Diego J. Maselli, MD, on Biologics for Moderate to Severe Asthma
Five biologic agents are currently approved for the treatment of moderate to severe asthma, including omalizumab, mepolizumab, reslizumab, benralizumab, and dupilumab. Several additional agents are in development as well. With an increase of these therapies on the horizon, the treatment of moderate to severe asthma is moving toward a personalized medicine approach.
To answer our questions about biologic therapies for treating asthma, Pulmonology Consultant caught up with Diego J. Maselli, MD, who is an associate professor of medicine in the Division of Pulmonary Diseases and Critical Care at UT Health San Antonio, is the director of Respiratory Care at University Health System, and is director of the Severe Asthma Program at University Health System in San Antonio, Texas.
PULM CON: How do you choose the right biologic for patients with severe asthma? And what is the importance of personalized medicine in this patient population?
DM: The selection of biologicals depends on multiple factors. It includes evidence of type 2 inflammation, comorbid conditions, patient and provider preference, and availability. Biomarkers, such as serum immunoglobin E (IgE), allergy profile, exhaled nitric oxide, and blood/sputum eosinophils, can be used to identify the predominant endotype. Nevertheless, there is often overlap and multiple biomarkers may be elevated.
Additionally, some experts advocate trending these biomarkers, since the results can be affected by the use of systemic corticosteroids. The 2019 Global Initiative for Asthma (GINA) guidelines1 recommend repeating blood/sputum eosinophils up to 3 times at the lowest possible corticosteroid dose. Comorbid conditions such as atopic dermatitis or nasal polyps may also aid in the selection of therapy.
For example, dupilumab is approved for atopic dermatitis and nasal polyps in addition to the asthma indication. In patients with these conditions, dupilumab is an attractive option. Shared decision-making is always encouraged, and taking into consideration the patient’s preference increases adherence. To this effect, patients may choose home or office administration to best suit their preference.
PULM CON: The cost of biologics may deter patients from adhering to therapy. What are your tips for pulmonologists and pediatricians who may manage patients with severe asthma who do not adhere to biologic therapy?
DM: Patient non-adherence continues to be an area of increased focus, particularly in severe asthma. It is encouraged that in all clinical visits the patients should be reminded of the importance of using their controller medications. With the recent approval of biologics for home use (i.e., dupilumab, mepolizumab, benralizumab), there have been some concerns about adherence.
The patients may require more frequent visits to review the effects of the medication and ensure adequate adherence. Some providers have incorporated interval telephone calls to the patients to periodically assess their treatments. In patients who have a strong history of non-adherence or struggle with home use, in-office administration of biologics remains an option.
PULM CON: What are your key take-home messages about biologic therapies for patients with severe asthma?
DM: The approach to severe asthma therapy of “one size fits all” is long gone. In the age of personalized medicine, it is possible to identify subgroups of patients that have a high likelihood of responding to therapy, particularly in severe asthma. Other factors, such as comorbid conditions and patient preference, are useful for individualizing therapy. With this strategy, biologics have shown to reduce exacerbations, decrease the need for oral steroids, and improve lung function and the quality of life in patients with severe asthma.
Reference:
- Difficult-to-treat & severe asthma in adolescent and adult patients: diagnosis and management. Global Initiative for Asthma. April 2019. https://ginasthma.org/wp-content/uploads/2019/04/GINA-Severe-asthma-Pocket-Guide-v2.0-wms-pdf.