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Mepolizumab improves clinical outcomes in severe eosinophilic asthma despite comorbidity

Published: December 23, 2022

Severe asthma is a high burden and heterogeneous disease. Comorbid conditions are common in severe asthma and add to the complexity and burden of disease. Comorbidities may change the asthma phenotype and response to treatment. Mepolizumab is an effective targeted biologic treatment for severe eosinophilic asthma (SEA). However, comorbidities are often under-represented in large randomized controlled trials, and it is important to understand how comorbidities may impact the SEA phenotype and treatment response. Real-world data on the use of mepolizumab in SEA in the presence of comorbid conditions are important to inform clinical practice.

In a recent article in The Journal of Allergy and Clinical Immunology: In Practice, Kritikos et al reported the results of an observational study which investigated the impact of comorbidities on baseline clinical phenotype in patients with SEA and explored the effectiveness of mepolizumab treatment according to the presence of comorbidities. A detailed characterization of 309 patients enrolled in the Australian Mepolizumab Registry was completed before they started mepolizumab treatment. Patients were classified according to whether they had (or did not have) certain comorbidities, including nasal polyps (NP), aspirin-exacerbated airway disease (AERD), asthma-chronic obstructive pulmonary disease overlap (ACO), fungal sensitization, and obesity. Their biological and clinical response to mepolizumab treatment was assessed after 12 months. The authors also explored the possibility that treatment effect would be differentially affected by comorbidities.

The authors found that mepolizumab treatment was associated with comparable clinical improvements in the presence of comorbidity. Across comorbidity subgroups, patients experienced a reduction in the rate of asthma attacks requiring oral corticosteroid (OCS) use (range: 47%-77%) and reduction in maintenance OCS use (dose reduction: 4.2-13.3 mg/day). They had improved asthma symptom control (Asthma Control Questionnaire-5 score: 1.9-2.4 point improvement) and lung function (mean: 3.4-9.3 post-bronchodilator percent predicted FEV1). Peripheral blood eosinophil (PBE) levels were reduced (mean: 480-780 cells/mL) across groups. The authors also reported that certain comorbidities (NP, obesity, ACO and fungal sensitization) modified the baseline clinical phenotype in SEA. For example, patients with NP were significantly younger and had higher baseline PBE levels compared to patients without NP.  Patients with AERD had more obesity and anaphylaxis compared to those without AERD. Both NP and AERD groups appeared to have increased mepolizumab effectiveness. In summary, mepolizumab should be considered for patients with severe eosinophilic asthma in the presence of comorbidity, to effectively minimize disease impact and corticosteroid burden.  It is also important that comorbidities be assessed to identify potential for enhanced treatment effectiveness in the face of multiple biologic treatment options.

The Journal of Allergy and Clinical Immunology: In Practice is an official journal of the AAAAI, focusing on practical information for the practicing clinician.

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