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Editorials: Point and Counterpoint |

Rebuttal From Dr O’Byrne FREE TO VIEW

Paul M. O'Byrne, MBBCh, FCCP
Author and Funding Information

FINANCIAL/NONFINANCIAL DISCLOSURES: The authors have reported to CHEST the following: P. M. O. has held grants-in aid from GSK for the investigation of mepolizumab and from Medimmune for the investigation of benralizumab. He also reports consulting fees from AstraZeneca, Chiesi, Boehringer Ingelheim, GSK, Medimmune, Merck, Takeda, and Abbott and grants-in-aid from AstraZeneca, Amgen, Genentech, Novartis Axican, and Alakos.

Firestone Institute of Respiratory Health and the Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada

CORRESPONDENCE TO: Paul M. O’Byrne, MBBCh, FCCP, Room 3W10, McMaster University Medical Center, 1280 Main St W, Hamilton, ON, L8S 4K1, Canada


Copyright 2016, American College of Chest Physicians. All Rights Reserved.


Chest. 2017;151(1):20-21. doi:10.1016/j.chest.2016.09.024
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Dr Barnes makes a number of cogent arguments as to why new anti-eosinophilic drugs, which are biologic agents, will not be widely used in the management of uncontrolled asthma. These include the fact that most uncontrolled asthma is caused by lack of adherence to effective therapies (particularly inhaled corticosteroids) and that some patients with severe refractory asthma do not have persistent airway eosinophilia. He is also correct that the use of anti-eosinophilic biologic agents must be restricted to those patients with evidence of persistent eosinophilic asthma who are not responding to high doses of conventional antiasthma treatment, many of whom require oral corticosteroids to manage their disease. However, identifying these patient phenotypes that may potentially respond to a very specific biological treatment, even if they represent a small proportion of the entire patient population with the disease, is the whole purpose of precision medicine.

Dr Barnes makes no argument about the efficacy of the anti-eosinophilic biologic agents, particularly those directed against IL-5, in patients with severe refractory eosinophilic asthma. The studies demonstrating a consistent reduction in severe asthma exacerbation risk in patients with severe refractory eosinophilic asthma, and to date an excellent safety profile, have convinced regulators in many countries to approve both mepolizumab and reslizumab for the treatment of severe refractory eosinophilic asthma.

Patients with severe refractory asthma, although representing a small percentage of the asthma population (about 50% of whom have persistent airway eosinophilia), are responsible for a large proportion of the overall costs of managing asthma., This is because of the high direct costs of managing severe asthma exacerbations, as well as the indirect costs of lost productivity at work or school. Although studies of the cost-effectiveness of using anti-eosinophilic biologic agents in these populations of patients have not yet been reported, the clinical benefits for patients with severe refractory eosinophilic asthma are very clear (eg, the ability to minimize or discontinue oral corticosteroids) for patients who have often required these medications for years, as well as markedly reducing severe asthma exacerbation risks.

Finally, although Dr Barnes is correct that the anti-eosinophilic biologic agents will provide clinical benefit to a small percentage of patients with asthma, there is a high prevalence of asthma (at least 10% of the population in many developed countries). Because of this, there is a large absolute number of patients with severe refractory eosinophilic asthma who have a heavy burden of costs associated with their disease; for these patients, anti-eosinophilic biologic agents are a real clinical advance and will prove useful in the management of their asthma.

References

Barnes P.J. . Counterpoint: Will new anti-eosinophilic drugs be useful in asthma management? No. Chest. 2017;151:17-20 [PubMed]journal
 
Wenzel S.E. .Schwartz L.B. .Langmack E.L. .et al Evidence that severe asthma can be divided pathologically into two inflammatory subtypes with distinct physiologic and clinical characteristics. Am J Respir Crit Care Med. 1999;160:1001-1008 [PubMed]journal. [CrossRef] [PubMed]
 
O'Neill S. .Sweeney J. .Patterson C.C. .et al The cost of treating severe refractory asthma in the UK: an economic analysis from the British Thoracic Society Difficult Asthma Registry. Thorax. 2015;70:376-378 [PubMed]journal. [CrossRef] [PubMed]
 
Sullivan S.D. .Rasouliyan L. .Russo P.A. .Kamath T. .Chipps B.E. .Group T.S. . Extent, patterns, and burden of uncontrolled disease in severe or difficult-to-treat asthma. Allergy. 2007;62:126-133 [PubMed]journal. [PubMed]
 
Pearce N. .Ait-Khaled N. .Beasley R. .et al Worldwide trends in the prevalence of asthma symptoms: phase III of the International Study of Asthma and Allergies in Childhood (ISAAC). Thorax. 2007;62:758-766 [PubMed]journal. [CrossRef] [PubMed]
 

Figures

Tables

References

Barnes P.J. . Counterpoint: Will new anti-eosinophilic drugs be useful in asthma management? No. Chest. 2017;151:17-20 [PubMed]journal
 
Wenzel S.E. .Schwartz L.B. .Langmack E.L. .et al Evidence that severe asthma can be divided pathologically into two inflammatory subtypes with distinct physiologic and clinical characteristics. Am J Respir Crit Care Med. 1999;160:1001-1008 [PubMed]journal. [CrossRef] [PubMed]
 
O'Neill S. .Sweeney J. .Patterson C.C. .et al The cost of treating severe refractory asthma in the UK: an economic analysis from the British Thoracic Society Difficult Asthma Registry. Thorax. 2015;70:376-378 [PubMed]journal. [CrossRef] [PubMed]
 
Sullivan S.D. .Rasouliyan L. .Russo P.A. .Kamath T. .Chipps B.E. .Group T.S. . Extent, patterns, and burden of uncontrolled disease in severe or difficult-to-treat asthma. Allergy. 2007;62:126-133 [PubMed]journal. [PubMed]
 
Pearce N. .Ait-Khaled N. .Beasley R. .et al Worldwide trends in the prevalence of asthma symptoms: phase III of the International Study of Asthma and Allergies in Childhood (ISAAC). Thorax. 2007;62:758-766 [PubMed]journal. [CrossRef] [PubMed]
 
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