From the Guidelines
Dupilumab is the most beneficial asthma biologic for most patient-important outcomes, based on recent network meta-analysis results. The choice of asthma biologic depends on various factors, including the patient's specific type of asthma, biomarkers, and clinical presentation. For patients with severe eosinophilic asthma, anti-IL5 therapies like mepolizumab (Nucala), reslizumab (Cinqair), or benralizumab (Fasenra) may be considered, while omalizumab (Xolair) may be preferred for those with allergic eosinophilic asthma 1. However, dupilumab (Dupixent) has shown to be superior in patients with type 2 inflammation, especially those with comorbid atopic dermatitis or chronic rhinosinusitis with nasal polyps, as it targets IL-4 and IL-13 pathways. Key considerations in selecting an asthma biologic include:
- Patient's biomarkers, such as blood eosinophil counts, FeNO levels, and IgE levels
- Presence of comorbid diseases, like atopic dermatitis or chronic rhinosinusitis with nasal polyps
- Patient's preferences and values, including the burden of payment and insurance approvals, and the inconvenience of trying less effective medical therapies
- Disease severity and the need for more efficacious therapies. Treatment response should be assessed after 3-6 months, and if inadequate improvement is seen, switching to a different biologic, such as dupilumab, may be considered, as it has been shown to be beneficial for most patient-important outcomes 1.
From the Research
Asthma Biologics Comparison
- The choice of optimal therapy for each patient with severe asthma is a challenge for clinicians due to the lack of head-to-head studies comparing biological agents among themselves and with conventional therapy 2.
- Five biologicals (benralizumab, dupilumab, mepolizumab, omalizumab, and reslizumab) have been approved for severe eosinophilic asthma, and all reduce exacerbation rates with high certainty of evidence 3.
- Mepolizumab has been shown to be a well-tolerated and efficacious regimen for use in severe eosinophilic asthma, reducing the rate of clinically significant exacerbations by 44-68% versus placebo 4.
Mepolizumab Efficacy
- Mepolizumab reduces exacerbations and improves asthma control, health-related quality of life, and lung function in patients with severe eosinophilic asthma despite comorbid conditions 4.
- Real-world effectiveness of mepolizumab in reducing exacerbations has been demonstrated in patients with severe asthma and an eosinophilic phenotype, regardless of any overlapping allergic phenotype 5.
- A systematic review and meta-analysis of real-world studies found that mepolizumab provides consistent clinical benefits, including a reduction in clinically significant exacerbations and oral corticosteroid dose, and an improvement in asthma control 6.
Comparison with Other Biologics
- Benralizumab, dupilumab, and mepolizumab reduce the daily dose of oral corticosteroids with high certainty of evidence, while all evaluated biologicals probably improve asthma control, quality of life, and FEV1 3.
- The incremental cost-effectiveness ratio per quality-adjusted life year value is above the willingness to pay threshold for all biologicals, with potential savings driven by a decrease in hospitalizations, emergency, and primary care visits 3.