Asthma Monoclonal Antibody

Aka: Asthma Monoclonal Antibody, Asthma Biologic, Interleukin-5 Antagonist, IL-5 Antagonist, Benralizumab, Fasenra, Mepolizumab, Nucala, Reslizumab, Cinqair, Interleukin-4 Alpha Receptor Antagonist, Dupilumab, Dupixent

1. See Also
   1. Severe Persistent Asthma
   2. Omalizumab (Xolair)
2. 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
3. Adverse Effects
   1. Anaphylaxis risk with all agents (several of the agents have a reported 0.2% risk)
      1. Consider prescribing Epinephrine injector
4. Disadvantages
   1. $2500 to $4500 per month
5. Preparations: Interleukin-5 Antagonist (alpha-directed cytolytic Monoclonal Antibody, IgG1 Kappa)
   1. General
      1. May be used in age >=12 years old U.S. (>=18 years old Canada)
   2. Benralizumab (Fasenra)
      1. Dose 30 mg SQ every 4 weeks for 3 doses, then every 8 weeks
      2. Uncommon Headache, Pharyngitis
   3. Mepolizumab (Nucala)
      1. Dose 100 mg SQ q 4 weeks
      2. Common Headache, uncommon injection site irritation, back pain ,Fatigue
   4. References
      1. Ortega (2014) N Engl J Med 371(13): 1198-207 [PubMed]
6. 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 Pharyngitis
   3. References
      1. Nair (2017) N Engl J Med 376(25): 2448-58 [PubMed]
7. Preparations: Interleukin-4 Alpha Receptor Antagonist
   1. General
      1. May be used in age >= 6 years old
   2. Dupilumab (Dupixent)
      1. Adult Dose: 600 mg SQ once, then 300 mg SQ every 2 weeks
   3. 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]
8. 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
9. Management: Monitoring
   1. Re-evaluate every 3-6 months
   2. Taper off oral Corticosteroids and other add-on management
10. Resources
    1. Biologic Therapy in Asthma
       1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5405559/
11. References
    1. (2018) Biologics for Asthma, Presc Lett
    2. Narasimhan (2021) Am Fam Physician 103(5): 286-90 [PubMed]