What is the recommended treatment for a severe exacerbation of eosinophilic asthma, in addition to the patient's regular medications, such as bronchodilators (e.g., Albuterol (Salbutamol)) and corticosteroids (e.g., Prednisone (Prednisone))?

From the Guidelines

For a severe exacerbation of eosinophilic asthma, I recommend starting with systemic corticosteroids such as methylprednisolone 125mg or dexamethasone 10mg, along with frequent short-acting beta-agonists (like albuterol) for immediate bronchodilation, as this approach has been shown to hasten the resolution of airflow obstruction and reduce hospital admissions 1.

Key Considerations

• Systemic corticosteroids should be administered early, as their anti-inflammatory effects may not be apparent for 6 to 12 hours 1.
• The IV route is preferable in patients with severe asthma, although there may be no difference in clinical effects between oral and IV formulations of corticosteroids 1.
• Consider adding ipratropium bromide, as a recent meta-analysis indicated a reduced number of hospital admissions associated with its use, particularly in patients with severe exacerbations 1.

Additional Therapies

• Supplemental oxygen should be added if oxygen saturation is below 92% to prevent hypoxemia.
• IV magnesium sulfate (2g over 20 minutes) may be considered for additional bronchodilation in severe cases, as it has been shown to be beneficial in some studies 1.

Monitoring and Maintenance

• Monitor the patient closely for signs of respiratory failure, including increased work of breathing, inability to complete sentences, or deteriorating oxygen levels, which would necessitate ICU admission.
• After the acute phase, reassess the patient's maintenance therapy, potentially increasing the dose of inhaled corticosteroids or considering initiation or change of biologic therapy targeting the IL-5 or IL-4/IL-13 pathway to better control the underlying eosinophilic inflammation.

Biologic Therapies

• If the patient is already on a biologic therapy for eosinophilic asthma (such as mepolizumab, benralizumab, or dupilumab), continue this treatment as scheduled, but note that it will not provide immediate relief during the acute exacerbation.

From the FDA Drug Label

The primary endpoint for SIROCCO and CALIMA was the rate of asthma exacerbations in patients with baseline blood eosinophil counts of greater than or equal to 300 cells/μL who were taking high‑dose ICS and LABA. Asthma exacerbation was defined as a worsening of asthma requiring use of oral/systemic corticosteroids for at least 3 days, and/or emergency department visits requiring use of oral/systemic corticosteroids and/or hospitalization In SIROCCO, 35% of patients receiving FASENRA experienced an asthma exacerbation compared to 51% on placebo In CALIMA, 40% of patients receiving FASENRA experienced an asthma exacerbation compared to 51% on placebo

To treat a severe exacerbation of eosinophilic asthma, in addition to the patient's regular medications, oral or systemic corticosteroids should be used for at least 3 days.

• The definition of an asthma exacerbation from the SIROCCO and CALIMA trials supports this treatment approach.
• The use of benralizumab (FASENRA) as an add-on maintenance treatment may help reduce the rate of asthma exacerbations in patients with severe asthma and an eosinophilic phenotype 2.
• Omalizumab (XOLAIR) has also been shown to reduce the number of exacerbations per patient in clinical trials 3.

From the Research

Treatment Options for Severe Eosinophilic Asthma

In addition to the patient's regular medications, treatment for a severe exacerbation of eosinophilic asthma may involve the use of biologic therapies that target eosinophilic inflammation.

• Biologic therapies such as mepolizumab, reslizumab, benralizumab, and dupilumab have been approved for the treatment of moderate to severe asthma with an eosinophilic phenotype 4, 5.
• These therapies have been shown to reduce the frequency and severity of exacerbations, improve lung function, and enhance quality of life in patients with severe eosinophilic asthma 6, 7.
• For example, reslizumab has been demonstrated to significantly improve clinical asthma exacerbation rates, time to first exacerbation, and lung function in patients with severe eosinophilic asthma 6.
• Benralizumab, an anti-interleukin-5 receptor α monoclonal antibody, has also been shown to reduce annual exacerbation rates and improve pre-bronchodilator forced expiratory volume in 1 second (FEV1) and total asthma symptom score in patients with severe, uncontrolled, eosinophilic asthma 8.

Identifying Patients with Eosinophilic Asthma

Patients with severe eosinophilic asthma can be identified by the presence of eosinophils ≥150-300 cells/μL on a complete blood count with differential 4.

• Eosinophilic asthma is characterized by increased airway expression of type 2 cytokines IL-4, IL-5, and IL-13, and is often associated with a poor response to conventional therapies 4, 5.
• The use of biologic therapies in these patients has been shown to be effective in reducing exacerbations and improving symptoms, and should be considered as an add-on treatment for patients with severe, uncontrolled eosinophilic asthma 5, 6, 7, 8.