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

  1. 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. 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]

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 Pharyngitis
  3. References
    1. Nair (2017) N Engl J Med 376(25): 2448-58 [PubMed]

VII. 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]

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

XI. References

Images: Related links to external sites (from Bing)

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Ontology: mepolizumab (C0969324)

Concepts Pharmacologic Substance (T121) , Amino Acid, Peptide, or Protein (T116) , Immunologic Factor (T129)
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English mepolizumab

Ontology: reslizumab (C1869620)

Concepts Immunologic Factor (T129)
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Ontology: benralizumab (C2982078)

Definition (NCI) An afucosylated, humanized monoclonal antibody against the alpha chain of the interleukin-5 receptor (IL-5Ra), with potential anti-asthmatic activity. Upon administration, benralizumab binds to IL-5Ra and elicits an antibody-directed cell cytotoxicity (ADCC) against IL-5Ra-expressing cells. This induces apoptosis in IL-5Ra-expressing cells and may reduce asthmatic episodes. IL-5Ra, expressed on both eosinophils and basophils, plays a key role in asthma.
Concepts Immunologic Factor (T129) , Pharmacologic Substance (T121)
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English BIW-8405, Anti-CD125 Humanized Monoclonal Antibody, IgG1-kappa, KHK-4563, Benralizumab, MEDI-563, benralizumab, BENRALIZUMAB