Editorial
Emerging Therapies in Severe Eosinophilic Asthma
Nuevas terapias para el asma eosinofílica grave
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"apellidos" => "Brightling" "email" => array:1 [ 0 => "ceb17@le.ac.uk" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Department of Respiratory and Critical Care Medicine, Tan Tock Seng Hospital, Singapore" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Institute for Lung Health, NIHR Respiratory Biomedical Research Unit, Department of Infection, Immunity & Inflammation, University of Leicester and University Hospitals of Leicester NHS Trust, Leicester, UK" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Nuevas terapias para el asma eosinofílica grave" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Asthma is a complex, heterogeneous disease characterized by chronic airway inflammation, episodic respiratory symptoms, and associated with variable expiratory airflow limitation. The prevalence of asthma is increasing, and is estimated to affect 358 million people worldwide in the recent Global Burden of Disease report.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">1</span></a> 5%–10% are said to have severe asthma, defined as asthma that requires treatment with high dose inhaled corticosteroids and a second controller for the previous year, and/or systemic corticosteroids for ≥50% of the previous year to prevent it from becoming uncontrolled or that remains uncontrolled despite this therapy.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">2</span></a> This subset of patients has poorer lung function, quality of life, and recurrent exacerbations; is at increased risk of significant morbidity and mortality, and exerts a substantial burden on healthcare resources.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Understanding the heterogeneity of the airway inflammation in severe asthma is of particular importance to predict future risk of exacerbations and response to therapy. The presence of eosinophilic airway inflammation is associated with poorer asthma control and increased risk of exacerbations,<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">3</span></a> and is a good predictor of a favorable response to corticosteroids.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">4</span></a> Beyond corticosteroids, monoclonal antibodies targeting Type 2 (T2) immunity and consequent eosinophilic inflammation in severe asthma has been developed.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The first monoclonal antibody for asthma was omalizumab, a humanized monoclonal antibody against IgE used since 2003 in adults, adolescents and children over 6 years of age with moderate to severe persistent allergic asthma inadequately controlled with standard therapy. It improved asthma symptoms and health-related quality of life. It also reduced exacerbations and daily inhaled corticosteroid dose.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">5</span></a> Response to omalizumab was better in asthmatics with increased biomarkers of T2 immunity and eosinophilic inflammation including serum periostin, blood eosinophil count and fraction of exhaled nitric oxide.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">6</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Anti-interleukin-5 (IL-5) monoclonal antibodies are the second class of biological therapy for severe eosinophilic asthma. IL-5 cytokine plays an important role in the maturation and activation of eosinophils. Mepolizumab is a humanized monoclonal antibody that binds to IL-5, preventing it from binding to IL-5 receptors. The first large phase IIb/III trial (DREAM study) showed that mepolizumab at a range of doses significantly reduced severe exacerbation rate in subjects with recurrent exacerbations and evidence of eosinophilic inflammation.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">7</span></a> The results were also replicated in another phase III trial using a lower intravenous Mepolizumab dose of 75<span class="elsevierStyleHsp" style=""></span>mg and a subcutaneous dose of 100<span class="elsevierStyleHsp" style=""></span>mg.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">8</span></a> Mepolizumab has also been shown to have steroid-sparing effects by significantly reducing daily systemic corticosteroid use compared to placebo, while maintaining its exacerbation reduction effect.