2019 Nahid Sherbini

1. ASTHMA: A STEP TOWARD
PERSONALIZED TREATMENT AND NEW
THERAPIES
Dr Nahid Sherbini
Consultant Pulmonologist

2. Objectives
Explain how phenotypic, endotypic, and genetic characteristics account into
personalized management of asthma
Characterization of Inflammatory Pathways
and Biomarkers
Compare biologic agents currently available or emerging in the treatment of
severe asthma

3. Introduction
Asthma is generally accepted as
heterogeneous disease

4. Heterogeneity in Asthma— Not a New
Concept
Spector SL, Farr RS. J Allergy Clin Immunol. 1976 May;57(5):499-511.
.

5. Clinical Differentiation of Asthma Into Subgroups
Back to Asthma Basics
◦Definition
◦ Airway hyperresponsiveness
◦ Airflow limitation, which is
spontaneously variable or reversible
with bronchodilators
◦Diagnosis
◦ Based on a combination of clinical
symptoms and physiologic
abnormalities

6. Basis for Disease is Present Early and
Evolves Throughout Life
Genetics
Proteins, biochemical pathways, cells
Physiology, symptoms


, environment

7. What is personalised medicine?
◦ an approach to treating and preventing disease by taking into consideration the
individual variability in genes, environment and lifestyle for each subject.
“the right patient with the right drug at the right time”

8. Genetic profiling
◦ – to provide “the right treatment to the right patient at the
right time” – is dependent on genetic variation and gene–
environmental interactions, which need to be understood
for each individual patient.

9. “precision medicine”
◦ Precision medicine,
◦ Stratified medicine
◦ Or targeted medicine.
◦ These will ultimately lead to the development of targeted therapeutics.
The concept of P4 medicine (predictive, preventive personalised and participatory)
developed by Leroy Hood

13. Fitting the Individual Into a Larger Group
What is a phenotype?
The outward manifestation of a disease state related to both genetics and environmental influences
What is an endotype?
A phenotype of a disease state that has been well-characterized with regard to pathophysiologic
mechanisms

14. Rational of Classifying Asthma Phenotypes
Asthma is characterized by variety of
◦ Clinical features
◦ Disease onset
◦ Atopic history
◦ Disease progression
◦ Pathophysiologic Pathways
◦ Airway inflammation
◦ Molecular pathways
◦ Response to treatment

15. Asthma is Not a Clinically
Homogeneous Condition
◦Multiple areas of difference:
◦ Clinical presentations
◦ Physiological characteristics
◦ Responses to therapy
◦Time of asthma development is a key factor:
◦ Children—relatively homogeneous with a strong personal
and family allergic history of atopy
◦ Adults—very mixed group of patients

16. Separation of Asthma Into Clinical Phenotypes
◦Cluster analysis -------------more specification
◦ Clinical characteristics (gender, age of onset, severity)
◦ Physiology (lung function, airway hyperresponsiveness)
◦ Triggers (allergens, tobacco, occupation)
◦ Sputum inflammatory cells (eosinophils, neutrophils)

17. Severe Asthma Phenotypes
OCS=oral corticosteroids; SARP=severe asthma research program; U-BIOPRED=unbiased biomarkers in prediction of respiratory disease outcomes.
1. Chung KF et al. J Intern Med. 2016;249:192-204. 2. Moore WC et al. Am J Resp Crit Care Med. 2010;181:315-323.
Cluster analysis of clinical, physiological and inflammatory features 1,2
SARP1,2
Adult onset
nonatopic
asthma
Hyper-
eosinophilic
adult onset
asthma
Childhood
onset allergic
asthma
Adult onset
atopic
asthma
Severe Asthma Research Program

18. Phenotypes/Endotypes of Severe Asthma
Phenotype Clinical/Physiologic Characteristics
Early-onset allergic History of food allergy, atopic dermatitis and
allergic rhinitis
Late-onset
minimally atopic
eosinophilic
Chronic rhinosinusitis/nasal polyps
Severe airway obstruction
Subset = AERD
Late-onset
non-eosinophilic
Poorly characterized
May have significant LRT infection and/or GERD
AERD, Aspirin-exacerbated respiratory disease; eNO, exhaled nitric oxide; IgE, Immunoglobulin E; LRT, lower respiratory tract
Wenzel SE. Nat Med. 2012;18:716-725.
Trejo Bittar HE, et al. Ann Rev Pathol Mech Dis. 2015.10:511-545.
Corren J. Discov Med. 2013;15:243-249.

