Dr. P. Saitheja reddy Lilavati hospital Mumbai

1. Newer drugs and therapeutics for Asthma
or
Targeted therapy of Asthma
or
Biologics in management of Asthma
Dr. P. Saitheja Reddy
Lilavati hospital

2. Severe Asthma
Def :
When a diagnosis of asthma is confirmed and comorbidities
have been addressed, severe asthma is defined as -
“asthma which requires treatment with high dose inhaled
corticosteroids (ICS) plus a second controller (and/or
systemic CS) to prevent it from becoming “uncontrolled” or
which remains “uncontrolled“ despite this therapy.”
International ERS/ATS Guidelines on Definition, Evaluation, and Treatment of
Severe Asthma • 2013

4. • The complexity of chronic severe asthma with different underlying
mechanisms (or endotypes) suggests that phenotyping patients with
severe asthma and personalized therapy could lead to improved
outcomes and fewer side effects.
• Biomarkers can help group patients into phenotypes / endotypes, predict
those who will respond to a specific therapy, and assess the response to
treatment.
• The introduction of anti-IgE therapy for severe asthma inaugurated the
era of specific therapies for certain severe asthma patients, although
predicting responder to therapy remains problematic.

5. Biomarkers of Asthma
• Sputum : Eosinophils > 3%
• Exhaled biomarkers : FeNO (fractional exhaled NO), exhaled
breath condensate
• Blood : (i) IgE
(ii) Eosinophils (>150-300/ul)
(iii) serum periostin

6. Potential phenotype targeted therapies in severe asthma
International ERS/ATS Guidelines on Definition, Evaluation, and Treatment of Severe Asthma • 2013

7. T-2 / Th-2 mediated pathway

8. Non T-2 / Non Th-2 mediated pathway

9. T-2 / Th-2 related therapies
• Anti IgE Ab - Omalizumab
• Anti IL-5 Ab - Mepolizumab, Reslizumab
• Anti IL-5 r Ab - Benralizumab
• Anti IL-4 & 13 Ab - Pitrakinra
• Anti IL-4 r Ab - Dupilimab
• Anti IL-4 Ab - Altrakincept, Pascolizumab
• Anti IL-13 Ab - Lebrikizumab, Tralokinumab
• Anti TSLP Ab
• Anti IL-33 Ab

11. Non T-2 / Th-2 related therapies
• Anti TNF-alfa Ab - Infliximab, Golimumab
• Anti TNF-alfa r antagonist - Etanercept
• Anti IL-17 Ab - Brodalumab
• Anti CD 25 Ab - Daclizumab
• CXCR-2 antagonist - Navarixin
• Tyrosine kinase inhibitor - masitinib
• Macrolides – Azithromycin for neutrophilic asthma

13. Approved for use
• Three monoclonal antibody-based therapies that target immunologic
mediators common in specific severe asthma phenotypes are now
available:
• Omalizumab - ZOLAIR
• Mepolizumab - NUCALA
• Reslizumab – CINQAIR
• Omalizumab is a monoclonal anti-IgE antibody for patients aged >= 6 yrs
with moderate-to-severe allergic asthma that is uncontrolled on step 4
treatment.
• Mepolizumab (sc) and Reslizumab (iv) are monoclonal anti-IL-5 antibody
treatments for patients aged >=12 yrs with severe eosinophilic asthma
that is uncontrolled on step 4 treatment.

14. Omalizumab

15. Indications and contraindications
• Moderate to severe allergic asthma patients aged >=6 yrs whose asthma is
uncontrolled with step 4 treatment.
• Used to treat chronic idiopathic urticaria in patients 12 years of age and
older that are not controlled by H1 antihistamine treatment.
• Contraindicated in patients with a severe hypersensitivity reaction to
XOLAIR or to any ingredient of XOLAIR.

18. Administration
• Subcutaneous injection
• The injection may take 5-10 seconds to administer because the solution is
slightly viscous.
• Do not administer more than 150 mg (contents of one vial) per injection
site. Divide doses of more than 150 mg among two or more injection sites.

19. When to stop ??
• Total IgE levels are elevated during treatment and remain elevated for up
to one year after the discontinuation of treatment. Therefore, re-testing
of IgE levels during Xolair treatment cannot be used as a guide for dose
determination.
• Interruptions lasting less than one year: Dose based on serum IgE levels
obtained at the initial dose determination.
• Interruptions lasting one year or more: Re-test total serum IgE levels for
dose determination using Table 1, 2, or 3 based on the patient’s age.
### Periodically reassess the need for continued therapy based upon the
patient’s disease severity and level of asthma control

20. Adverse effects
• Injection site reactions (45%) - bruising, redness, warmth, burning, stinging,
itching, hive formation, pain, induration, mass, and inflammation.
- Most of these reactions occurred within 1 hour of injection, resolved within 8
days, and generally decreased in frequency with subsequent dosing.
• Viral infections (23%)
• Upper respiratory tract infections (20%)
• Sinusitis (16%)
• Headache (15%)
• Pharyngitis (11%)
• Warnings: Anaphylaxis – rare
cancer – rare
parasitic infections
acute asthma
eosinophilic conditions

21. Mepolizumab
• NUCALA
• MOA: inhibits the bioactivity of IL-5 by blocking its binding to the alpha
chain of the IL-5 receptor complex expressed on the eosinophil cell
surface.
• SC
• 100 mg every 4 weeks
• Indication: severe eosinophilic asthma pts >=12 yrs
• Contraindication: allergic to drug or ingrediants
• Adverse effects and warnings are same as ZOLAIR

22. Reslizumab
• CINQAIR
• IV
• Dose: 3 mg/kg every 4 weeks infusion over 20-50 mins
• Indication: severe eosinophilic asthma pts of age >=18 yrs
• MOA, Contraindication, AE and warnings are same as NUCALA

23. Issues
• Considerable proportion of uncontrolled patients were not
eligible for any of the biologics.
• Overlap in treatment eligibility among patients with different
phenotypes of severe asthma.
• Most of them are still under clinical trials.
• Side effect profile is not well understood.

24. New therapies
• Bronchial thermoplasty
• Allergen immunotherapy
• Vitamin D

25. Vitamin D
• Several cross-sectional studies have shown that low serum levels of vit D
is associated with:
- reduction in lung function,
-higher exacerbation ferquency and
-reduced corticosteroid response
• But there is no good quality evidence that vit D supplementation leads
improvement in the above mentioned sections.

26. Allergen specific immunotherapy
• 2 approaches:
-subcutaneous (SCIT)
-sublingual (SLIT)- new
• Recommended for adult patients with asthma + allergic rhinitis and
sensitized to HDM, with exacerbations despite low to high dose ICS,
provided FEV1 is >70% predicted.
( HDM- house dust mite)

27. THANQ