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Severe Asthma: A 5-question POP Quiz
C. Andrew Schroeder, MD
Severe asthma affects 5% to 10% of adults with asthma. Find out what you know about diagnosis and treatment options for these patients with 5 no-nonsense questions.
Severe asthma affects about 5% to 10% of adults who have asthma but is estimated to account for approximately 50% of the annual healthcare costs associated with the disease. Find out what you know about the severe asthma patient profile, inflammatory pathways, biologic agents used to treat severe asthma, and a few other important aspects of the disease in this short quiz.
Answer: C. The 21-year-old patient. Patient C is experiencing uncontrolled asthma symptoms despite using a high-dose ICS/LABA combination as directed.
Severe asthma is defined as asthma that requires treatment with high-dose ICS plus a second controller but remains “uncontrolled” despite this therapy.
Patient A has undertreated asthma since she is only taking a short acting bronchodilator and an oral leukotriene inhibitor.
Patient B likely does not have asthma but needs a workup for congestive heart failure. The clue is the frothy sputum and peripheral edema.1
Answer: C. Use of novel therapies that target specific pathways in asthma. Biologic therapy for asthma is based on blocking specific downstream pathways.
Answer A refers to avoiding asthma triggers by managing one’s surroundings, which is a fundamental concept in the holistic approach to asthma but is not referred to as biologic.
Answer B mentions exercise, which is also part of a comprehensive asthma treatment plan, however, this is
not biologic therapy.
Answer: B. IL6 is NOT a target in severe asthma. IL6 antagonism is used in the treatment of rheumatoid arthritis.
All of the other pathways are fundamental in the treatment of severe asthma.
Omalizumab binds to IgE thus inhibiting activation of mast cells and basophils.
Benralizumab, mepolizumab, and reslizumab antagonize IL5; dupilumab antagonizes IL4 and IL13.
4. Which of the above 3 are the most common biomarkers used when considering which biologic medication to use in severe asthma?
Answer: A. IgE, Eos, FeNO. IgE, Eos count, and FeNO are the 3 key biomarkers to help guide clinicians in the selection of a biologic agent for the treatment of severe asthma.
Fibrinogen is used as a weak biomarker for COPD progression.
Mast cell degranulation assays are not commonly used in clinical practice.
Serum periostin measurement as a biomarker for IL13 antagonists failed to meet investigational outcome goals and is no longer considered for use as an asthma biomarker.2
5. The primary outcome in studies in severe asthma and the use of biologic therapies is which one of the above?
Answer: A. Decreased exacerbations. Decreased exacerbations was the primary outcome of Phase III clinical trials for omalizumab, all IL5 antagonists, and dupilumab, the IL4 and IL13 dual antagonist.
Dupilumab also showed improvement in lung function.
No clinical trial studying biologic asthma treatment measured a significant decrease in mortality.
Exercise performance was not routinely measured in clinical trials for biologic agents.
IgE level and Eos counts were not primary endpoints.3