greater asthma morbidity and is required for treatment with omalizumab. OBJECTIVE To investigate the predictive relationship between the number of aeroallergen sensitizations, total serum IgE, and serum eosinophil count, and response to omalizumab in children and adolescents with asthma treated during the fall season. METHODS This analysis includes inner-city patients with persistent asthma and recent exacerbations aged 6-20 years comprising the placebo- and omalizumab-treated groups in 2 completed randomized clinical trials, the Inner-City Anti-IgE Therapy for Asthma study and the Preventative Omalizumab or Step-Up Therapy for Fall Exacerbations study. Logistic regression modeled the relationship between greater degrees of markers of allergic inflammation and the primary outcome of fall season asthma exacerbations. RESULTS The analysis included 761 participants who were 62% male and 59% African American with a median age of 10 years. Fall asthma exacerbations were significantly higher in children with greater numbers of aeroallergen-specific sensitizations in the placebo group (odds ratio [OR], 1.33; 95% confidence interval [CI], 1.11-1.60; P < .01), but not in the omalizumab-treated children (OR, 1.08; 95% CI, 0.91-1.28; P = .37), indicating a significant differential effect (P < .01). Likewise, there was a differential effect of omalizumab treatment in children with greater baseline total serum IgE levels (P < .01) or greater baseline serum eosinophil counts (P < .01). Multiple aeroallergen sensitization was the best predictor of response to omalizumab; treated participants sensitized to ≥4 different groups of aeroallergens had a 51% reduction in the odds of a fall exacerbation (OR, 0.49; 95% CI, 0.30-0.81; P < .01). CONCLUSIONS In preventing fall season asthma exacerbations, treatment with omalizumab was most beneficial in children with a greater degree of allergic inflammation.
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Affiliation(s)
- William J Sheehan
- Children's National Hospital and George Washington University School of Medicine and Health Sciences, Washington, DC.
| | | | | | - Peter J Gergen
- National Institute of Allergy and Infectious Diseases, Rockville, Md
| | - James E Gern
- University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Michelle A Gill
- University of Texas Southwestern Medical Center, Dallas, Tex
| | | | | | - Meyer Kattan
- College of Physicians and Surgeons, Columbia University, New York, NY
| | | | - Carin I Lamm
- College of Physicians and Surgeons, Columbia University, New York, NY
| | | | - Melanie M Makhija
- Lurie Children's Hospital and Northwestern University School of Medicine, Chicago, Ill
| | - Daniel A Searing
- Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, Colo
| | - Edward Zoratti
- Henry Ford Health System and Wayne State University School of Medicine, Detroit, Mich
| | - William W Busse
- University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Stephen J Teach
- Children's National Hospital and George Washington University School of Medicine and Health Sciences, Washington, DC
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16
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Pijnenburg MW, Fleming L. Advances in understanding and reducing the burden of severe asthma in children. Lancet Respir Med 2020; 8:1032-1044. [PMID: 32910897 DOI: 10.1016/s2213-2600(20)30399-4] [Citation(s) in RCA: 68] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 08/10/2020] [Accepted: 08/22/2020] [Indexed: 01/16/2023]
Abstract
Severe asthma in children is rare, accounting for only a small proportion of childhood asthma. After addressing modifiable factors such as adherence to treatment, comorbidities, and adverse exposures, children whose disease is not well controlled on high doses of medication form a heterogeneous group of severe asthma phenotypes. Over the past decade, considerable advances have been made in understanding the pathophysiology of severe therapy-resistant asthma in children. However, asthma attacks and hospital admissions are frequent and mortality is still unacceptably high. Strategies to modify the natural history of asthma, prevent severe exacerbations, and prevent lung function decline are needed. Mechanistic studies have led to the development of several biologics targeting type 2 inflammation. This growing pipeline has the potential to reduce the burden of severe asthma; however, detailed assessment and characterisation of each child with seemingly severe asthma is necessary so that the most effective and appropriate management strategy can be implemented. Risk stratification, remote monitoring, and the integration of multiple data sources could help to tailor management for the individual child with severe asthma.
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Affiliation(s)
- Mariëlle W Pijnenburg
- Department of Paediatrics, Division of Respiratory Medicine and Allergology, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, Netherlands.
| | - Louise Fleming
- National Heart and Lung Institute, Imperial College, London, UK
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17
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Nolasco S, Campisi R, Intravaia R, Porto M, Pelaia C, Crimi N, Crimi C. Case Report: Acute effect of benralizumab on asthma exacerbation without concomitant corticosteroid use. F1000Res 2020; 9:637. [DOI: 10.12688/f1000research.24603.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/16/2020] [Indexed: 12/25/2022] Open
Abstract
Background: Monoclonal antibodies are a relatively new therapeutic option for patients with severe refractory asthma, which can be used as an add-on to maintenance therapy, reducing the need for systemic corticosteroid usage, improving asthma symptom control and reducing exacerbations. We report a case of a patient with severe refractory eosinophilic asthma, reluctant to take systemic steroids, who was successfully treated with benralizumab alone during an acute asthma attack. Case presentation: A 59-year-old Caucasian woman with a history of allergic asthma since childhood showed a progressive decline in lung function with difficult to control symptoms and an increased number of hospitalizations despite maximal maintenance treatment, and was diagnosed with severe refractory asthma. She was reluctant to take systemic corticosteroids during exacerbations due to severe urinary retention; therefore, she started omalizumab with a partial reduction of symptoms and exacerbations over time. During a follow-up visit, she showed signs of acute exacerbation and she was switched to benralizumab during her acute phase with a rapid, dramatic amelioration of respiratory symptoms and pulmonary function, without concomitant systemic corticosteroid administration. During the treatment and at follow-up after one month, good tolerance and no side effects were observed. Conclusions: The use of benralizumab seems to be feasible, rapid, and safe in treating acute exacerbation of severe eosinophilic asthma without the use of systemic corticosteroids.
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18
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Nolasco S, Campisi R, Intravaia R, Porto M, Pelaia C, Crimi N, Crimi C. Case Report: Acute effect of benralizumab on asthma exacerbation without concomitant corticosteroid use. F1000Res 2020; 9:637. [PMID: 32864107 PMCID: PMC7443779 DOI: 10.12688/f1000research.24603.2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/20/2020] [Indexed: 12/23/2022] Open
Abstract
Background: Monoclonal antibodies are a relatively new therapeutic option for patients with severe refractory asthma, which can be used as an add-on to maintenance therapy, reducing the need for systemic corticosteroid usage, improving asthma symptom control and reducing exacerbations. We report a case of a patient with severe refractory eosinophilic asthma, reluctant to take systemic steroids, who was successfully treated with benralizumab alone during an acute asthma attack. Case presentation: A 59-year-old Caucasian woman with a history of allergic asthma since childhood showed a progressive decline in lung function with difficult to control symptoms and an increased number of hospitalizations despite maximal maintenance treatment, and was diagnosed with severe refractory asthma. She was reluctant to take systemic corticosteroids during exacerbations due to severe urinary retention; therefore, she started omalizumab with a partial reduction of symptoms and exacerbations over time. During a follow-up visit, she showed signs of acute exacerbation and she was switched to benralizumab during her acute phase with a rapid, dramatic amelioration of respiratory symptoms and pulmonary function, without concomitant systemic corticosteroid administration. During the treatment and at follow-up after one month, good tolerance and no side effects were observed. Conclusions: The use of benralizumab seems to be feasible, rapid, and safe in treating acute exacerbation of severe eosinophilic asthma without the use of systemic corticosteroids.
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Affiliation(s)
- Santi Nolasco
- Department of Clinical and Experimental Medicine, Section of Respiratory Diseases, University of Catania, Catania, Italy
| | - Raffaele Campisi
- Respiratory Medicine Unit, A.O.U. "Policlinico-Vittorio Emanuele", Catania, Italy
| | - Rossella Intravaia
- Department of Clinical and Experimental Medicine, Section of Respiratory Diseases, University of Catania, Catania, Italy
| | - Morena Porto
- Department of Clinical and Experimental Medicine, Section of Respiratory Diseases, University of Catania, Catania, Italy
| | - Corrado Pelaia
- Department of Medical and Surgical Sciences, University "Magna Graecia", Catanzaro, Italy
| | - Nunzio Crimi
- Department of Clinical and Experimental Medicine, Section of Respiratory Diseases, University of Catania, Catania, Italy.,Respiratory Medicine Unit, A.O.U. "Policlinico-Vittorio Emanuele", Catania, Italy
| | - Claudia Crimi
- Respiratory Medicine Unit, A.O.U. "Policlinico-Vittorio Emanuele", Catania, Italy
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19
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Henriksen DP, Bodtger U, Sidenius K, Maltbaek N, Pedersen L, Madsen H, Andersson EA, Norgaard O, Madsen LK, Chawes BL. Efficacy of omalizumab in children, adolescents, and adults with severe allergic asthma: a systematic review, meta-analysis, and call for new trials using current guidelines for assessment of severe asthma. Allergy Asthma Clin Immunol 2020; 16:49. [PMID: 32565844 PMCID: PMC7302157 DOI: 10.1186/s13223-020-00442-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Accepted: 05/23/2020] [Indexed: 12/14/2022] Open
Abstract
Background Omalizumab is approved for treating severe allergic asthma from age 6, but the definition of severe asthma including a systematic assessment to rule out difficult-to-treat asthma has changed since the drug was approved in 2003. Methods We conducted a systematic review and meta-analysis of two critical (exacerbation rate, oral corticosteroid (OCS) treatment) and eight important clinical outcomes in children, adolescents and adults, and specifically searched papers for systematic assessment of severe asthma. Results Adults: seven studies (n = 2159) ascertaining exacerbation rate showing a 37% (95% CI 21–50) reduction in favor of omalizumab, larger than the pre-specified minimal clinically important difference (MCID) of 25%. Only one open-label study (n = 82) was identified assessing the percentage of patients experiencing reduction of OCS-maintenance treatment showing a significantly greater decrease in the omalizumab group (− 45% vs. + 18.3%, p = 0.002). Children and adolescents: four studies (n = 1551) reported data on exacerbations (no meta-analysis conducted), showed overall improvements in exacerbation rate and some passed MCID. No OCS studies were identified. No included studies provided systematic assessment of severe asthma according to current guidelines. Conclusions Omalizumab provides clinically relevant improvements in exacerbation rate among children, adolescents, and adults and in OCS-reduction among adults. New studies incorporating a guideline-approached definition of severe asthma are warranted.