19. Phenotypic Clusters in Adults With Asthma
Show Significant Differences
Cluster Age/Obesity Allergy Severity
1 Early Yes Mild
2 Early Yes Moderate
3 Late, obese No Severe
4 Early Yes Severe
5 Late No Severe
Moore WC, et al. J Allergy Clin Immunol. 2010; 181:315–23.

20. Other Features Considered in Severe
Asthma Phenotypes
◦ Glucocorticoid resistance
◦ Adult onset nonatopic asthma
◦ Frequent exacerbation (30%)
◦ 2-3 exacerbations per year
◦ Greater obstructive defect
◦ Eosinophilic inflammation
◦ More comorbidities
Severe Asthma Research Program
A National Institutes of Health/ National Heart, Lung & Blood Institute sponsored network

21. Characterization of
Inflammatory Pathways and
Biomarkers

22. Type 2 inflammation

24. Characterization of Inflammatory Pathways
and Biomarkers
Type 2 (T2)—50% to 70% Non-type 2—30% to 50%
Main cytokines = IL-4, IL-5, IL-13 Cytokines and cells not well-characterized;
may involve IL-8 IL-23 IL-17, GM-CSF ,
TNF
Cell sources = Th2 cells, IL-C2 cells, mast
cells
Frequently related to bronchial infection
Variable airway, tissue and blood
eosinophilia and eNO; leukotrienes in AERD
No increase in eosinophils, eNO; may have
increase in sputum PMNs
Large portion have elevated total IgE and
specific IgE
Typically do not have elevated IgE or
relevant specific IgE
eNO, exhaled nitric oxide; GM-CSF, Granulocyte-macrophage colony-stimulating factor; IgE, Immunoglobulin E; PMN,
polymorphonuclear; Th2, T helper 2

25. Biomarkers for personalised asthma:
current and future biomarkers
◦ Biomarkers are important in asthma in order to define the phenotypes that
constitute the whole range of asthma and to identify patients who will respond to
specific therapies.
◦ A biomarker is defined as a characteristic that can be measured and evaluated as an
indicator of normal or pathological biological processes or the biological response to
a therapeutic intervention.

26. What Makes an Ideal Biomarker?
◦ Reproducible
◦ Accurate
◦ Accessible
◦ Correlates with severity of disease at baseline and reflects responsiveness to therapy
◦ Reasonable cost
◦ Noninvasive

27. Utilization of Inflammatory Markers
◦ Inflammatory markers have been shown to play an important
role in predicting severity and responsiveness to therapies
◦ Inflammatory profile may be characterized by:
◦ Genotyping
◦ Cytokines
◦ Cell populations (in airway, tissue and blood)
◦ Exhaled gases (nitric oxide)
◦ Serum proteins (periostin, DPP4)
DPP4, dipeptidyl peptidase-4

28. Eosinophil as an Inflammatory Biomarker
◦Variable numbers of blood and airway eosinophils are
present in patients with type 2 cytokine profiles
◦ Likely relates to level of type 2 activation
◦Eosinophils in blood and airway are correlated with:
◦ Frequency of asthma exacerbations
◦ Degree of airflow limitation
◦ Presence and severity of chronic rhinosinusitis/nasal polyposis
Peters SP, et al. J Allergy Clin Immunol. 2014;2(6):650-2.

29. Sputum and Blood Eosinophils Correlate With
Bronchial Type-2 Cytokine mRNA
Parameter Threshold
Value
Sensitivity Specificity
Sputum
eosinophils
2% 54% 100%
0.8% 84% 100%
Blood eosinophils 230 cells/mcl 76% 100%
Peters SP, et al. J Allergy Clin Immunol. 2014;2(6):650-2.

