As a physician specializing in allergy and immunology, one of the most satisfying things I do is help patients enjoy good control of asthma. What is it?
Good asthma control can allow people to live:
• Without daily symptoms.
• Without waking up at night coughing and wheezing.
• Without urgent care visits.
• Without missed work and school days.
Good control allows people to be as active as they want to be, so they can live life without limits.
What is asthma?
Asthma is a common lung disorder that arises due to increased inflammation in the airways. This inflammation leads to symptoms of coughing, wheezing, chest tightness and shortness of breath in response to a variety of triggers. These can include allergens, exercise, cold air, smoke, fumes, air pollution, heavy laughter or even emotional stress.
The severity of asthma ranges from mild to severe — or even deadly, with 4,000 Americans per year succumbing to it.
Two-thirds of people with asthma have allergic triggers. Consultation with an allergist is helpful to identify allergic triggers, such as pollens, molds, animal danders or dust mites. Asthma therapy includes allergen and trigger avoidance, medications (frequently inhalers) and sometimes allergy shots (allergen immunotherapy).
Some patients are prone to frequent flare-ups that can require acute care and, in many cases, a course of oral steroids (such as prednisone or Medrol packs).
Oral steroids sometimes are necessary for asthma care. However, frequent oral steroids can lead to numerous side effects so one of my goals is to help patients limit the amount or frequency of oral steroids.
Several new biologic therapies have been approved during the past several years that can help patients achieve better control. These new medications are called biologic because they contain antibodies produced from living organisms that inhibit or turn down certain parts of the human inflammatory immune response.
These are some of the biologic therapies that can help patients improve their asthma control and avoid or reduce oral steroid use:
• Xolair (omalizumab) was approved in 2003 for allergic asthma not well controlled by inhaled steroid medications. Xolair works by binding IgE antibodies, which are the antibodies that recognize allergens. Xolair is given by subcutaneous injection in the doctor’s office. For asthma, it is given either once every two or four weeks, based on the patient’s weight and IgE level. In 2014, Xolair was approved for chronic idiopathic urticaria (frequent hives where the cause is unknown).
• Nucala (mepolizumab) was approved in 2015 for uncontrolled eosinophilic asthma. Eosinophils are one of the types of white blood cells and have an important role in allergic airway inflammation. Some asthmatics have an eosinophilic “phenotype” in which eosinophils play a larger role in the disease process. Nucala binds with a cytokine called IL-5. Cytokines are substances used by the cells of the immune system to communicate with each other. IL-5 promotes the growth and activation of eosinophils. Nucala is given by subcutaneous injection once per month.
• Fasenra (benralizumab) was approved in 2017 for uncontrolled eosinophilic asthma. It is given by subcutaneous injection once per month for three months, then once every two months thereafter. Fasenra works by binding to the IL-5 receptor on eosinophils.
• Dupixent (dupilumab) was approved for certain types of uncontrolled asthma in 2018 and was approved for certain types of eczema in 2017. Dupixent works by binding to the IL-4 receptor and blocks the action of both IL-4 and IL-13, which are cytokines that are important in stimulating the allergic immune response. It is given by subcutaneous injection every two weeks.
• Cinqair (reslizumab) was approved for eosinophilic asthma in 2016. It is given by IV infusion once per month.
The number of biologic therapies has exploded in the past few years and there are others in clinical trials. The information presented about these medications is a brief summary, and these therapies will not be appropriate for all patients.