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Affiliation(s)
- Daniel P Henriksen
- Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense, Denmark.,Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Uffe Bodtger
- Department of Respiratory Medicine, Næstved Hospital, Næstved, Denmark.,Department of Medicine, Zealand University Hospital, Roskilde, Denmark
| | | | - Niels Maltbaek
- Department of Medicine, Zealand University Hospital, Roskilde, Denmark
| | - Lars Pedersen
- Department of Respiratory Medicine, Bispebjerg Hospital, Copenhagen, Denmark
| | - Hanne Madsen
- Department of Respiratory Medicine, Odense University Hospital, Odense, Denmark
| | - Ehm A Andersson
- The Danish Medicines Council Secretariat, Copenhagen, Denmark
| | - Ole Norgaard
- The Danish Medicines Council Secretariat, Copenhagen, Denmark
| | - Louise K Madsen
- The Danish Medicines Council Secretariat, Copenhagen, Denmark
| | - Bo L Chawes
- COPSAC, Copenhagen Prospective Studies on Asthma in Childhood, Herlev and Gentofte University Hospital, University of Copenhagen, Ledreborg Allé 34, Gentofte, 2820 Copenhagen, Denmark
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20
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Rodriguez-Martinez CE, Sossa-Briceño MP, Castro-Rodriguez JA. Predictors of response to medications for asthma in pediatric patients: A systematic review of the literature. Pediatr Pulmonol 2020; 55:1320-1331. [PMID: 32297708 DOI: 10.1002/ppul.24782] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 04/08/2020] [Indexed: 02/01/2023]
Abstract
OBJECTIVES There has been no systematic review of studies aimed to predict differential responses to medication regimens for asthma controller therapies in pediatric patients. The aim of the present study was to summarize those identifying biomarkers for the different asthma controller therapies. METHODS Studies published by June 2019 that report phenotypic or genotypic characteristics or biomarkers that could potentially serve as response predictors to asthma controller therapies in pediatric patients were included. The quality of studies was assessed using the Cochrane Risk of Bias tool and the Newcastle-Ottawa Scale tool. RESULTS Of 385 trials identified, 30 studies were included. Children with asthma and a positive family history of asthma, with more severe disease, of the white race, with allergy biomarkers, nonobese, with lower lung function, high bronchial hyperresponsiveness to methacholine, or having variants in the FCER2 and CRHR1 gene respond better to inhaled corticosteroids (ICS). Younger age (<10 years), short disease duration (<4 years), high cotinine and urinary leukotriene E4 (LTE4) levels, and 5/5 ALOX5 were associated with a better response to leukotriene receptor antagonist (LTRA). For patients that remain symptomatic, white Hispanics were more likely to respond to LTRA, blacks to ICS, white non-Hispanics to LTRA or LABA, and children without a history of eczema, regardless of race or ethnicity to LABA set-up therapy. In severe persistent asthma, those with atopy and body mass index greater than or equal 25 were more likely to benefit from omalizumab. CONCLUSION Several phenotypic characteristics, biomarkers, or pharmacogenomics markers could be useful for predicting the best drug for asthma treatment.
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Affiliation(s)
- Carlos E Rodriguez-Martinez
- Department of Pediatrics, School of Medicine, Universidad Nacional de Colombia, Bogota, Colombia.,Department of Pediatric Pulmonology and Pediatric Critical Care Medicine, School of Medicine, Universidad El Bosque, Bogota, Colombia
| | - Monica P Sossa-Briceño
- Department of Internal Medicine, School of Medicine, Universidad Nacional de Colombia, Bogotá, Colombia
| | - Jose A Castro-Rodriguez
- Department of Pediatric Pulmonology, School of Medicine, Pontificia Universidad Catolica de Chile, Santiago, Chile
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21
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Agache I, Beltran J, Akdis C, Akdis M, Canelo‐Aybar C, Canonica GW, Casale T, Chivato T, Corren J, Del Giacco S, Eiwegger T, Firinu D, Gern JE, Hamelmann E, Hanania N, Mäkelä M, Hernández‐Martín I, Nair P, O'Mahony L, Papadopoulos NG, Papi A, Park H, Pérez de Llano L, Posso M, Rocha C, Quirce S, Sastre J, Shamji M, Song Y, Steiner C, Schwarze J, Alonso‐Coello P, Palomares O, Jutel M. Efficacy and safety of treatment with biologicals (benralizumab, dupilumab, mepolizumab, omalizumab and reslizumab) for severe eosinophilic asthma. A systematic review for the EAACI Guidelines - recommendations on the use of biologicals in severe asthma. Allergy 2020; 75:1023-1042. [PMID: 32034960 DOI: 10.1111/all.14221] [Citation(s) in RCA: 186] [Impact Index Per Article: 46.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 01/31/2020] [Indexed: 12/13/2022]
Abstract
Five biologicals have been approved for severe eosinophilic asthma, a well-recognized phenotype. Systematic reviews (SR) evaluated the efficacy and safety of benralizumab, dupilumab, mepolizumab, omalizumab and reslizumab (alphabetical order) compared to standard of care for severe eosinophilic asthma. PubMed, Embase and Cochrane Library were searched to identify RCTs and health economic evaluations, published in English. Critical and important asthma-related outcomes were evaluated for each of the biologicals. The risk of bias and the certainty of the evidence were assessed using GRADE. 19 RCTs (three RCTs for benralizumab, three RCTs for dupilumab, three RCTs for mepolizumab, five RCTs for omalizumab and five RCTs for reslizumab), including subjects 12 to 75 years old (except for omalizumab including also subjects 6-11 years old), ranging from 12 to 56 weeks were evaluated. All biologicals reduce exacerbation rates with high certainty of evidence: benralizumab incidence rate ratio (IRR) 0.53 (95% CI 0.39 to 0.72), dupilumab (IRR) 0.43 (95% CI 0.32 to 0.59), mepolizumab IRR 0.49 (95% CI 0.38 to 0.66), omalizumab (IRR) 0.56 (95% CI 0.40 to 0.77) and reslizumab (IRR) 0.46 (95% CI 0.37 to 0.58). Benralizumab, dupilumab and mepolizumab reduce the daily dose of oral corticosteroids (OCS) with high certainty of evidence. All evaluated biologicals probably improve asthma control, QoL and FEV1 , without reaching the minimal important difference (moderate certainty). Benralizumab, mepolizumab and reslizumab slightly increase drug-related adverse events (AE) and drug-related serious AE (low to very low certainty of evidence). The incremental cost-effectiveness ratio per quality-adjusted life year value is above the willingness to pay threshold for all biologicals (moderate certainty). Potential savings are driven by decrease in hospitalizations, emergency and primary care visits. There is high certainty that all approved biologicals reduce the rate of severe asthma exacerbations and for benralizumab, dupilumab and mepolizumab for reducing OCS. There is moderate certainty for improving asthma control, QoL, FEV1 . More data on long-term safety are needed together with more efficacy data in the paediatric population.
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Abstract
INTRODUCTION Severe pediatric asthma is associated with significant morbidity as well as with a high economic burden. It represents a heterogeneous disease with multiple clinical phenotypes. Currently, physicians are facing the challenge to provide a 'personalized medicine approach', which is tailored to the diverse pathomechanisms underlying clinical presentations. Three main endotypes of airway inflammation have been described in children with severe asthma. While neutrophilic and paucigranulocytic inflammatory patterns are quite uncommon in childhood, type Th2 inflammation asthma with elevated IgE is the most prevalent in pediatric asthma. Considering the pivotal role of IgE in type Th2 inflammation asthma, the blockade of IgE using anti-IgE therapy represents a potent therapeutic option for severe pediatric asthma in children. AREAS COVERED This review aims to focus on the role of omalizumab as a treatment option in pediatric patients (aged six years and above) with severe allergic asthma. EXPERT OPINION The clinical efficacy and safety of omalizumab for the treatment of pediatric asthma is well documented in clinical trials and observational studies. Further studies are still required to characterize the potential benefit of anti-IgE therapy in airway remodeling, identify additional biomarkers of clinical response and address current unmet needs, including the limit on omalizumab use in children younger than six years.
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Affiliation(s)
| | - Riccardo Castagnoli
- Department of Pediatrics, Foundation IRCCS Policlinico San Matteo, University of Pavia , Pavia, Italy
| | - Stefania Arasi
- Pediatric Allergology Unit, Bambino Gesù Hospital (IRCCS) , Rome, Italy
| | - Amelia Licari
- Department of Pediatrics, Foundation IRCCS Policlinico San Matteo, University of Pavia , Pavia, Italy
| | - Lucia Caminiti
- Department of Pediatrics, Allergy Unit, University of Messina , Messina, Italy
| | - Gian Luigi Marseglia
- Department of Pediatrics, Foundation IRCCS Policlinico San Matteo, University of Pavia , Pavia, Italy
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23
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Slob EM, Maitland-Van der Zee AH, Koppelman GH, Pijnenburg MW. Precision medicine in childhood asthma. Curr Opin Allergy Clin Immunol 2019; 19:141-7. [PMID: 30649013 DOI: 10.1097/ACI.0000000000000517] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Childhood asthma is a heterogeneous disease and many children have uncontrolled disease. Therefore an individualized approach is needed to improve asthma outcomes in children. Precision medicine using clinical characteristics, biomarkers, and the rapidly involving field of genomics and pharmacogenomics aims to achieve asthma control and reduce future risks with less side-effects in individual children with asthma. RECENT FINDINGS It is not yet possible to select treatment options on clinical characteristics. Novel monoclonal antibodies are efficacious in patients with severe, eosinophilic asthma. Reduced lung function growth and early decline is a prevalent finding in children with persistent asthma. Pharmacogenetic studies have identified children at risk for cortisol suppression when using inhaled corticosteroids. SUMMARY Clinical characteristics and simple biomarkers like eosinophils, IgE, and the fraction of exhaled nitric oxide may be used in clinical practice for a basic precision medicine approach, deciding which children will have the best chance to respond to inhaled corticosteroids and to the biologicals omalizumab and mepolizumab.Further application of pharmacogenomics and breathomics needs additional studies before they can be applied as tools for precision medicine in individual children with asthma.