30. Blood Eosinophil Counts Correlate With
Risk of Asthma Exacerbations
Eosinophil Stratum Severe Exacerbations Relative Risk
201–300 cells per µL (n=25,882) .8
301–400 cells per µL (n=15,030) 1.1
401–500 cells per µL (n=8659) 1.2
501–600 cells per µL (n=4928) 1.4
601–700 cells per µL (n=2726) 1.6
701–800 cells per µL (n=1631) 1.5
801–900 cells per µL (n=947) 1.6
901–1000 cells per µL (n=1019) 2.1
>1000 cells per µL (n=1019) 2.4
Adapted from Price DB, et al. Lancet Respir Med. 2015;3:849-858.

31. Sputum Eosinophils Identify Patients With
Frequent Asthma Exacerbations
Parameter Non-frequent
exacerbators
Frequent
exacerbators
ICS dose (mcg/day) 800 1700*
OCS dose (mg/day) 1.7 6.7*
ACQ 1.4 2.3*
Sputum eosinophils (%) 8.2 25.7*
*P<0.05
Kupczyk M. et al. Clin Exp Allergy. 2014;44(2):212-21.
ACQ, asthma control questionnaire; ICS, inhaled corticosteroid; OCS, oral corticosteroid

32. Blood Eosinophils Predicted Response to
IL-5 Inhibition
0
0.05
0.1
0.15
0.2
0.25
0.3
<100 >100 <200 >200 <300 >300 <400 >400
Baseline eosinophils count strata (cells/µL)
Adapted from Corren J, et al. Chest. 2016;150(4):799-810.
Placebo n=16 n=65 n=37 n=44 n=54 n=27 n=68 n=13
Reslizumab n=62 n=282 n=158 n=186 n=239 n=105 n=275 n=69
P value .6537 .1202 .5122 .2401 .2579 .2818 .5422 .0436
TreatmentdifferencevsplaceboinFEV1(L)

33. Sputum Neutrophil as an Inflammatory Biomarker
◦ Sputum neutrophilia (>60% of total WBC) present in subgroup of asthmatics
◦ Most often in combination with eosinophils but may occur as isolated neutrophilia
◦ Factors that influence PMN count in sputum:
◦ Use of inhaled corticosteroids
◦ Air pollution
◦ LRTI
◦ Sensitization to fungi
◦ GERD
◦ Found to correlate with higher levels of asthma severity

34. Exhaled NO as a Marker of Type 2 Pathway
◦ eNO is produced by NO synthase in respiratory epithelium under direct control of IL-13 and possibly
other factors
◦ Often, but not always, correlated with sputum/blood eosinophil
numbers
◦ Is a moderately reproducible marker of Th2 phenotype
◦ Type 2 biomarkers predictive of responsiveness to ICS
◦ NO >33 ppb  positive response to ICS
◦ NO <22 ppb  successful discontinuation of ICS
ICS, inhaled corticosteroid; eNO, exhaled nitric oxide; ppb, parts per billion

35. Serum Proteins
◦ Cytokine protein measurements in blood and sputum are
difficult
◦ Airway IL-13 found to correlate with epithelial proteins—
periostin and dipeptidyl peptidase-4 (DPP4):
◦ Secreted by airway epithelium into blood
◦ Initial studies showed good correlation with IL-13 and predictive of
response to anti-IL-13 agents
◦ Uncertain whether these tests will be employed as biomarkers
in the future

36. Novel Treatment Options
Review the latest biologic-based targeted therapies.
Differentiate between biologic agents, focusing on
mechanism of action, as well as the latest safety and efficacy
data of targeted therapy.

37. Pathogenic Mechanism
◦ Study of pathophysiology of asthma, especially type 2 and eosinophilic inflammation led to latest
targeted interventions
◦ Targeted therapies shown to reduce number of exacerbations
◦ 4 approved, type-2 targeted-biologic therapies that target IL-5 and IgE and one that is in
development IL-4/-13
Bagnasco D, et al. Front Med. 2017;4:135; Farne HA, et al. Cochrane Database Syst Rev. 2017;9:CD010834.

