With the advent of new biological medications for severe eosinophilic asthma, patients have improved significantly. Approximately 10% of individuals with asthma have severe disease, and this accounts for most asthma related morbidity and mortality. Previously the mainstay of treatment was inhaled steroids and beta agonists. In patients with severe asthma who have high eosinophils (greater than 150 cells or greater than 300 cells depending on the study), Nucala, Fasenra and Dupixent have all been shown to decrease exacerbation rates, improve lung function and improve quality of life among individuals.
There are no head to head studies comparing Nucala, Fasenra or Dupixent for severe eosinophilic asthma. But a recent study published in The Journal of Allergy and Clinical Immunology; November 2022 titled “Comparative efficacy of mepolizumab, benralizumab, and dupilumab in eosinophilic asthma: A Bayesian network meta-analysis”, the authors sought to compare these medications based on their safety and efficacy.
A total of 8 studies were included in this analysis for a total of 6461 patients.
All the biologics examined were associated with significant improvement of exacerbation rates compared to placebo, although the relative ranking of treatments varied according to eosinophil thresholds. The study authors noted minimal differences between the biologics, and all of them leading to a similar decrease in exacerbation rates. They also found that the differences in the safety and efficacy of nucala, fasenra and dupixent were relatively small. None of the biologics had a significant reduction in FEV1 (values on a Pulmonary Function Test), compared to each other.
All of them showed a greater response to therapy as the eosinophil count was higher. There was a greater effect in individuals with eosinophil counts >300 compared to the 150-299 range. They did find that Fasenra performed a bit better with the eosinophil count range of 150-299 cells compared to Dupixent and Nucala, but it was not statistically significant.
The ultimate choice of biologic for each patient would depend on multiple factors including costs, co-morbid conditions (i.e. nasal polyps, eczema) and timing of administration.
Other biologics not compared here are Cinqair which is dosed on weight and Tezspire, which does not require biomarker and is indicated for both eosinophilic and non-eosinophilic asthma.
In conclusion, the choice of biologics is diverse and you should speak to you doctor about which one would be right for you if you have uncontrolled severe eosinophilic asthma.
New Asthma Drug Nucala (Mepolizumab) for Severe Eosinophilic Asthma
Fasenra (Benralizumab) for Severe Asthma
Asthma biologic agents (Xolair, Cinqair, Nucala, Fasenra, Dupixent)
Cinqair (Reslizumab) for Eosinophil Disorders (formerly Cinquil)
Tezspire Tezepelumab for Severe Asthma