What are the considerations for using Tezspire (benralizumab) in patients with viral infections?

Considerations for Using Tezspire (Benralizumab) in Patients with Viral Infections

Patients receiving Tezspire (benralizumab) should temporarily discontinue treatment during active viral infections until clinical resolution of symptoms or until viral load is not clinically significant. 1

Viral Infection Risk with Benralizumab

• Patients on benralizumab may have an increased risk of viral infections, with upper respiratory tract viral infections being the most common adverse event (14-16% of patients) 2, 3
• Long-term safety studies of benralizumab (up to 5 years) have shown stable and low rates of serious infections, without increasing risk over time 3
• The mechanism of action (IL-5 receptor α-directed cytolytic monoclonal antibody) causes eosinophil depletion, which may impact immune response to viral pathogens 4

Monitoring Recommendations

• Monitoring for viral infections should be carried out based on symptoms and clinical presentation 1
• PCR-based viral panels are recommended to diagnose active viral infections and reactivations 1
• For patients with persistent fever and fatigue, consider monitoring for viral reactivation, particularly for viruses like EBV 1

Management of Specific Viral Infections

Herpes Simplex Virus (HSV) and Varicella Zoster Virus (VZV)

• Prophylaxis with acyclovir or valacyclovir is recommended for patients receiving benralizumab 1
• Maintain prophylaxis throughout the duration of benralizumab treatment 1
• For VZV reactivation, treat with valacyclovir or IV acyclovir according to standard treatment guidelines 1
• VZV vaccination is recommended for patients prior to starting benralizumab 1

Cytomegalovirus (CMV)

• Collect baseline CMV history and IgG/IgM status prior to starting benralizumab 1
• If CMV infection risk is suspected, monitor CMV DNA copies 1
• Treat CMV reactivation with oral valganciclovir or alternatively with IV ganciclovir or foscarnet 1

Hepatitis B Virus (HBV)

• Screen for HBV core antibodies and surface antigens before initiating benralizumab 1
• For patients who are core antibody positive, either administer prophylaxis or monitor for HBV DNA copies 1
• If surface antigen positive, administer antiviral prophylaxis (entecavir, tenofovir, lamivudine) under specialist supervision 1
• Discontinue benralizumab if patient experiences HBV reactivation 1

SARS-CoV-2 (COVID-19)

• Patients with COVID-19 should temporarily discontinue benralizumab until clinical resolution and RT-PCR clearance 1
• Patients on benralizumab may have reduced antibody response to COVID-19 vaccination, potentially requiring additional booster doses 1
• Follow CDC guidelines or local health authority guidelines for vaccination 1

Hypogammaglobulinemia Considerations

• Monitor immunoglobulin levels in patients receiving benralizumab, as hypogammaglobulinemia can increase susceptibility to viral infections 5
• Consider immunoglobulin replacement therapy (IVIG) for patients who develop hypogammaglobulinemia with recurrent infections 5
• Target IgG trough levels of >500-700 mg/dL when administering replacement therapy 5

Treatment Algorithm During Viral Infections

1. Identify viral infection through clinical manifestations, physical examinations, and PCR testing 1
2. Document the specific viral infection and assess severity 1
3. Temporarily discontinue benralizumab during active viral infection 1
4. Initiate appropriate antiviral treatment based on the specific pathogen 1
5. Resume benralizumab only after clinical resolution of infection symptoms or when viral load is not clinically significant 1

Common Pitfalls and Caveats

• Do not overlook the importance of prophylaxis against HSV/VZV reactivation, as these can lead to severe complications in immunocompromised patients 1
• Be aware that patients on benralizumab may have diminished response to vaccines, particularly those targeting viral pathogens 1
• Recognize that the risk of severe outcomes from viral infections may be increased in patients receiving benralizumab due to potential depletion of functional immune cells 1
• Regular monitoring of immunoglobulin levels is important to identify patients at risk for recurrent infections 5