38. Allergens
Goblet cells
Pollutants, microbes, glycolipids
Macrophages
NKT cells
Mast cells
FcεRI
lgE
B cells Smooth muscle cells
Eosinophils
Naive T cell
Airway
epithelium
Dendritic
cells
CD25 Lipoxin A4
ALX/FPR2
PGD2
CRTH2
lL-6
lL-2
MHCII
TCR
ILC2
GATA3
RORα
TH2
GATA3
ST2
TSLPR
IL-17RB
IL-33
IL-25
TSLP
IL-33
IL-33
IL-25
TSLP
Anti-IgE
Anti–IL-13
Anti–IL-4
Anti–IL-5
Anti–IL-5Rα
Asthma Phenotype Target Therapy
Emerging therapies target multiple pathways in severe asthma1
ALX/FPR2=formyl peptide receptor 2; CD25=chronotropic dose 25; CRTH2=prostaglandin D2 receptor 2; FcεRI=high-affinity IgE receptor; GATA3=GATA binding protein 3; IgE=immunoglobulin E; IL=interleukin;
ILC=innate lymphoid cell; MCHII=major histocompatibility complex class II; NKT=natural killer T cell; PGD2=prostaglandin D2; RORα=retinoid-related orphan receptor α; ST2=suppression of tumorigenicity 2; TCR=T
cell receptor; TH2=T-helper type 2 cell; TSLP=thymic stromal lymphopoietin; TSLPR=TSLP receptor.
Image from Brusselle GG et al. Nat Med. 2013;19:978. Pavord ID et al. Immunol Allergy Clin North Am. 2016;36:609-623.

39. Targeted Pathways for Biologic Therapies
Targeted Pathways Type 2
IgE Inhaled allergens stimulate production of IgE by B lymphocytes and bind to mast cells 
degranulation
IL-5
Pro-eosinophilic cytokine; cytokine that regulates proliferation, maturation, migration, and
effector functions of eosinophils
IL-4
IL-13
Cytokine found in increased levels in airways and sputum of asthma patients and involved
in eosinophil trafficking and B cell production of IgE
Cytokine associated with eosinophil trafficking and production of eNO from epithelial cells
TSLP
Novel target; epithelial-cell-derived cytokine; drives allergic inflammatory responses by
activating dendritic cells and mast cells
Non Type 2 Inflammatory Pathways
IL-17 Cytokine produced by Th17 cells; plays important role in the immunologic responses seen
in asthma
CXCR2 Potent chemo-attractant for neutrophils; under investigation in asthma and COPD
CSCR2, Chemokine receptor 2; IgE, Immunoglobulin E; Th2, T helper 2 cells; TSLP, Thymic stromal lymphopoietin
Wechsler ME. Respir Care. 2018;63:699-707.

40. Approved Biologics and Targets
Target
Antigen
Agent
(FDA
Approved)
Mode of
Delivery Safety and Adverse Events Clinical Data Trial Results
IL-5Ra Benralizumab
(Nov 2017)
Injectable Safe and well tolerated.
Most common AEs: nasopharyngitis;
asthma worsening (CALIMA: 14% Q4W
group, 11% Q8W, 15% placebo arm)
(SIORCCO: 13% vs 19% of placebo-
treated)
Approved for use in
eosinophilic asthma. For
patients with blood
eosinophil count of at
least 300/mL.
CALIMA trial (n=1306): Q4W & Q8W
regimens decreased exacerbations by
36% and 28%, respectively; lowered blood
counts1
SIROCCO trial (n=1,205): 48 weeks 1 of 3
add-on SQ; exacerbations reduced 45% &
51% in Q4W and Q8W; Exacerbations
decreased 17%–30% in patients with
>300 blood eosinophils/μL2
IL-5 Reslizumab
(April 2017)
Intravenous
(3 mg/kg)
monthly
Safe and well tolerated in patients
exposed
>2 yr 3
Infusion-site reactions uncommon (<2%).
Most common AEs: nasopharyngitis,URTI ,
sinusitis, influenza, and headache. 2 in
reslizumab grp anaphylactic reactions.
Approved for
maintenance treatment
w/severe exacerbations,
despite on current
asthma medications.
For patients with blood
eosinophil count of at
least 400/mL.
BREATH program: 4 studies (n=1656),
serum eosinophil counts reduced (mean
diff vs placebo: −476.83, 95% CI −499.32
to −454.34)3
Reduced number of eosinophils in the
blood and lungs; decreased blood
eosinophils.3
Asthma Control Questionnaire 5 (ACQ5); LABA, long-acting β-agonists; LD, loading dose; mL, microliter; SQ, subcutaneous; QoL, quality of life
1. Fitzgerald JM, et al; Lancet. 2016;388:2128–2141. 2.Bleecker ER, et al. Lancet. 2016;388:2115–2127. 3. Cazzola M, et al. Expert Opin Drug Saf. 2018;17:429-435.