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24
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Licari A, Manti S, Marseglia A, De Filippo M, De Sando E, Foiadelli T, Marseglia GL. Biologics in Children with Allergic Diseases. Curr Pediatr Rev 2020; 16:140-147. [PMID: 31660839 DOI: 10.2174/1573396315666191029123822] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 09/23/2019] [Accepted: 09/24/2019] [Indexed: 11/22/2022]
Abstract
The prevalence of allergic diseases has been remarkably increased in the last decades. The global health burden of these conditions is substantial, since patients may experience disability, anxiety and emotional distress, social restrictions, and reduced quality of life and productivity, in particular, in the most severe cases. Recent advances in understanding the pathophysiology of allergic disorders have allowed identifying novel therapeutic strategies for the treatment of severe and uncontrolled allergic diseases. Although most studies have been performed in allergic asthma, biological drugs targeting other allergic diseases such as chronic spontaneous urticaria, atopic dermatitis, and food allergy are showing promising results. In this review, the most recent evidence on biologic therapies for allergic diseases, focusing on the pediatric age has been presented.
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Affiliation(s)
- Amelia Licari
- Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, University of Pavia, viale Golgi 19, 27100 Pavia, Italy
| | - Sara Manti
- Department of Pediatric, Pediatric Unit, University of Messina, via Consolare Valeria, 1, 98125, Messina, Italy.,Respiratory Unit, AOU Policlinico-Vittorio Emanuele, Department of Clinical and Experimental Medicine, University of Catania, Via Santa Sofia 78, I-95123 Catania, Italy
| | - Alessia Marseglia
- Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, University of Pavia, viale Golgi 19, 27100 Pavia, Italy
| | - Maria De Filippo
- Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, University of Pavia, viale Golgi 19, 27100 Pavia, Italy
| | - Elisabetta De Sando
- Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, University of Pavia, viale Golgi 19, 27100 Pavia, Italy
| | - Thomas Foiadelli
- Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, University of Pavia, viale Golgi 19, 27100 Pavia, Italy
| | - Gian Luigi Marseglia
- Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, University of Pavia, viale Golgi 19, 27100 Pavia, Italy
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25
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Abstract
Asthma is a heterogeneous disorder described by a large number of clinical features. A growing body of literature on more specific asthma phenotypes provides evidence for a phenotype-based approach to management in which specific therapies are recommended based on patient and disease characteristics. This understanding, coupled with an increase in the number of available therapies for children with asthma, as well as emerging therapies and phenotypic markers, will allow for improved asthma management in the future.
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Affiliation(s)
- Nathan M Pajor
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 7041, Cincinnati, OH 45229, USA
| | - Theresa W Guilbert
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA; Pulmonary Division, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 7041, Cincinnati, OH 45229, USA.
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Burg GT, Covar R, Oland AA, Guilbert TW. The Tempest: Difficult to Control Asthma in Adolescence. J Allergy Clin Immunol Pract 2019; 6:738-748. [PMID: 29747981 DOI: 10.1016/j.jaip.2018.02.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Revised: 02/02/2018] [Accepted: 02/03/2018] [Indexed: 02/06/2023]
Abstract
Severe asthma is associated with significant morbidity and is a highly heterogeneous disorder. Severe asthma in adolescence has some unique elements compared with the features of severe asthma a medical provider would see in younger children or adults. A specific focus on psychological issues and adherence highlights some of the challenges in the management of asthma in adolescents. Treatment of adolescents with severe asthma now includes 3 approved biologic phenotype-directed therapies. Therapies available to adults may be beneficial to adolescents with severe asthma. Research into predictors of specific treatment response by phenotypes is ongoing. Optimal treatment strategies are not yet defined and warrant further investigation.
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Affiliation(s)
- Gregory T Burg
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
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Abstract
Advances in the management of pediatric asthma, including biologics, offer practitioners the ability to tailor therapies to individual patients. However, asthma treatment guidelines have not kept up with current studies. This review explores the current literature incorporating the use of phenotyping in pediatric patients with asthma to provide precision therapy. Biomarkers can be used to more accurately predict the development of asthma, identify features that may be associated with difficult-to-control or severe asthma, and forecast response to therapies. Biomarkers and other phenotypic data can also be helpful in patients with uncontrolled, severe asthma in the selection of a biologic therapy.
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Affiliation(s)
- Hannah Duffey
- Department of Pediatrics, Division of Allergy and Immunology, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 East 16th Avenue, Box 518, Aurora, CO 80045, USA
| | - William C Anderson
- Department of Pediatrics, Division of Allergy and Immunology, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 East 16th Avenue, Box 518, Aurora, CO 80045, USA.
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Licari A, Manti S, Castagnoli R, Parisi GF, Salpietro C, Leonardi S, Marseglia GL. Targeted Therapy for Severe Asthma in Children and Adolescents: Current and Future Perspectives. Paediatr Drugs 2019; 21:215-37. [PMID: 31325115 DOI: 10.1007/s40272-019-00345-7] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Severe asthma in children remains a significant issue. It places a heavy burden on affected individuals and society as a whole in terms of high morbidity, mortality, consumption of healthcare resources, and side effects from high-dose corticosteroid therapy. New, targeted biologic therapies for asthma have emerged as effective add-on options, complementing our expanding understanding of asthma phenotypes/endotypes and the underlying immunopathology of the disease spectrum. They include omalizumab, mepolizumab, reslizumab, benralizumab, and dupilumab. Omalizumab represents the first available therapeutic option for allergic asthma in patients as young as 6 years of age. Its efficacy and safety have been established by several randomized controlled trials specifically conducted in pediatric patients, leading to its final registration > 10 years ago. Three new interleukin (IL)-5 targeted agents, mepolizumab, reslizumab, and benralizumab, have been approved for the treatment of severe eosinophilic asthma starting from 6 years of age, and varying by country. More recently, dupilumab, a targeted agent against the IL-4 receptor α-chain, was approved for patients ≥12 years of age in the United States after pivotal trials were completed. The late-stage clinical testing of these targeted agents has mostly involved patients aged 12 years and up, and the application of those data to younger children can be inappropriate and carry risk. The efficacy and safety of these newer biologics in children should be supported by adequate research within this targeted age group. In this review, we will present the most recent evidence on these five biological therapies for severe asthma and will discuss dosage and administration, their efficacy, safety, and future prospects, with a focus on the pediatric age group, defined as age < 18 years.
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Kucuksezer UC, Ozdemir C, Akdis M, Akdis CA. Precision/Personalized Medicine in Allergic Diseases and Asthma. Arch Immunol Ther Exp (Warsz) 2018; 66:431-42. [PMID: 30251122 DOI: 10.1007/s00005-018-0526-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2017] [Accepted: 09/16/2018] [Indexed: 12/21/2022]
Abstract
Like many other chronic diseases, every allergic patient has different characteristics based on clinical course, treatment responsiveness and disease outcomes, which are associated with the genetic and epigenetic control of molecular mechanisms and environment. This variability necessitates the establishment of patient-tailored and precision approaches in handling allergic disorders. Better understanding of the underlying pathophysiological mechanisms for the development of allergic disorders will provide more rationale strategies based on individual cases in controlling and treating these disorders. Endotyping, phenotyping, genotyping and theratyping, and biomarkers are keywords in this area and have been gaining lots of attention in the field of precision medicine, which aims to revolutionize patient care and develop better prevention and treatment strategies. In addition, precision health is a new concept that brings precise approaches to the scene for being healthy and prevention of allergic disease and asthma. The specialty of allergy has a leading role in the field, because allergen-specific immunotherapy started 105 years ago, and is historically a leading personalized/precision medicine approach in all medicine disciplines providing the possibility of cure in an individualized manner instead of conventional symptomatic treatments.
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Tortajada-Girbés M, Bousquet R, Bosque M, Carrera Martínez JJ, Ibáñez MD, Moreira A, Nieto A, Plaza AM, Rivas C, Requena G, Sánchez-Solis M, Tabar A, Torres-Borrego J, Zapatero L. Efficacy and effectiveness of omalizumab in the treatment of childhood asthma. Expert Rev Respir Med 2018; 12:745-754. [PMID: 30141696 DOI: 10.1080/17476348.2018.1507740] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Omalizumab is a monoclonal antibody that binds and inhibits free serum immunoglobulin E, a mediator involved in the clinical manifestations of allergic asthma. Evidence for its efficacy and safety in the treatment of moderate-to-severe allergic asthma is based primarily on studies in adolescents and adults. However, there is increasing evidence of its utility in children with allergic asthma aged 6-12 years. Areas covered: This article reviews efficacy, safety, and effectiveness of omalizumab in the treatment of moderate-to-severe allergic asthma in children aged 6-12 years in clinical trials and in studies in clinical practice. Pharmacoeconomic aspects of its use among this population and the positioning of omalizumab in pediatric asthma management guidelines are also discussed. Additionally, an algorithm for the management of poorly controlled severe pediatric asthma in children older than 6 years is proposed. Electronic databases, such as PubMed, were searched for terms Asthma and Omalizumab and for asthma management guidelines. Expert commentary: Add-on omalizumab is an effective maintenance therapy in children aged 6-12 years with poorly controlled moderate-to-severe allergic asthma treated with medium-high inhaled corticosteroids doses and inhaled long-acting β2-agonists. Omalizumab appears safe in children in both clinical trials and real-life setting and may be cost-effective.