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">9</span></a> The efficacy of mepolizumab appeared to be more pronounced in subjects with higher baseline blood eosinophil levels and more frequent exacerbations, with no benefit in exacerbation reduction in those with a blood eosinophil count <150<span class="elsevierStyleHsp" style=""></span>cells/μL. On the strength of these positive trial results, it has since been licensed for use in severe eosinophilic asthma. Reslizumab, another monoclonal antibody targeting IL-5, was also recently licensed for use in severe eosinophilic (≥400 blood eosinophils/μL) asthma following phase III trials demonstrating significant improvement in forced expiratory volume in 1 second (FEV1), asthma control scores, asthma-related quality of life and frequency of asthma exacerbations.<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">10,11</span></a> However, when used across a broad range of blood eosinophil counts, reslizumab had no effect on lung function and asthma control.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">12</span></a> Benralizumab differs from mepolizumab and reslizumab as it acts on the alpha chain of the IL-5 receptor causing eosinophil apoptosis. Two recent phase III trials in subjects with inadequately controlled asthma, frequent exacerbations and elevated blood eosinophil count showed significant reduction of annual asthma exacerbation rate compared to placebo.<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">13,14</span></a> It also significantly improved FEV1, Asthma Control Questionnaire (ACQ) and Asthma Quality of Life Questionnaire (AQLQ) scores in those receiving the treatment every 8 weeks.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Inhibiting other T2-cytokines such as IL-13 neutralization (Lebrikizumab and Tralokinumab) or the alpha chain of the IL-4 receptor which attenuates both IL-4 and IL-13 signaling (Dupilumab) are attractive targets. None of these strategies have demonstrated an effect on reducing eosinophilic inflammation, but benefits for these approaches are greater in those with upregulated T2-immunity and eosinophilic inflammation. Recent phase III studies for Lebrikizumab failed to demonstrate consistent benefit for reduction in asthma exacerbations<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">15</span></a> and phase III studies for Tralokinumab are ongoing (<a href="ctgov:NCT02194699">NCT02194699</a> and <a href="ctgov:NCT02161757">NCT02161757</a>). Findings from a phase IIb study of Dupilumab were more encouraging, showing reductions in exacerbation frequency and improvements in symptoms in all comers with greatest response in those with eosinophilic inflammation.<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">16</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In addition to biological therapy, small molecule inhibitors have shown promising results in severe asthma. Prostaglandin D<span class="elsevierStyleInf">2</span> (PGD<span class="elsevierStyleInf">2</span>) is a prostanoid mainly produced by mast cells, which binds and activates G protein-coupled receptors: D prostanoid 1, thromboxane A<span class="elsevierStyleInf">2</span> receptor and D prostanoid 2 (DP<span class="elsevierStyleInf">2</span>). DP<span class="elsevierStyleInf">2</span> is also known as chemoattractant receptor-homologous molecule on T helper Type 2 cells (CRTh<span class="elsevierStyleInf">2</span>), selectively expressed on Th2 cells, eosinophils, basophils, Type 2 innate lymphoid cells (ILC2s), epithelial cells and airway smooth muscle. In a recent single-center randomized placebo-controlled study of patients with moderate-to-severe asthma and sputum eosinophilia (≥2%), fevipiprant (a potent and highly selective DP<span class="elsevierStyleInf">2</span> antagonist) showed significant reduction in eosinophilic inflammation in both sputum and bronchial submucosa compared with placebo.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">17</span></a> There was significant effect on AQLQ score, post bronchodilator FEV1 and functional residual capacity in all patients, and the ACQ-7 score in a pre-defined subgroup of patients who had uncontrolled asthma. The effect on asthma exacerbations is now being evaluated in phase III clinical trials.