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Asthma Monoclonal Antibody

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

  • 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
  • Adverse Effects
  1. Anaphylaxis risk with all agents (several of the agents have a reported 0.2% risk)
    1. Consider prescribing Epinephrine injector
  • Disadvantages
  1. $2500 to $4500 per month
  • 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]
  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]
  • 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]
  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
  • Management
  • Monitoring
  1. Re-evaluate every 3-6 months
  2. Taper off oral Corticosteroids and other add-on management
  • References