Biologics in severe asthma: Outcomes in clinical trials-Similarities and differences

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.

KEYWORDS:

• Severe asthma
• T2-high
• omalizumab
• mepolizumab
• benralizumab
• dupilumab
• tezepelumab

Article highlights

• Biologics in severe asthma target the T2-high process

• The selection of a biologic is based on the underlying endotyping mechanism and the corresponding phenotype

• Comorbidities such as allergic rhinitis, atopic dermatitis, nasal polyps and urticaria may influence the choice of biologic therapy

• For patients with severe asthma with an ‘overlap’ phenotype, who are thus eligible for more than one biologic, the predominant mechanism should be assessed, and the findings used to lead the therapy decision

• The main outcomes in randomized controlled trials for biologics in severe asthma are the rate of exacerbation and the use of systemic maintenance corticosteroids

• Lung function, asthma control and quality of life are also improved by almost all the biologics discussed

• No significant safety issues have been raised with biologic treatments in severe asthma

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.