Available biologics for treating asthma and allergic skin disease

For some patients with asthma or allergic skin disease, using a biologic may be the best available option. At the virtual 2021 American Academy of Pediatrics National Conference & Exhibition, Heather De Keyser, MD, MS, assistant professor of pediatric pulmonology at the Breathing Institute, University of Colorado School of Medicine and Children’s Hospital in Aurora, covered determine what children may benefit from a referral for biologics and the biologic treatments available for asthma, atopic dermatitis, and urticaria.

Asthma is most common chronic condition in children, impacting 1 out of 12 children. In children, it often follows a similar atopic pathway as urticaria and atopic dermatitis. Severe asthma, which features frequent exacerbations and chronic morbidity, is divided into 3 groups: untreated asthma (those who either have no available therapies or poor adherence), difficult to treat asthma (variable medication adherence), and treatment-resistant severe asthma, which may or may not be controlled with high dose medication. When considering whether to refer for biologics, a clinician should answer yes to all of the following questions:

• Does the child truly have asthma? Have asthma mimickers been eliminated?
• Is there a history of good adherence to medications?
• Can the child show good inhaler technique?
• Have modifiable risk factors been corrected?
• Does the child have severe or difficult to treat asthma, which is not controlled in spite of high dose inhaled corticostroid?

Biologics for asthma and allergic skin disease target certain markers such as immunoglobulin E (IgE), interleukin (IL)-5, and IL-4. It can be administered either in the home or at a clinician’s office, every 2 to 8 weeks.

Omalizumab is the oldest available biologic for asthma and is anti-IgE. It’s the most studied in children and has been efficacious in reducing exacerbations. It’s current pediatric indication is for children aged 6 and older who have moderate-severe persistent asthma that is inadequately controlled with inhaled steroids. Anaphylaxis is a known side effect and an epinephrine auto injector should be given to children in case of delayed reactions. It isn’t meant for acute asthma attacks and steroids should not be abruptly stopped. Mepolizumab, an anti-IL-5 biologic, has been shown to reduce exacerbations and eosinophils; decrease hospitalizations as well as steroid use; and resulted in improved markers of control. It’s indicated for add-on maintenance for severe asthma with an eosinophilic phenotype in children aged 6 years and older. It response best in patients with eosinophil levels (>150 cells/microliter). It shouldn’t be used acute attacks and helminthic infections should be treated before start of treatment. Benralizumab, an anti-IL-5 biologic, significantly reduced exacerbation risk and increased markers of lung function in patients with higher eosinophil levels (>300 cells/microliter). It’s indicated for add-on maintenance for severe asthma with an eosinophilic phenotype in children aged 12 years and older. It carries a risk of anaphylaxis, angioedema, and urticaria. It isn’t for use with acute attacks and helminthic infections should be treated before start of treatment. Dupilumab, an anti-IL-4 therapy, results in reductions in corticosteroid doses and severe exacerbations as well as improvements in lung function. It can be used for add-on maintenance for severe asthma with an eosinophilic phenotype in children aged 12 years and older. It carries a risk of eosinophilia and urticaria/hypersensitivity. Corticosteroids shouldn’t be abruptly halted when using dupilumab. It shouldn’t be used for acute exacerbations.

For urticaria, omalizumab is approved for the treatment of chronic idiopathic urticaria in children aged 12 years and older. The side effects are similar to those seen when using the therapy to treat asthma. In patients with atopic dermatitis, dupilumab is approved for use in children aged 6 years and older and led to improvements in quality of life markers and pruritus. Clinicians should monitor for worsening eye symptoms and keratitis. Other biologics are still being studied for both conditions.

For general pediatricians, De Keyser recommended:

• Evaluate current medication adherence in patients with poorly controlled asthma, atopic dermatitis, or urticaria.
• Refer the patient to a subspecialist to determine if a patient is candidate for biologics
• Be knowledgeable about the adverse effects of biologics
• Check adherence to biologics, if they are being administered at home

Pediatric subspecialists should:

• Confirm the diagnosis
• Evaluate for medication adherence
• Work with general pediatricians to identify patients are ideal candidates
• Keep an eye out for adverse events associated with the chosen biologic
• Track clinical improvement in symptoms following treatment initiation

Reference

1. De Keyser H. Biologics for asthma and allergic skin diseases. American Academy of Pediatrics 2021 National Conference & Exhibition; virtual. Accessed October 11, 2021.