Approximately 10% of adults and 2.5% of children suffer from severe asthma. For those people, one potential treatment option is biologic therapy.
People with severe asthma tend to:
- Have a lower quality of life.
- Experience frequent exacerbations requiring oral or intravenous steroids in addition to their typical medications.
- Need hospitalizations.
- Have a higher risk of death.
If typical treatments like inhalers are not helping to control severe asthma, biologic therapy is an option. Biologic therapy uses injectable medicines that target specific inflammation pathways in the body that cause asthma symptoms.
“In these patient populations with severe asthma, we can classify these patients into different phenotypes and then determine if a patient might benefit from a specific biologic,” says Akshay Avula, MD, pulmonary and critical care medicine specialist, UPMC in Central Pa.
Learn more about biologic therapy and how it can benefit people with severe asthma.
What Is Biologic Therapy for Asthma?
Biologic therapy uses medications made from a living organism. These medications target specific proteins or genes in your body that can cause or exacerbate disease. For asthma, biologic therapy targets specific pathways that cause inflammation, which can lead to symptoms.
When it comes to asthma, there are two types of inflammation:
- Type 2-low inflammation asthma.
- Type 2-high inflammation asthma.
Patients with Type 2-high inflammation may have too many eosinophils — a type of white blood cell that can cause airway inflammation. Eosinophils suggest an allergic component to your asthma. High levels of eosinophils can raise your risk of severe asthma.
People with Type-2 low inflammation don’t have the high levels of eosinophils and don’t have an allergic component. They may have a type of severe asthma called neutrophilic asthma. High levels of neutrophils, another type of white blood cell, can cause neutrophilic asthma.
Biologics bind to different antibodies, molecules, or receptors to prevent the inflammation that can cause symptoms of severe asthma.
“They can reduce the frequency of severity of asthma attacks, improve lung function, and reduce need of oral corticosteroids and hospitalizations, while improving quality of life,” Dr. Avula says.
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Who Is a Candidate for Biologic Therapy for Asthma?
Patients with severe asthma who have not responded to traditional therapies like inhalers are candidates for biologic therapy.
“Patients who are requiring multiple hospitalizations, requiring multiple doses of steroids, and have uncontrolled symptoms, are the patients who will benefit from these kinds of biological agents,” Dr. Avula says.
Biologic therapy candidates often get referrals to pulmonologists from their primary care doctors. Before biologic therapy can begin, patients go through testing to determine that the root of their problems is actually asthma or if it’s another cause.
Once that’s done, doctors perform several allergy tests to determine if a patient’s asthma has an allergic component. Dr. Avula says they typically use blood tests such as a:
- Complete blood count (CBC).
- Radioallergosorbent test (RAST).
- Immunoglobulin (IgE) level check.
“We classify patients depending upon workup and determine if a patient would benefit from a biological agent or not,” Dr. Avula says.
Types of Biologic Medicines for Asthma
There are six approved biologics for asthma, and more are in the works.
The biologics target different pathways that cause severe asthma. Which biologic you receive depends on the specific causes of your asthma, along with any other underlying conditions you have.
Depending on which biologic you receive, you will receive the treatment anywhere from every two weeks to every eight weeks.
If you are getting one of the subcutaneous medicines, your first two or three treatments may take place in your doctor’s office. Afterward, you can self-inject the medicine at home.
After about six months, doctors will reassess you to see how well the biologic is working.
“If the patient is benefiting from the biologics, then we try to reduce the rest of the inhalers, and if they are chronically on steroids, we taper off the steroids,” Dr. Avula says. “We lower the rest of the medications that are needed to control their asthma, and we continue the biologic medications indefinitely most of the time unless they develop some kind of side effects.”
Benefits of Biologic Therapy for Asthma
Biologics can improve the quality of life for people with severe asthma. A January 2022 study published in the New England Journal of Medicine reported biologics are effective in controlling asthma and reducing exacerbations for people with Type 2-high severe asthma. The study also reported tezepelumab — another biologic — showed effectiveness in a wider patient population, including people with Type 2-low severe asthma.
“The most important benefit is reducing the dose of any oral steroids, which have higher complication risks,” Dr. Avula says. “It reduces hospitalizations with asthma and reduces the exacerbations of asthma. It improves their overall lung function and reduces the risk of death as well.”
More studies of biologics are ongoing.
Risks of Biologic Therapy for Asthma
The risk of severe bad reactions to biologic therapy is low, in general. The biggest risks are allergic reactions, including anaphylaxis, and hypersensitivity reactions. Two approved biologics, omalizumab and reslizumab, carry black box warnings from the U.S. Food and Drug Administration (FDA) because of the risk of anaphylaxis.
To prevent severe risks, your doctor may observe you for up to 30 minutes after your first couple of treatments to monitor for adverse reactions.
Certain parasitic infections also can cause adverse reactions. Doctors will check you for those infections during your initial workup.
Biologics also can cause more minor side effects, including:
- Injection site reaction.
- Joint pain.
- Back pain.
- Sore throat.
Should I Get Biologic Therapy for Severe Asthma?
The decision to go on biologics is not an easy one. It can be an indefinite treatment. It also can be more expensive than other typical treatments, although patient assistance programs are available.
But the benefits of biologic therapy can be significant for people with severe asthma. They can lower the amount of exacerbations your condition causes and reduce your need for steroids. They also can lower your risk of hospitalization and death.
Dr. Avula says if you have severe asthma and want to know about biologics, it’s best to talk about the treatment with a pulmonologist.
“I would say if they’re seeing their primary care doctor for severe asthma, they should talk to them to be referred to a pulmonologist so that they can discuss biologics,” he says.
“We have a group in our practice that is dedicated to patients that need biologics. Prescribing a biologic is the easy part. But then, getting it approved and getting it from the pharmacy is a hurdle many times that many practices face. We have a well-run setup where the process is very phased, it’s well sorted-out, and the outcomes are good.”
At UPMC, our pulmonary experts can help treat a wide range of respiratory conditions, from acute to chronic and from common to complex. To find care near you, visit our website.
American Academy of Allergy, Asthma, and Immunology, Biologics for the Management of Severe Asthma. Link
Guy G. Brusselle, MD, PhD, and Gerard H. Koppelman, MD, PhD, New England Journal of Medicine, Biologic Therapies for Severe Asthma. Link
Gary Fitzgerald, Allergy and Asthma Network, When Asthma Is Not Just Asthma: Type 2 Inflammation. LinkMary Clare McGregor, James G. Krings, Parameswaran Nair, and Mario Castro, American Journal of Respiratory and Critical Care Medicine, Role of Biologics in Asthma. Link
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