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Affiliation(s)
- Miguel Tortajada-Girbés
- a Department of Pediatrics, Obstetrics and Gynecology , University of Valencia , Valencia , Spain.,b Pediatric Pulmonology and Allergy Unit , Dr. Peset University Hospital , Valencia , Spain
| | - Rosa Bousquet
- c Pediatric Pulmonology and Allergy Unit, Pediatric Service , Hospital del Mar , Barcelona , Spain
| | - Montserrat Bosque
- d Pediatric Allergy and Pulmonology Unit , Hospital Universitario Parc Taulí , Sabadell , Spain
| | | | | | - Ana Moreira
- g Medical Advisor Xolair-Asma, Novartis , Barcelona , Spain
| | - Antonio Nieto
- h Pediatric Pulmonology and Allergy Unit , Children's Hospital la Fe , Valencia , Spain
| | - Ana María Plaza
- i Allergy and Clinical Immunology Service , Hospital Sant Joan de Déu , Barcelona , Spain
| | - Cristina Rivas
- j Pediatric Service , Hospital de Sagunto , Valencia , Spain
| | - Gloria Requena
- k Allergy Department , Hospital Vithas-Xanit Internacional , Málaga , Spain
| | - Manuel Sánchez-Solis
- l Pediatric Pulmonology Unit, University Hospital Virgen de la Arrixaca , IMIB Bio-Health Research Institute , Murcia , Spain
| | - Ana Tabar
- m Allergology Service , Complejo Hospitalario de Navarra , Pamplona , Spain
| | - Javier Torres-Borrego
- n Pediatric Allergy and Pulmonology Unit , Children´s University Hospital Reina Sofía , Córdoba , Spain
| | - Lydia Zapatero
- o Pediatric Allergy Unit , Maternal and Child Hospital Gregorio Marañón , Madrid , Spain
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Corren J, Kavati A, Ortiz B, Vegesna A, Colby JA, Ruiz K, Panettieri RA. Patient-reported outcomes in moderate-to-severe allergic asthmatics treated with omalizumab: a systematic literature review of randomized controlled trials. Curr Med Res Opin 2018; 34:65-80. [PMID: 29057669 DOI: 10.1080/03007995.2017.1395734] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVE Randomized controlled trials (RCTs) have established the safety and efficacy of omalizumab on clinical parameters, and have also evaluated its impact on patient-reported outcomes (PROs). The purpose of this systematic literature review was to review published data based on PRO endpoints in order to determine the benefit of omalizumab as add-on therapy to inhaled corticosteroids in patients with moderate-to-severe persistent allergic asthma. METHODS A systematic literature review was conducted of reference databases and recent conferences. RCTs of add-on omalizumab therapy in adults, adolescents, and children with moderate-to-severe persistent asthma were included. Two researchers independently screened and reviewed articles with regards to inclusion and exclusion criteria for relevant studies. RESULTS Twenty-six trials met the criteria for inclusion. Of these, PRO measures were included in 19 trials to capture the impact of omalizumab on symptoms, 11 assessed patients for health-related quality-of-life (HRQoL), and four evaluated asthma control. Other PROs related to global evaluation of treatment effectiveness and work productivity. Overall, results demonstrated a significant difference across most PROs in favor of omalizumab add-on therapy vs placebo or comparators. CONCLUSIONS PROs are an integral part of outcome assessment in clinical trials related to asthma. The RCTs reviewed demonstrate that omalizumab treatment improves PROs in patients with moderate-to-severe persistent allergic asthma, particularly symptom control and HRQoL.
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Affiliation(s)
- Jonathan Corren
- a David Geffen School of Medicine at UCLA , Los Angeles , CA , USA
| | - Abhishek Kavati
- b Novartis Pharmaceuticals Corporation , East Hanover , NJ , USA
| | - Benjamin Ortiz
- b Novartis Pharmaceuticals Corporation , East Hanover , NJ , USA
| | - Ashok Vegesna
- b Novartis Pharmaceuticals Corporation , East Hanover , NJ , USA
| | | | | | - Reynold A Panettieri
- d Rutgers, The State University of New Jersey, Rutgers Institute for Translational Medicine and Science , New Brunswick , NJ , USA
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Abstract
Asthma is the most common chronic respiratory disease in children characterized by airways inflammation, bronchial hyperresponsiveness, recurrent reversible airways obstruction, and respiratory symptoms. The diagnosis of the disease is based on clinical history, airways obstruction at spirometry, and bronchial reversibility. Asthma treatment is aimed to disease control, through the use of controller treatment and monitoring lung function. However, lung function and symptoms not always reflect the underlying airways inflammation and response to the therapy. Objective parameters of asthma inflammation could be important for the clinician in the management of patients with asthma. In the last years, some studies were focused on biomarkers to identify phenotype, inflammation, and pathobiological pathways to help the clinician in the diagnosis and in personalizing the management. Accordingly, clinically feasible tests are represented by the collection of exhaled breath condensate (EBC) and measurement of exhaled nitric oxide (FeNO). Other-methods such as the evaluation of volatile organic compound (VOCs), that reflect airways inflammation and treatment efficacy, are currently used for research purposes For some of these methods, The lack of standardization in pre-collection, collection, post-collection of samples, and interpretation of the results may a problem in clinical practice. Improved these limitations, several biomarkers will be useful to distinguish patients with a different disease condition to personalize the treatment.
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Affiliation(s)
- Laura Tenero
- Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, Verona, Italy
| | - Marco Zaffanello
- Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, Verona, Italy
| | - Michele Piazza
- Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, Verona, Italy
| | - Giorgio Piacentini
- Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, Verona, Italy
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Wright LS, Phipatanakul W. Treatment of moderate to severe pediatric asthma: Omalizumab and potential future use of monoclonal antibodies. Ann Allergy Asthma Immunol 2017; 117:17-20. [PMID: 27371967 DOI: 10.1016/j.anai.2016.03.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Revised: 03/18/2016] [Accepted: 03/22/2016] [Indexed: 10/21/2022]
Affiliation(s)
- Lakiea S Wright
- Division of Rheumatology, Immunology, and Allergy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Division of Immunology and Allergy, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Wanda Phipatanakul
- Division of Immunology and Allergy, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts.
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Abstract
BACKGROUND This review is the first update of a previously published review in The Cochrane Library (Issue 7, 2015). Interleukin-5 (IL-5) is the main cytokine involved in the activation of eosinophils, which cause airway inflammation and are a classic feature of asthma. Monoclonal antibodies targeting IL-5 or its receptor (IL-5R) have been developed, with recent studies suggesting that they reduce asthma exacerbations, improve health-related quality of life (HRQoL) and lung function. These are being incorporated into asthma guidelines. OBJECTIVES To compare the effects of therapies targeting IL-5 signalling (anti-IL-5 or anti-IL-5Rα) with placebo on exacerbations, health-related qualify of life (HRQoL) measures, and lung function in adults and children with chronic asthma, and specifically in those with eosinophilic asthma refractory to existing treatments. SEARCH METHODS We searched the Cochrane Airways Trials Register, clinical trials registries, manufacturers' websites, and reference lists of included studies. The most recent search was March 2017. SELECTION CRITERIA We included randomised controlled trials comparing mepolizumab, reslizumab and benralizumab versus placebo in adults and children with asthma. DATA COLLECTION AND ANALYSIS Two authors independently extracted data and analysed outcomes using a random-effects model. We used standard methods expected by Cochrane. MAIN RESULTS Thirteen studies on 6000 participants met the inclusion criteria. Four used mepolizumab, four used reslizumab, and five used benralizumab. One study in benralizumab was terminated early due to sponsor decision and contributed no data. The studies were predominantly on people with severe eosinophilic asthma, which was similarly but variably defined. Eight included children over 12 years but these results were not reported separately. We deemed the risk of bias to be low, with all studies contributing data being of robust methodology. We considered the quality of the evidence for all comparisons to be high overall using the GRADE scheme, with the exception of intravenous mepolizumab because this is not currently a licensed delivery route.All of the anti-IL-5 treatments assessed reduced rates of 'clinically significant' asthma exacerbation (defined by treatment with systemic corticosteroids for three days or more) by approximately half in participants with severe eosinophilic asthma on standard of care (at least medium-dose inhaled corticosteroids (ICS)) with poorly controlled disease (either two or more exacerbations in the preceding year or Asthma Control Questionnaire (ACQ) 1.5 or more). Non-eosinophilic participants treated with benralizumab also showed a significant reduction in exacerbation rates, but no data were available for non-eosinophilic participants, and mepolizumab or reslizumab.We saw modest improvements in validated HRQoL scores with all anti-IL-5 agents in severe eosinophilic asthma. However these did not exceed the minimum clinically important difference for ACQ and Asthma Quality of Life Questionnaire (AQLQ), with St. George's Respiratory Questionnaire (SGRQ) only assessed in two studies. The improvement in HRQoL scores in non-eosinophilic participants treated with benralizumab, the only intervention for which data were available in this subset, was not statistically significant, but the test for subgroup difference was negative.All anti-IL-5 treatments produced a small but statistically significant improvement in mean pre-bronchodilator forced expiratory flow in one second (FEV1) of between 0.08 L and 0.11 L.There were no excess serious adverse events with any anti-IL-5 treatment, and indeed a reduction in favour of mepolizumab that could be due to a beneficial effect on asthma-related serious adverse events. There was no difference compared to placebo in adverse events leading to discontinuation with mepolizumab or reslizumab, but significantly more discontinued benralizumab than placebo, although the absolute numbers were small (36/1599 benralizumab versus 9/998 placebo).Mepolizumab, reslizumab and benralizumab all markedly reduced blood eosinophils, but benralizumab resulted in almost complete depletion, whereas a small number remained with mepolizumab and reslizumab. The implications for efficacy and/or adverse events are unclear. AUTHORS' CONCLUSIONS Overall our study supports the use of anti-IL-5 treatments as an adjunct to standard of care in people with severe eosinophilic asthma and poor control. These treatments roughly halve the rate of asthma exacerbations in this population. There is limited evidence for improved HRQoL scores and lung function, which may not meet clinically detectable levels. There were no safety concerns regarding mepolizumab or reslizumab, and no excess serious adverse events with benralizumab, although there remains a question over adverse events significant enough to prompt discontinuation.Further research is needed on biomarkers for assessing treatment response, optimal duration and long-term effects of treatment, risk of relapse on withdrawal, non-eosinophilic patients, children (particularly under 12 years), and comparing anti-IL-5 treatments to each other and, in people eligible for both, to anti-immunoglobulin E. For benralizumab, future studies should closely monitor rates of adverse events prompting discontinuation.
