Onset of Effect, Changes in Airflow Obstruction and Lung Volume, and Health-Related Quality of Life Improvements with Benralizumab for Patients with Severe Eosinophilic Asthma: Phase IIIb Randomized, Controlled Trial (SOLANA)

Objective

In the SOLANA trial, we sought to physiologically characterize benralizumab’s onset of effect and maintenance of that effect for patients with severe eosinophilic asthma.

Methods

SOLANA (NCT02869438) was a multicenter, randomized, double-blind, parallel-group, placebo-controlled, Phase IIIb study conducted at 49 centers in six countries (Chile, Germany, Hungary, the Philippines, South Korea, and the United States). Eligible patients with baseline blood eosinophil counts ≥300 cells/µL were randomized to subcutaneous benralizumab (30 mg) or placebo administered at Days 0, 28, and 56. The primary endpoint was the average change from baseline in prebronchodilator forced expiratory volume in 1 s (pre-BD FEV₁) during the Day 28‒Day 84 period for benralizumab vs placebo. Secondary endpoints included patient-reported outcomes (PROs). A subset of patients participated in a whole-body plethysmography substudy. Safety was also assessed.

Results

In total, 233 patients were randomized to benralizumab (n=118) or placebo (n=115). Improvement from baseline in pre-BD FEV₁ with benralizumab 30 mg was not statistically significant compared with placebo (least-squares mean change difference [95% confidence interval] 57 mL [−22 to 135]; p=0.16). Compared with placebo, benralizumab demonstrated early (Day 7) nonstatistically significant improvements in whole-body plethysmography assessments of hyperinflation and clinically meaningful improvements in PRO measures (Asthma Control Questionnaire 6 at Day 14 and St. George’s Respiratory Questionnaire at Day 28), which were maintained over the treatment period. Benralizumab’s safety profile was commensurate with previously reported studies.

Conclusion

The observed early changes in lung volume despite relatively small improvements in airflow obstruction suggest that the anti-inflammatory effect of benralizumab may be manifested as deflation over time for patients with hyperinflation, who potentially have a greater degree of airway remodeling. This early effect could partially explain the rapid PRO improvements observed for certain patients.

Platelet dysfunction-eosinophilia syndrome in parasitized Venezuelan children

Platelet dysfunction was detected in six children with purpura and eosinophilia. We conducted clinical evaluations, hematologic and platelet function tests, clotting studies (bleeding time, prothrombin time, partial thromboplastin time, thrombin time, factor XIII, factor VIII, and von Willebrand factor), assays for IgG and IgM antibodies to platelets, and a search for stool parasites. Mild bleeding phenomena (ecchymoses, petechiae, epistaxis, and gingival) were transient. All children showed intestinal parasites and marked eosinophilia (mean count = 2,615.2 cells/muL, 95% confidence interval = 1,259.6-5,429.8). Main abnormalities included prolonged bleeding times (50%) and defective aggregation with collagen (100%) adrenaline (66%), or ADP (66%). Antibodies to platelets were not detected. Anti-parasite therapy reversed the hemorrhagic manifestations and normalized eosinophil counts and platelet alterations. No relationship could be established between excess eosinophils, intensity of bleeding, or type and degree of platelet abnormalities. Thrombocytopathic features mimicked the intrinsic defect of storage pool disease. The possible pathogenic roles of eosinophilia and parasitism are reviewed. This is the first report of this pathologic combination in Latin American children.

A prospective safety-monitoring study of immunotherapy in mite-allergy patients with mass-units-standardized extract

To determine the tolerance of an allergen extract standardized in mass units, we closely monitored the side-effects, during the buildup phase of immunotherapy treatment, in 88 patients with well-documented respiratory allergy to house-dust mite (Dermatophagoides pteronyssinus). Thirty-four patients (38.6%) suffered from moderate perennial rhinitis, and 54 had mild to moderate bronchial asthma (61.4%). For the desensitizing treatment, we used a depot extract adsorbed in aluminum hydroxide of D. pteronyssinus (Pangramin Depot UM), biologically standardized and having the major allergens Der p 1 and Der p 2 quantified in micrograms. A total of 1244 doses were administered. All patients except one (98.9%) reached the expected maximum dose of 4 micrograms Der p 1. Only five patients suffered mild adverse reactions (5.7%). All adverse reactions except one appeared to be related to the vial of maximum concentration: vial III (4 micrograms Der p 1). Considering the number of patients who had adverse reactions and the frequency of adverse reactions per dose, we found no significant differences between rhinitis and asthma sufferers. We think that immunotherapy in doses of 4 micrograms Der p 1 and 2 micrograms Der p 2 is well tolerated and should not be avoided in mildly to moderately asthmatic patients when treating house-dust mite allergy.