Asthma Monoclonal Antibody

Aka: Asthma Monoclonal Antibody, Asthma Biologic, Interleukin-5 Antagonist, IL-5 Antagonist, Interleukin-4 Alpha Receptor Antagonist

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II. Indications

  1. Third-line agents for refractory, Type 2 Asthma (Allergic Asthma or Eosinophilic Asthma, represents 50% of Asthma)
    1. Despite long acting Bronchodilator and Inhaled Corticosteroids
  2. One of the following findings present
    1. Blood Eosinophils >150/uL
    2. Sputum Eosinophils >2%
    3. Ferrous Nitrous Oxide >20 parts per billion
    4. Maintenance oral Corticosteroids required

III. Adverse Effects: General

  1. Injection site irritation
  2. Antibody development
  3. Anaphylaxis risk with all agents (several of the agents have a reported 0.2% risk)
    1. Consider prescribing Epinephrine injector

IV. Disadvantages

  1. $2500 to $4500 per month

V. Preparations: Interleukin-5 Antagonist (alpha-directed cytolytic Monoclonal Antibody, IgG1 Kappa)

  1. Benralizumab (Fasenra)
    1. Dose 30 mg SQ every 4 weeks for 3 doses, then every 8 weeks
    2. May be used in age >=12 years old U.S. (>=18 years old Canada)
    3. Uncommon
      1. Fever
      2. Headache
      3. Pharyngitis
  2. Mepolizumab (Nucala)
    1. Dose 100 mg SQ q 4 weeks
    2. May be used in age >=6 years old
    3. Common
      1. Headache
    4. Uncommon
      1. Angioedema
      2. Fever
      3. Back pain
      4. Fatigue
      5. Urinary Tract Infection
  3. References
    1. Ortega (2014) N Engl J Med 371(13): 1198-207 [PubMed]

VI. Preparations: Interleukin-5 Antagonist (Monoclonal Antibody, IgG4 Kappa)

  1. General
    1. May be used in age >=18 years old
  2. Reslizumab (Cinqair)
    1. Dose 3 mg/kg IV infusion over 20-50 min every 4 weeks
    2. Uncommon
      1. Pharyngitis
      2. Anaphylaxis
        1. Observe first dose by health care professional (as done with Omalizumab)
  3. References
    1. Nair (2017) N Engl J Med 376(25): 2448-58 [PubMed]

VII. Preparations: Interleukin-4/13 Alpha Receptor Antagonist

  1. General
    1. As of 2022, approved for use down to age 6 years for moderate to severe Eczema
    2. Costs $3400/month in 2022, U.S.
    3. Live Vaccines are best completed at least 4 weeks before starting agent
  2. Indications
    1. Moderate to severe refractory, persistent Asthma
      1. High Eosinophil Counts or on chronic Systemic Corticosteroids
    2. Other Indications
      1. Eosinophilic Esophagitis
      2. Severe Atopic Eczema
      3. Chronic Sinusitis with Nasal Polyps
  3. Adverse Effects
    1. Eye (Conjunctivitis, Dry Eyes)
    2. Alopecia
    3. Arthralgias
    4. Rash
    5. Gastritis
    6. Insomnia
    7. Secondary infection (Oral HSV, Helminths)
  4. Dupilumab (Dupixent)
    1. Adult Dose: 600 mg SQ once, then 300 mg SQ every 2 weeks
  5. References
    1. Castro (2018) N Engl J Med 378(26):2486-96 [PubMed]
    2. Rabe (2018) N Engl J Med 378(26): 2475-85 [PubMed]
    3. (2022) Presc Lett 29(7): 40-1

VIII. Preparations: Anti-IgE Antibody

  1. General
    1. May be used in age >=6 years old (if positive skin test or RAST to perennial allergen)
  2. Omalizumab (Xolair)
    1. Dose 75 to 375 mg SQ every 2-4 weeks (variable dose based on age, weight, serum IgE)
    2. Uncommon Arthralgias

IX. Management: Monitoring

  1. Re-evaluate every 3-6 months
  2. Taper off oral Corticosteroids and other add-on management

X. Resources

  1. Biologic Therapy in Asthma
    1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5405559/

XI. References

  1. (2018) Biologics for Asthma, Presc Lett
  2. Narasimhan (2021) Am Fam Physician 103(5): 286-90 [PubMed]
  3. Raymond (2023) Am Fam Physician 107(4): 358-68 [PubMed]

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