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Key Words
- adolescent
- adult
- child
- humans
- adrenal cortex hormones
- adrenal cortex hormones/administration & dosage
- anti‐asthmatic agents
- anti‐asthmatic agents/administration & dosage
- anti‐asthmatic agents/adverse effects
- antibodies, monoclonal, humanized
- antibodies, monoclonal, humanized/administration & dosage
- antibodies, monoclonal, humanized/adverse effects
- asthma
- asthma/etiology
- asthma/therapy
- disease progression
- injections, intravenous
- injections, subcutaneous
- interleukin‐5
- interleukin‐5/antagonists & inhibitors
- quality of life
- randomized controlled trials as topic
- receptors, interleukin‐5
- receptors, interleukin‐5/antagonists & inhibitors
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Affiliation(s)
| | - Amanda Wilson
- University of NewcastleSchool of Nursing and MidwiferyNewcastleAustralia
| | - Colin Powell
- Cardiff UniversityDepartment of Child Health, The Division of Population Medicine, The School of MedicineCardiffUK
| | - Lynne Bax
- Lancashire Care NHS Foundation TrustSceptre Point, Sceptre WayWalton SummitPrestonUKPR5 6AW
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Abstract
Current asthma treatments are effective for the majority of patients with mild-to-moderate disease. However, in those with more severe refractory asthma, agents other than inhaled corticosteroids and beta-agonists are needed both to better manage this group of patients and to avoid the side effects of high-dose corticosteroids and the social and personal hardship endured. Several biological pathways have been targeted over the last 20 years, and this research has resulted in pharmacological approaches to attempt to better treat patients with severe refractory asthma. The flagship of the biologics, the anti-IgE monoclonal antibody, omalizumab, has proven efficacious in selected subgroups of asthma patients. Tailoring asthma treatments to suit specific subtypes of asthma patients is in keeping with ideals of personalized medicine. Research in the complex interplay of allergens, epithelial host defenses, cytokines, and innate and adaptive immunity interactions has allowed better understanding of the mechanics of allergy and inflammation in asthma. As a result, new biologic treatments have been developed that target several different phenotypes and endotypes in asthma. As knowledge of the efficacy of these biological agents in asthma emerges, as well as the type of patients in whom they are most beneficial, the movement toward personalized asthma treatment will follow.
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Affiliation(s)
- Patrick D Mitchell
- Firestone Institute for Respiratory Health and the Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Amani I El-Gammal
- Firestone Institute for Respiratory Health and the Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Paul M O'Byrne
- Firestone Institute for Respiratory Health and the Department of Medicine, McMaster University, Hamilton, ON, Canada.
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Kallieri M, Papaioannou AI, Papathanasiou E, Ntontsi P, Papiris S, Loukides S. Predictors of response to therapy with omalizumab in patients with severe allergic asthma - a real life study. Postgrad Med 2017; 129:598-604. [PMID: 28427296 DOI: 10.1080/00325481.2017.1321945] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVES Omalizumab is a recombinant humanized IgG1 monoclonal anti-IgE antibody, used for the treatment of severe refractory allergic asthma. However, not all patients with IgE levels within the limits of administration, respond to treatment. The aim of the present study, was to determine clinical and inflammatory characteristics that could predict response to omalizumab. METHODS We studied retrospectively patients treated with omalizumab as per GINA guidelines in one asthma tertiary referral center. Demographic and functional characteristics, level of asthma control, fractional exhaled nitric oxide, blood and eosinophils and IgE level, induced sputum cell count, eosinophil cationic protein and Interleukin-13 in sputum supernatant were recorded. All measurements were performed before starting treatment with omalizumab. Response to treatment was evaluated according to the physician's global evaluation of treatment effectiveness. Patients were characterized as early responders when improvement was achieved within 16 weeks and as late responders when improvement was achieved between 16 and 32 weeks. Patients who did not show any improvement after 32 weeks of therapy were considered as non-responders. RESULTS Forty-one patients treated with omalizumab were included in the study. 28 (68.3%) patients were characterized as responders while 13 patients (31.7%) were considered as non-responders. Among responders, 25 (89%) were early responders and 3 (n = 11%) were late responders. Responders were characterized by lower baseline FEV1 and FEV1/FVC and higher IL-13 levels in induced sputum supernatant compared to non-responders. Late responders had higher serum IgE levels, shorter disease duration and higher number of blood eosinophils. Finally, using ROC curve analysis, the best predictors of response to omalizumab were FEV1 (AUC = 0.718) and IL-13 in sputum supernatant (AUC = 0.709). CONCLUSION Lower baseline FEV1 and higher IL-13 levels in induced sputum supernatant were predictors of response to omalizumab. Patients with higher baseline serum IgE levels, shorter disease duration and higher blood eosinophils may experience a late response and might benefit from a more prolonged treatment before being characterized as non-responders.
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Affiliation(s)
- Maria Kallieri
- a 2nd Respiratory Medicine Department, "Attikon" University Hospital, Athens Medical School , National and Kapodistrian University of Athens , Greece
| | - Andriana I Papaioannou
- a 2nd Respiratory Medicine Department, "Attikon" University Hospital, Athens Medical School , National and Kapodistrian University of Athens , Greece
| | - Evgenia Papathanasiou
- a 2nd Respiratory Medicine Department, "Attikon" University Hospital, Athens Medical School , National and Kapodistrian University of Athens , Greece
| | - Polyxeni Ntontsi
- a 2nd Respiratory Medicine Department, "Attikon" University Hospital, Athens Medical School , National and Kapodistrian University of Athens , Greece
| | - Spyridon Papiris
- a 2nd Respiratory Medicine Department, "Attikon" University Hospital, Athens Medical School , National and Kapodistrian University of Athens , Greece
| | - Stelios Loukides
- a 2nd Respiratory Medicine Department, "Attikon" University Hospital, Athens Medical School , National and Kapodistrian University of Athens , Greece
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Potaczek DP, Harb H, Michel S, Alhamwe BA, Renz H, Tost J. Epigenetics and allergy: from basic mechanisms to clinical applications. Epigenomics 2017; 9:539-571. [PMID: 28322581 DOI: 10.2217/epi-2016-0162] [Citation(s) in RCA: 173] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Allergic diseases are on the rise in the Western world and well-known allergy-protecting and -driving factors such as microbial and dietary exposure, pollution and smoking mediate their influence through alterations of the epigenetic landscape. Here, we review key facts on the involvement of epigenetic modifications in allergic diseases and summarize and critically evaluate the lessons learned from epigenome-wide association studies. We show the potential of epigenetic changes for various clinical applications: as diagnostic tools, to assess tolerance following immunotherapy or possibly predict the success of therapy at an early time point. Furthermore, new technological advances such as epigenome editing and DNAzymes will allow targeted alterations of the epigenome in the future and provide novel therapeutic tools.
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Affiliation(s)
- Daniel P Potaczek
- Institute of Laboratory Medicine and Pathobiochemistry, Molecular Diagnostics, Philipps-Universität Marburg, Marburg, Germany.,International Inflammation (in-FLAME) Network, Worldwide Universities Network (WUN).,German Centre for Lung Research (DZL).,John Paul II Hospital, Krakow, Poland
| | - Hani Harb
- Institute of Laboratory Medicine and Pathobiochemistry, Molecular Diagnostics, Philipps-Universität Marburg, Marburg, Germany.,International Inflammation (in-FLAME) Network, Worldwide Universities Network (WUN).,German Centre for Lung Research (DZL)
| | - Sven Michel
- Secarna Pharmaceuticals GmbH & Co KG, Planegg, Germany
| | - Bilal Alashkar Alhamwe
- Institute of Laboratory Medicine and Pathobiochemistry, Molecular Diagnostics, Philipps-Universität Marburg, Marburg, Germany
| | - Harald Renz
- Institute of Laboratory Medicine and Pathobiochemistry, Molecular Diagnostics, Philipps-Universität Marburg, Marburg, Germany.,International Inflammation (in-FLAME) Network, Worldwide Universities Network (WUN).,German Centre for Lung Research (DZL)
| | - Jörg Tost
- Laboratory for Epigenetics & Environment, Centre National de Génotypage, CEA-Institut de Génomique, Evry, France
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Ferrando M, Bagnasco D, Varricchi G, Bernardi S, Bragantini A, Passalacqua G, Canonica GW. Personalized Medicine in Allergy. Allergy Asthma Immunol Res 2017; 9:15-24. [PMID: 27826958 PMCID: PMC5102831 DOI: 10.4168/aair.2017.9.1.15] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Accepted: 04/21/2016] [Indexed: 12/12/2022]
Abstract
Allergic disease is among the most common pathologies worldwide and its prevalence has constantly increased up to the present days, even if according to the most recent data it seems to be slightly slowing down. Allergic disease has not only a high rate of misdiagnosis and therapeutic inefficacy, but represents an enormous, resource-absorbing black hole in respiratory and general medicine. The aim of this paper is to summarize principal therapeutic innovations in atopic disease management befallen in the recent years in terms of personalized/precision medicine.
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Affiliation(s)
- Matteo Ferrando
- Allergy & Respiratory Diseases, DIMI Department of Internal Medicine, IRCCS AOU San Martino-IST, University of Genoa, Genoa, Italy
| | - Diego Bagnasco
- Allergy & Respiratory Diseases, DIMI Department of Internal Medicine, IRCCS AOU San Martino-IST, University of Genoa, Genoa, Italy
| | - Gilda Varricchi
- Division of Clinical Immunology and Allergy, Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Stefano Bernardi
- Allergy & Respiratory Diseases, DIMI Department of Internal Medicine, IRCCS AOU San Martino-IST, University of Genoa, Genoa, Italy
| | - Alice Bragantini
- Allergy & Respiratory Diseases, DIMI Department of Internal Medicine, IRCCS AOU San Martino-IST, University of Genoa, Genoa, Italy
| | - Giovanni Passalacqua
- Allergy & Respiratory Diseases, DIMI Department of Internal Medicine, IRCCS AOU San Martino-IST, University of Genoa, Genoa, Italy
| | - Giorgio Walter Canonica
- Allergy & Respiratory Diseases, DIMI Department of Internal Medicine, IRCCS AOU San Martino-IST, University of Genoa, Genoa, Italy.