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Thus, the armamentarium for the treatment of severe eosinophilic asthma is expanding. Future research is needed to give further insight into which patients are most likely to have the greatest response to which treatment, and to better define both response and failure to respond to these new therapies. This might require head-to-head pragmatic real life trials of licensed therapies. Notwithstanding this limitation, the prospect of new and effective treatments is now within our grasp.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of Interest</span><p id="par0040" class="elsevierStylePara elsevierViewall">PHP declares to have no conflict of interest directly or indirectly related to the manuscript contents. CEB has received consultancy fees and or grants paid to his Institution from AZ/Medimmune, GSK, Roche/Genentech, BI, Chiesi, Teva, Sanofi/Regeneron, Vectura, Theravance, Novartis, Gilead and Pfizer.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflict of Interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:17 [ 0 => array:3 [ "identificador" => "bib0090" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990-2015: A systematic analysis for the global burden of disease study 2015" "autores" => array:1 [ 0 => array:2 [ "colaboracion" => "GBD 2015 Disease and Injury Incidence and Prevalence Collaborators" "etal" => false ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/S0140-6736(16)31678-6" "Revista" => array:6 [ "tituloSerie" => "Lancet" "fecha" => "2016" "volumen" => "388" "paginaInicial" => "1545" "paginaFinal" => "1602" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27733282" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0095" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "International ERS/ATS guidelines on definition, evaluation and treatment of severe asthma" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "K.F. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 4 | 1 | 5 |
| 2024 October | 34 | 20 | 54 |
| 2024 September | 29 | 9 | 38 |
| 2024 August | 39 | 30 | 69 |
| 2024 July | 33 | 19 | 52 |
| 2024 June | 37 | 18 | 55 |
| 2024 May | 67 | 26 | 93 |
| 2024 April | 25 | 22 | 47 |
| 2024 March | 28 | 19 | 47 |
| 2024 February | 24 | 20 | 44 |
| 2023 March | 7 | 1 | 8 |
| 2023 February | 39 | 22 | 61 |
| 2023 January | 41 | 34 | 75 |
| 2022 December | 37 | 32 | 69 |
| 2022 November | 63 | 28 | 91 |
| 2022 October | 33 | 32 | 65 |
| 2022 September | 23 | 28 | 51 |
| 2022 August | 26 | 41 | 67 |
| 2022 July | 26 | 41 | 67 |
| 2022 June | 21 | 27 | 48 |
| 2022 May | 22 | 35 | 57 |
| 2022 April | 31 | 28 | 59 |
| 2022 March | 31 | 41 | 72 |
| 2022 February | 34 | 24 | 58 |
| 2022 January | 46 | 31 | 77 |
| 2021 December | 35 | 47 | 82 |
| 2021 November | 31 | 51 | 82 |
| 2021 October | 41 | 45 | 86 |
| 2021 September | 22 | 41 | 63 |
| 2021 August | 16 | 36 | 52 |
| 2021 July | 23 | 29 | 52 |
| 2021 June | 40 | 29 | 69 |
| 2021 May | 38 | 36 | 74 |
| 2021 April | 86 | 90 | 176 |
| 2021 March | 56 | 15 | 71 |
| 2021 February | 20 | 16 | 36 |
| 2021 January | 29 | 24 | 53 |
| 2020 December | 21 | 20 | 41 |
| 2020 November | 12 | 14 | 26 |
| 2020 October | 22 | 16 | 38 |
| 2020 September | 22 | 8 | 30 |
| 2020 August | 18 | 18 | 36 |
| 2020 July | 18 | 18 | 36 |
| 2020 June | 24 | 11 | 35 |
| 2020 May | 26 | 8 | 34 |
| 2020 April | 18 | 16 | 34 |
| 2020 March | 18 | 10 | 28 |
| 2020 February | 17 | 15 | 32 |
| 2020 January | 21 | 10 | 31 |
| 2019 December | 23 | 17 | 40 |
| 2019 November | 13 | 23 | 36 |
| 2019 October | 14 | 17 | 31 |
| 2019 September | 21 | 8 | 29 |
| 2019 August | 31 | 13 | 44 |
| 2019 July | 34 | 16 | 50 |
| 2019 June | 17 | 7 | 24 |
| 2019 May | 19 | 23 | 42 |
| 2019 April | 25 | 20 | 45 |
| 2019 March | 39 | 28 | 67 |
| 2019 February | 42 | 19 | 61 |
| 2019 January | 22 | 16 | 38 |
| 2018 December | 50 | 18 | 68 |
| 2018 November | 74 | 20 | 94 |
| 2018 October | 93 | 26 | 119 |
| 2018 September | 33 | 11 | 44 |
| 2018 May | 5 | 1 | 6 |
| 2018 April | 45 | 5 | 50 |
| 2018 March | 35 | 2 | 37 |
| 2018 February | 38 | 4 | 42 |
| 2018 January | 98 | 8 | 106 |
| 2017 December | 129 | 8 | 137 |
| 2017 November | 38 | 6 | 44 |
| 2017 October | 21 | 14 | 35 |
| 2017 September | 26 | 19 | 45 |
| 2017 August | 16 | 15 | 31 |
| 2017 June | 0 | 1 | 1 |
| 2017 May | 4 | 3 | 7 |
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