Biologics in severe asthma: the overlap endotype - opportunities and challenges

ABSTRACT

Introduction

Patients with severe asthma experience a significant burden of symptoms, disease exacerbations and medication side-effects. Severe asthma interferes with the patients’ quality of life and has high health-care costs. New targeted biologic therapies have improved the management of severe asthma by significantly reducing exacerbations and maintenance corticosteroid use, and also improving lung function and patient quality of life.

Areas covered

Not all severe asthmatics are eligible for such therapies. Those with allergic and eosinophilic asthma, usually referred to as ‘T2-high’ asthma benefit from anti-IgE and anti-IL-5/5 R antibodies respectively, whereas some asthmatics are eligible for both: ‘overlap’ endotype. In this review, we present briefly the monoclonal antibodies that have been approved in the management of severe asthma and we focus on the ‘overlap’ endotype.

Expert opinion

Since these therapies are costly, it is extremely important to choose the right treatment for the right patient especially in the ‘overlapping’ one. The decision is mainly based on the judgment of the clinician and is often driven by the most easily obtainable biomarker, thus the blood eosinophil count. Comorbidities, patient’s input and administration frequency may aid the decision of choosing one over another biologic.

KEYWORDS:

• Asthma
• severe asthma
• biologicals
• eosinophils
• IgE

Article highlights

• Biologics have changed the management of severe T2 high asthma

• The ‘overlap’ allergic and eosinophilic endotype – eligible for both anti-IgE and anti-IL5 therapy – is a common endotype of severe asthma

• No head-to-head studies exist to compare anti-IgE with anti-IL5s

• The decision is mainly based on the clinician s judgment

• Such decision is often driven by the most easily obtainable biomarker, thus blood eosinophil count

• Comorbidities may aid the decision of choosing one over another biologic

This box summarizes key points contained in the article.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial relationships or otherwise to disclose.

Additional information

Funding

This paper is not funded.