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Affiliation(s)
- Monica J Federico
- Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, 13123 East 16th Avenue, Aurora, CO 80045, USA
| | - Heather E Hoch
- Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, 13123 East 16th Avenue, Aurora, CO 80045, USA
| | - William C Anderson
- Pediatric Allergy & Immunology, University of Colorado School of Medicine, Children's Hospital Colorado, 13123 East 16th Avenue, Aurora, CO 80045, USA
| | - Joseph D Spahn
- Pediatric Allergy & Immunology, University of Colorado School of Medicine, Children's Hospital Colorado, 13123 East 16th Avenue, Aurora, CO 80045, USA
| | - Stanley J Szefler
- Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, 13123 East 16th Avenue, Aurora, CO 80045, USA.
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Hew M, Gillman A, Sutherland M, Wark P, Bowden J, Guo M, Reddel HK, Jenkins C, Marks GB, Thien F, Rimmer J, Katsoulotos GP, Cook M, Yang I, Katelaris C, Bowler S, Langton D, Wright C, Bint M, Yozghatlian V, Burgess S, Sivakumaran P, Yan KY, Kritikos V, Peters M, Baraket M, Aminazad A, Robinson P, Jaffe A, Powell H, Upham JW, McDonald VM, Gibson PG. Real-life effectiveness of omalizumab in severe allergic asthma above the recommended dosing range criteria. Clin Exp Allergy 2016; 46:1407-1415. [PMID: 27377155 DOI: 10.1111/cea.12774] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 05/26/2016] [Accepted: 06/01/2016] [Indexed: 01/09/2023]
Abstract
BACKGROUND Omalizumab (Xolair) dosing in severe allergic asthma is based on serum IgE and bodyweight. In Australia, patients eligible for omalizumab but exceeding recommended ranges for IgE (30-1500 IU/mL) and bodyweight (30-150 kg) may still receive a ceiling dose of 750 mg/4 weeks. About 62% of patients receiving government-subsidized omalizumab are enrolled in the Australian Xolair Registry (AXR). OBJECTIVES To determine whether AXR participants above the recommended dosing ranges benefit from omalizumab and to compare their response to within-range participants. METHODS Data were stratified according to dose range status (above-range or within-range). Further sub-analyses were conducted according to the reason for being above the dosing range (IgE only vs. IgE and weight). RESULTS Data for 179 participants were analysed. About 55 (31%) were above recommended dosing criteria; other characteristics were similar to within-range participants. Above-range participants had higher baseline IgE [812 (IQR 632, 1747) IU/mL vs. 209 (IQR 134, 306) IU/mL] and received higher doses of omalizumab [750 (IQR 650, 750) mg] compared to within-range participants [450 (IQR, 300, 600) mg]. At 6 months, improvements in Juniper 5-item Asthma Control Questionnaire (ACQ-5, 3.61 down to 2.01 for above-range, 3.47 down to 1.93 for within-range, P < 0.0001 for both) and Asthma Quality of Life Questionnaire (AQLQ mean score (3.22 up to 4.41 for above-range, 3.71 up to 4.88 for within-range, P < 0.0001) were observed in both groups. Forced expiratory volume in one second (FEV1 ) improved among above-range participants. There was no difference in response between above-range and within-range participants. Above-range participants due to either IgE alone or IgE and weight had similar improvements in ACQ-5, AQLQ and FEV1 . CONCLUSIONS AND CLINICAL RELEVANCE Patients with severe allergic asthma above recommended dosing criteria for omalizumab have significantly improved symptom control, quality of life and lung function to a similar degree to within-range participants, achieved without dose escalation above 750 mg.
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Affiliation(s)
- M Hew
- The Alfred Hospital & Monash University, Melbourne, Vic., Australia.
| | - A Gillman
- The Alfred Hospital & Monash University, Melbourne, Vic., Australia
| | | | - P Wark
- Hunter Medical Research Institute, John Hunter Hospital, University of Newcastle, New Lambton Heights, NSW, Australia
| | - J Bowden
- Flinders Medical Centre, Bedford Park, SA, Australia
| | - M Guo
- Woolcock Institute of Medical Research, Glebe, University of Sydney NSW, Australia
| | - H K Reddel
- Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - C Jenkins
- Concord Hospital, Concord, NSW, Australia
| | - G B Marks
- Liverpool Hospital, Liverpool, NSW, Australia
| | - F Thien
- Box Hill Hospital, Box Hill, Vic., Australia
| | - J Rimmer
- St Vincent's Clinic, Darlinghurst, NSW, Australia
| | | | - M Cook
- Canberra Hospital, Woden, ACT, Australia
| | - I Yang
- The Prince Charles Hospital, Chermside, Qld, Australia
| | - C Katelaris
- Campbelltown Hospital, Campbelltown, NSW, Australia
| | - S Bowler
- Mater Adult Hospital, South Brisbane, Qld, Australia
| | - D Langton
- Frankston Hospital, Frankston, Vic., Australia
| | - C Wright
- Nambour Hospital, Nambour, Qld, Australia
| | - M Bint
- Nambour Hospital, Nambour, Qld, Australia
| | | | - S Burgess
- QLD Children's Lung and Sleep Specialists, Woolloongabba, Qld, Australia
| | - P Sivakumaran
- Gold Coast District Hospital, Southport, Qld, Australia
| | - K Y Yan
- Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - V Kritikos
- Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - M Peters
- Concord Hospital, Concord, NSW, Australia
| | - M Baraket
- Liverpool Hospital, Liverpool, NSW, Australia
| | - A Aminazad
- St Vincent's Clinic, Darlinghurst, NSW, Australia
| | - P Robinson
- Children's Hospital at Westmead, Westmead, NSW, Australia
| | - A Jaffe
- School of Women's & Children's Health, UNSW Medicine, Randwick, NSW, Australia
| | - H Powell
- Hunter Medical Research Institute, John Hunter Hospital, University of Newcastle, New Lambton Heights, NSW, Australia
| | - J W Upham
- Princess Alexandra Hospital, Woolloongabba, Qld, Australia
| | - V M McDonald
- Hunter Medical Research Institute, John Hunter Hospital, University of Newcastle, New Lambton Heights, NSW, Australia
| | - P G Gibson
- Hunter Medical Research Institute, John Hunter Hospital, University of Newcastle, New Lambton Heights, NSW, Australia
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Abstract
INTRODUCTION Asthma is a common respiratory disorder, since about 10% of the population suffer from this disease, and up to 10% have a severe form. Recent findings have allowed a greater and deeper understanding of the pathophysiological mechanisms, distinguishing two groups of patients according to the prevalent cellular population that drives the inflammatory process, and consequentially, to intervene on different cellular targets. AREAS COVERED Currently, several biological drugs directly interfering with these pathophysiological mechanisms (namely IgE, IL-4, IL-5, IL-13, and IL-17) are under investigation. Expert commentary: With the elucidation of mechanisms, new-targeted drugs have been developed. Asthma therapy is changing from a 'one size fits all' therapy to a 'precision medicine' model, where we may prescribe the most appropriate treatment for each patient. Moreover, in the near future, the possibility to act a 'sequential bio-combination therapy' can be envisaged, using different biological drugs in the same patient to act on different pathophysiological mechanisms.
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Affiliation(s)
- Diego Bagnasco
- a Allergy & Respiratory Diseases, DIMI, Department of Internal Medicine , University of Genoa, IRCCS AOU San Martino - IST , Genoa , Italy
| | - Matteo Ferrando
- a Allergy & Respiratory Diseases, DIMI, Department of Internal Medicine , University of Genoa, IRCCS AOU San Martino - IST , Genoa , Italy
| | - Stefano Bernardi
- a Allergy & Respiratory Diseases, DIMI, Department of Internal Medicine , University of Genoa, IRCCS AOU San Martino - IST , Genoa , Italy
| | - Giovanni Passalacqua
- a Allergy & Respiratory Diseases, DIMI, Department of Internal Medicine , University of Genoa, IRCCS AOU San Martino - IST , Genoa , Italy
| | - Giorgio Walter Canonica
- a Allergy & Respiratory Diseases, DIMI, Department of Internal Medicine , University of Genoa, IRCCS AOU San Martino - IST , Genoa , Italy
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Abstract
PURPOSE OF REVIEW Asthma guidelines recognize the presence of different asthma endotypes and phenotypes but treatment recommendations are limited to age groups rather than phenotypes, as the phenotype literature is regarded as emerging evidence. This review will examine the current evidence regarding the management of asthma in school age children (5-18 years old) by endotype and phenotype. RECENT FINDINGS A number of studies have examined the effect of endotypes and phenotypes on response to conventional asthma therapy, omalizumab and specific allergen immunotherapy, and response in children with severe asthma. Emerging therapies, namely biologics and immunomodulators, have attracted considerable attention and appear to have favorable effects in adults with asthma, but additional pediatric studies are needed. SUMMARY The optimal treatment strategy for children with asthma is not yet defined and likely dependent on many patient and disease characteristics. Much of the phenotypic response literature presented in this review was constrained by a limited number of pediatric and adult studies available and as such should be regarded as preliminary. Better definition of asthma phenotypes and better targeting of therapy based on individual patient phenotypes are likely to improve asthma treatment in the future.
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Froidure A, Mouthuy J, Durham SR, Chanez P, Sibille Y, Pilette C. Asthma phenotypes and IgE responses. Eur Respir J 2015; 47:304-19. [PMID: 26677936 DOI: 10.1183/13993003.01824-2014] [Citation(s) in RCA: 159] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2014] [Accepted: 10/14/2015] [Indexed: 01/18/2023]
Abstract
The discovery of IgE represented a major breakthrough in allergy and asthma research, whereas the clinical interest given to IgE in asthma has been blurred until the arrival of anti-IgE biotherapy. Novel facets of the complex link between IgE and asthma have been highlighted by the effect of this treatment and by basic research. In parallel, asthma phenotyping recently evolved to the concept of endotypes, relying on identified/suspected pathobiological mechanisms to phenotype patients, but has not yet clearly positioned IgE among biomarkers of asthma.In this review, we first summarise recent knowledge about the regulation of IgE production and its main receptor, FcεRI. In addition to allergens acting as classical IgE inducers, viral infections as well as air pollution may trigger the IgE pathway, notably resetting the threshold of IgE sensitivity by regulating FcεRI expression. We then analyse the place of IgE in different asthma endo/phenotypes and discuss the potential interest of IgE among biomarkers in asthma.
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Affiliation(s)
- Antoine Froidure
- Institut de Recherche Expérimentale et Clinique, Pôle de Pneumologie, Université catholique de Louvain, Brussels and Walloon Institute for Excellence in Lifesciences and Biotechnology (WELBIO), Belgium Dept of Chest Medicine, Cliniques Universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium These authors contributed equally to this work
| | - Jonathan Mouthuy
- Institut de Recherche Expérimentale et Clinique, Pôle de Pneumologie, Université catholique de Louvain, Brussels and Walloon Institute for Excellence in Lifesciences and Biotechnology (WELBIO), Belgium Dept of Chest Medicine, Cliniques Universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium These authors contributed equally to this work
| | - Stephen R Durham
- Allergy and Clinical Immunology, National Heart and Lung Institute, Imperial College London, London, UK
| | - Pascal Chanez
- INSERM U 1067, CNRS UMR 7333 Aix Marseille Université and Dépt des Maladies Respiratoires, Assistance Publique des Hôpitaux de Marseille, Marseille, France
| | - Yves Sibille
- Institut de Recherche Expérimentale et Clinique, Pôle de Pneumologie, Université catholique de Louvain, Brussels and Walloon Institute for Excellence in Lifesciences and Biotechnology (WELBIO), Belgium Dept of Chest Medicine, Centre Hospitalier Universitaire de Mont-Godinne, Université catholique de Louvain, Yvoir, Belgium
| | - Charles Pilette
- Institut de Recherche Expérimentale et Clinique, Pôle de Pneumologie, Université catholique de Louvain, Brussels and Walloon Institute for Excellence in Lifesciences and Biotechnology (WELBIO), Belgium Dept of Chest Medicine, Cliniques Universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
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Mitchell PD, El-Gammal AI, O'Byrne PM. Emerging monoclonal antibodies as targeted innovative therapeutic approaches to asthma. Clin Pharmacol Ther 2015; 99:38-48. [PMID: 26502193 DOI: 10.1002/cpt.284] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Revised: 10/16/2015] [Accepted: 10/20/2015] [Indexed: 12/16/2022]
Abstract
Asthma is characterized by discordant responses among cells of the adaptive and innate immune systems. This interplay involves a complex pattern of cytokine-driven processes resulting in cell migration and recruitment, inflammation, and proliferative states. The significant majority of asthmatic patients respond well to conventional inhaled treatments. However, about 5% of asthmatics have severe refractory asthma and account for 50% of the health expenditure on asthma. Human(ized) monoclonal antibodies (hMabs) targeting inflammatory pathways are promising therapeutic agents in asthma management. The anti-IgE hMab omalizumab was the first biologic treatment approved for the treatment of allergic asthma. Potential future strategies and targets include interleukin (IL)-5, IL-4, and IL-13, anti-TSLP, IL-25, and IL-33. hMabs targeting IL-5 have shown great promise in severe refractory asthma with a persisting eosinophilia, and clinical trials with hMabs against IL-13 and IL4Rα have also shown clinical benefit. Studies of hMabs against other cytokines in severe asthma are under way.
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Affiliation(s)
- P D Mitchell
- Firestone Institute of Respiratory Health and the Department of Medicine, Michael G DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - A I El-Gammal
- Firestone Institute of Respiratory Health and the Department of Medicine, Michael G DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - P M O'Byrne
- Firestone Institute of Respiratory Health and the Department of Medicine, Michael G DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
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Teach SJ, Gill MA, Togias A, Sorkness CA, Arbes SJ, Calatroni A, Wildfire JJ, Gergen PJ, Cohen RT, Pongracic JA, Kercsmar CM, Khurana Hershey GK, Gruchalla RS, Liu AH, Zoratti EM, Kattan M, Grindle KA, Gern JE, Busse WW, Szefler SJ. Preseasonal treatment with either omalizumab or an inhaled corticosteroid boost to prevent fall asthma exacerbations. J Allergy Clin Immunol 2015; 136:1476-1485. [PMID: 26518090 DOI: 10.1016/j.jaci.2015.09.008] [Citation(s) in RCA: 371] [Impact Index Per Article: 41.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Revised: 09/01/2015] [Accepted: 09/04/2015] [Indexed: 12/19/2022]
Abstract
BACKGROUND Short-term targeted treatment can potentially prevent fall asthma exacerbations while limiting therapy exposure. OBJECTIVE We sought to compare (1) omalizumab with placebo and (2) omalizumab with an inhaled corticosteroid (ICS) boost with regard to fall exacerbation rates when initiated 4 to 6 weeks before return to school. METHODS A 3-arm, randomized, double-blind, double placebo-controlled, multicenter clinical trial was conducted among inner-city asthmatic children aged 6 to 17 years with 1 or more recent exacerbations (clincaltrials.gov #NCT01430403). Guidelines-based therapy was continued over a 4- to 9-month run-in phase and a 4-month intervention phase. In a subset the effects of omalizumab on IFN-α responses to rhinovirus in PBMCs were examined. RESULTS Before the falls of 2012 and 2013, 727 children were enrolled, 513 were randomized, and 478 were analyzed. The fall exacerbation rate was significantly lower in the omalizumab versus placebo arms (11.3% vs 21.0%; odds ratio [OR], 0.48; 95% CI, 0.25-0.92), but there was no significant difference between omalizumab and ICS boost (8.4% vs 11.1%; OR, 0.73; 95% CI, 0.33-1.64). In a prespecified subgroup analysis, among participants with an exacerbation during the run-in phase, omalizumab was significantly more efficacious than both placebo (6.4% vs 36.3%; OR, 0.12; 95% CI, 0.02-0.64) and ICS boost (2.0% vs 27.8%; OR, 0.05; 95% CI, 0.002-0.98). Omalizumab improved IFN-α responses to rhinovirus, and within the omalizumab group, greater IFN-α increases were associated with fewer exacerbations (OR, 0.14; 95% CI, 0.01-0.88). Adverse events were rare and similar among arms. CONCLUSIONS Adding omalizumab before return to school to ongoing guidelines-based care among inner-city youth reduces fall asthma exacerbations, particularly among those with a recent exacerbation.
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Affiliation(s)
- Stephen J Teach
- Division of Emergency Medicine and the Department of Pediatrics, Children's National Health System, Washington, DC.
| | - Michelle A Gill
- Departments of Pediatrics and Immunology, University of Texas Southwestern Medical Center, Dallas, Tex
| | - Alkis Togias
- National Institute of Allergy and Infectious Diseases, Bethesda, Md
| | | | | | | | | | - Peter J Gergen
- National Institute of Allergy and Infectious Diseases, Bethesda, Md
| | | | | | | | | | - Rebecca S Gruchalla
- Departments of Pediatrics and Immunology, University of Texas Southwestern Medical Center, Dallas, Tex
| | - Andrew H Liu
- National Jewish Health, Denver, Colo; Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, Colo
| | - Edward M Zoratti
- Department of Internal Medicine, Division of Allergy and Immunology, Henry Ford Hospital, Detroit, Mich
| | - Meyer Kattan
- College of Physicians and Surgeons, Columbia University, New York, NY
| | - Kristine A Grindle
- University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - James E Gern
- University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - William W Busse
- University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Stanley J Szefler
- Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, Colo
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46
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Odajima H, Ebisawa M, Nagakura T, Fujisawa T, Akasawa A, Ito K, Doi S, Yamaguchi K, Katsunuma T, Kurihara K, Kondo N, Sugai K, Nambu M, Hoshioka A, Yoshihara S, Sato N, Seko N, Nishima S. Omalizumab in Japanese children with severe allergic asthma uncontrolled with standard therapy. Allergol Int 2015; 64:364-70. [PMID: 26433533 DOI: 10.1016/j.alit.2015.05.006] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2014] [Revised: 04/07/2015] [Accepted: 05/01/2015] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Omalizumab has demonstrated clinical benefits in children with moderate to severe allergic asthma. However, no studies have been performed in Japanese asthmatic children. The aim of this study was to evaluate the efficacy including free IgE suppression and safety of omalizumab in Japanese children with severe allergic asthma. The primary objective was to examine whether omalizumab decreases serum free IgE levels to less than 25 ng/ml (target level of suppression). METHODS Thirty-eight Japanese children (6-15 years) with uncontrolled severe allergic asthma despite inhaled corticosteroids (>200 μg/day fluticasone propionate or equivalent) and two or more controller therapies received add-on treatment with omalizumab in a 24-week, multicenter, uncontrolled, open-label study. RESULTS The geometric mean serum free IgE level at 24 weeks was 15.6 ng/mL. Compared with baseline, total asthma symptom scores, daily activity scores and nocturnal sleep scores at 24 weeks were significantly improved. The rates of asthma exacerbation and hospitalization due to asthma were reduced by 69.2% and 78.2%, respectively (p < 0.001), versus baseline. Quality-of-life scores were also significantly improved (p < 0.001). In addition, 11 (28.9%) patients reduced the dose of any asthma controller medications. Thirty-six (94.7%) patients experienced at least one adverse event during the treatment period. All adverse events were mild or moderate in severity and no new safety concerns were detected. No patients discontinued the study. CONCLUSIONS In Japanese children with severe allergic asthma, omalizumab decreased free IgE levels to less than 25 ng/mL. Omalizumab improved asthma control and was well-tolerated, as well.
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Affiliation(s)
- Hiroshi Odajima
- Department of Pediatrics, Fukuoka National Hospital, Fukuoka, Japan.
| | - Motohiro Ebisawa
- Department of Allergy, Clinical Research Center for Allergology and Rheumatology, Sagamihara National Hospital, Kanagawa, Japan
| | | | - Takao Fujisawa
- Institute for Clinical Research, Mie National Hospital, Mie, Japan
| | - Akira Akasawa
- Division of Allergy, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Komei Ito
- Department of Allergy, Aichi Children's Health and Medical Center, Aichi, Japan
| | - Satoru Doi
- Department of Pediatrics, Osaka Prefectural Medical Center for Respiratory and Allergic Diseases, Osaka, Japan
| | - Koichi Yamaguchi
- Department of Pediatrics, The Fraternity Memorial Hospital, Tokyo, Japan
| | | | - Kazuyuki Kurihara
- Department of Allergy, Kanagawa Children's Medical Center, Kanagawa, Japan
| | - Naomi Kondo
- Department of Pediatrics, Graduate School of Medicine, Gifu University, Gifu, Japan
| | - Kazuko Sugai
- Department of Pediatrics, Fukuyama Medical Center, Hiroshima, Japan
| | | | - Akira Hoshioka
- Department of Allergy and Rheumatology, Chiba Children's Hospital, Chiba, Japan
| | | | - Norio Sato
- Clinical Development, Novartis Pharma K.K., Tokyo, Japan
| | - Noriko Seko
- Clinical Development, Novartis Pharma K.K., Tokyo, Japan
| | - Sankei Nishima
- Department of Pediatrics, Fukuoka National Hospital, Fukuoka, Japan
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Chiappori A, De Ferrari L, Folli C, Mauri P, Riccio AM, Canonica GW. Biomarkers and severe asthma: a critical appraisal. Clin Mol Allergy 2015; 13:20. [PMID: 26430389 PMCID: PMC4590266 DOI: 10.1186/s12948-015-0027-7] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Accepted: 08/04/2015] [Indexed: 01/17/2023] Open
Abstract
Severe asthma (SA) is a clinically and etiologically heterogeneous respiratory disease which affects among 5–10 % of asthmatic patients. Despite high-dose therapy, a large patients percentage is not fully controlled and has a poor quality of life. In this review, we describe the biomarkers actually known in scientific literature and used in clinical practice for SA assessment and management: neutrophils, eosinophils, periostin, fractional exhaled nitric oxide, exhaled breath condensate and galectins. Moreover, we give an overview on clinical and biological features characterizing severe asthma, paying special attention to the potential use of these ones as reliable markers. We finally underline the need to define different biomarkers panels to select patients affected by severe asthma for specific and personalized therapeutic approach.
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Affiliation(s)
- Alessandra Chiappori
- DIMI-Department of Internal Medicine, Respiratory Diseases and Allergy Clinic, University of Genoa, IRCCS AOU S.Martino-IST, Genoa, Italy
| | - Laura De Ferrari
- DIMI-Department of Internal Medicine, Respiratory Diseases and Allergy Clinic, University of Genoa, IRCCS AOU S.Martino-IST, Genoa, Italy
| | - Chiara Folli
- DIMI-Department of Internal Medicine, Respiratory Diseases and Allergy Clinic, University of Genoa, IRCCS AOU S.Martino-IST, Genoa, Italy
| | - Pierluigi Mauri
- Institute for Biomedical Technologies, CNR, Segrate, Milan, Italy
| | - Anna Maria Riccio
- DIMI-Department of Internal Medicine, Respiratory Diseases and Allergy Clinic, University of Genoa, IRCCS AOU S.Martino-IST, Genoa, Italy
| | - Giorgio Walter Canonica
- DIMI-Department of Internal Medicine, Respiratory Diseases and Allergy Clinic, University of Genoa, IRCCS AOU S.Martino-IST, Genoa, Italy
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48
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Anderson WC, Szefler SJ. New and future strategies to improve asthma control in children. J Allergy Clin Immunol 2015; 136:848-59. [PMID: 26318072 DOI: 10.1016/j.jaci.2015.07.007] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Revised: 07/09/2015] [Accepted: 07/09/2015] [Indexed: 12/13/2022]
Abstract
Symptomatic asthma in childhood has lifelong effects on lung function and disease severity, emphasizing the need for improved pediatric asthma control. Control of pediatric risk and impairment domains can be achieved through increased medication adherence or new therapeutic strategies. Developing electronic monitoring device technology with reminders might be a key noninvasive resource to address poor adherence in children and adolescents in a clinical setting. In patients who have persistently poor control despite optimal medication compliance, newly emerging pharmaceuticals, including inhaled therapies and biologics, might be key to their treatment. However, barriers exist to their development in the pediatric population, and insights must be drawn from adult studies, which has its own unique limitations. Biomarkers to direct the use of such potentially expensive therapies to those patients most likely to benefit are imperative. In this review the current literature regarding strategies to improve pediatric asthma control is addressed with the goal of exploring the potential and pitfalls of strategies that might be available in the near future.
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Affiliation(s)
- William C Anderson
- Section of Allergy and Immunology, Department of Pediatrics, Children's Hospital Colorado, Aurora, Colo; Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colo
| | - Stanley J Szefler
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colo; Pediatric Asthma Research Program, Section of Pediatric Pulmonary Medicine, Breathing Institute, Department of Pediatrics, Children's Hospital Colorado, and the Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colo.
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49
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Abstract
Omalizumab, a therapeutic humanized monoclonal antibody specific for human IgE, was introduced in clinical practice more than a decade ago as an add-on therapy for moderate-to-severe allergic asthma in patients aged ≥12 years. Omalizumab has been demonstrated to be effective in adults with uncontrolled persistent asthma, with an excellent safety profile. In simple terms, omalizumab works by inhibiting the allergic cascade, that is, by neutralization of the circulating free IgE. This leads to reduction in the quantity of cell-bound IgE, downregulation of high-affinity IgE receptors, and, eventually, prevention of mediator release from effector cells. Evidence is far less abundant on the role of omalizumab in pediatric asthma. Although efficacy and safety of omalizumab in children and adolescents with uncontrolled, persistent allergic asthma has been recognized as well, further studies are needed to clarify a number of open questions in this specific patient population.
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Affiliation(s)
- Ciro Romano
- a Division of Internal Medicine, Allergy and Clinical Immunology, Department of Medical and Surgical Sciences, Second University of Naples School of Medicine, Piazza Miraglia 3, 80138 Naples, Italy
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50
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Abstract
BACKGROUND Mepolizumab is a human monoclonal antibody against interleukin-5 (IL-5), the main cytokine involved in the activation of eosinophils, which in turn causes airway inflammation. Recent studies have suggested these agents may have a role in reducing exacerbations and improving health-related quality of life (HRQoL). There are no recommendations for the use of mepolizumab in adults or children in the recent update of the BTS/SIGN guidelines (BTS/SIGN 2014). OBJECTIVES To compare the effects of mepolizumab with placebo on exacerbations and HRQoL in adults and children with chronic asthma. SEARCH METHODS We searched the Cochrane Airways Group Register (CAGR) of trials, clinical trial registries, manufacturers' websites and the reference lists of included studies. Searches were conducted in November 2013 and updated in November 2014. SELECTION CRITERIA We included randomised controlled trials comparing mepolizumab versus placebo in adults and children with asthma. DATA COLLECTION AND ANALYSIS Two authors independently extracted data and analysed outcomes using a random-effects model. We used standard methods expected by The Cochrane Collaboration. MAIN RESULTS Eight studies on 1707 participants met the inclusion criteria. Only two studies included children (over 12 years of age), but they did not report separate findings for the adolescents. Seven studies involved intravenous mepolizumab alone; one included a subcutaneous arm. There was heterogeneity in the severity and clinical pattern of asthma among the participants in the eight studies, varying from mild to moderate atopic asthma, to persistent asthma and eosinophilic asthma with recurrent exacerbations. Selection bias was a concern in several of the studies included in this review.Four trials compared intravenous mepolizumab to placebo in relation to HRQoL. Two studies measured scores from the Asthma Quality of Life Questionnaire (AQLQ), which showed a non-significant difference between mepolizumab and placebo (mean difference (MD) 0.21, 95% confidence interval (CI) - 0.01 to 0.44; participants = 682), in the direction favouring mepolizumab. The third study used the St. George's Respiratory Questionnaire (SGRQ) and found a significant difference between mepolizumab and placebo (MD 6.40, 95% CI 3.15 to 9.65; participants = 576), which indicated a clinically important benefit favouring mepolizumab. A fourth study noted that there was no significant difference but did not provide any data. The two studies in people with eosinophilic asthma showed a reduction in clinically significant exacerbation rates (Risk Ratio 0.52, 95% CI 0.43 to 0.64; participants = 690). However, an analysis of four studies that were not confined to people with eosinophilic asthma indicated considerable heterogeneity and no significant difference in people with one or more exacerbations between mepolizumab and placebo using a random-effects model (Risk Ratio 0.67, 95% CI 0.34 to 1.31; participants = 468; I(2) = 59%).The analysis of serious adverse events indicated a significant difference favouring mepolizumab (Risk ratio 0.49, 95% CI 0.30 to 0.80; participants = 1441; studies = 5; I(2) = 0%). It was not possible to combine the results for adverse events, and we deemed the quality of this evidence to be low.A single study compared subcutaneous mepolizumab to placebo in 385 adults with severe eosinophilic asthma and found an improvement in HRQoL scores and a reduction in asthma exacerbations, including exacerbations requiring admission to hospital. AUTHORS' CONCLUSIONS It is not possible to draw firm conclusions from this review with respect to the role of mepolizumab in patients with asthma. Our confidence in the results of this review are limited by the fact that the intravenous route is not currently licensed for mepolizumab, and the evidence for the currently licenced subcutaneous route is limited to a single study in participants with severe eosinophilic asthma.The currently available studies provide evidence that mepolizumab can lead to an improvement in health-related quality of life scores and reduce asthma exacerbations in people with severe eosinophilic asthma.Further research is needed to clarify which subgroups of patients with asthma could potentially benefit from this treatment. Dosage, ideal dosing regimens and duration of treatment need to be clarified, as the studies included in this review differed in their protocols. There are no studies reporting results from children, so we cannot comment on treatment for this age group. At the present time, larger studies using licenced treatment regimens are required to establish the role of mepolizumab in the treatment of severe asthma.
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Affiliation(s)
- Colin Powell
- Department of Child Health, Institute of Molecular and Experimental Medicine, Cardiff University School of Medicine, Cardiff, UK
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