41. Approved Biologics and Targets (continued)
Target
Antigen
Agent
(FDA
approved)
Mode of
Delivery Safety and Adverse Events Clinical Data Trial Results
IL-5
Mepolizumab
(Nov 2015)
Injectable Safe and well tolerated
Most common AEs and SAEs:
injection-site reactions (12%),
infections (7%), systemic reactions
(3%), serious cardiac, vascular,
thromb events (3%); malignancies
(2%), serious ischemic events (<1%)
First long-term safety data
reported for IL-5; Approved for
patients with blood eosinophil
count of at least 150/mL.
COLUMBA trial (n=347): Pts treated w/100 mg SQ every 3-4
wks for 3.5–4.5 yrs; 61% decrease in exacerbation rate, 78%
reduction in blood eosinophils by wk 4, sustained; 1/3
experienced no exacerbations; ACQ5 improved.1
Dream study: reduced exacerbations by 40-60%; 50%
reduction in CS. Blood eosinophil counts decline by 75%
within a month, failure to achieve decrease raises questions
about biologic efficacy in patient; FeNO minimally
reduced.2,3
anti-IgE
Ab
Omalizumab
(2003)
Injectable AEs (80.4% vs 79.5%) and SAEs (9.3%
vs 10.5%) were similar in the
omalizumab and placebo groups,
respectively.
Note concerns about anaphylaxis
and cardiovascular risk and lack of
efficacy in some patients
Approved for patients with
total serum IgE level >30 IU/
mL; for moderate-to-severe
persistent allergic asthma
whose asthma symptoms are
not controlled by ICS.
MoA: Binds to free IgE;
prevents IgE from binding to
high-affinity receptors
Hanania et al. (n=850): 48 wks decreased exacerbations
25%; improved asthma QoL scores. Overall trial history:
reduced asthma exacerbations, serum-free IgE, ICS dose;
QOL improved.4
Anti-IL-4/
-13
Dupilumab
(FDA approved
for asthma
indication
October 19,
2018.)
Injectable Safe and well tolerated.
AEs similar across groups: injection-
site reactions (17% vs 8% placebo,
respectively), back pain (4%, both
groups), eosinophilia (4%
vs 1%, respectively).
Approved for patients with
asthma previously treated with
medium-dose or high-dose ICS
and LABAs.
Consider for patients with
allergies , elevated IgE,
eosinophilia, or high eNO
levels.
Quest trial (n=1902); 4 grps 200 mg (400 mg LD) and 300 mg
(600 mg LD) every other week; 60–80% reduction in
exacerbations; Reduced FeNO and IgE levels;. Improved lung
function and reduced dependence on OCS.5,6
1. Ortega H, et al. Presented at ATS 2018. Abstract A1367; 2. Bel EH, et al. N Engl J Med. 2014;371:1189-97; 3. Pavord ID, et al. Lancet. 2012; 380:651-9; 4.Hanania
NA, et al. Ann Intern Med. 2011;154:573-82; 5. Castro M, et al. N Engl J Med. 2018;378:2486-2496; 6. Wenzel S, et al. Lancet. 2016;388:31-44.

42. Farne et al Cochrane Review
◦ 13 studies reviewed Cochrane database; n=6000
◦ Compared agents targeting anti-IL-5 or anti-IL-5Rα (i.e., mepolizumab,
reslizumab, and benralizumab) against placebo
◦ Showed all IL-5 therapies reduced rates of clinically significant asthma exacerbation by ~50% in group with
severe eosinophilic asthma
◦ Supports use of anti-IL-5 treatments as an adjunct to standard of care in people with severe eosinophilic
asthma and poor control
◦ Noted limited evidence for improved HRQoL scores and lung function
Farne HA, et al. Cochrane Database Syst Rev. 2017;9:CD010834.

43. A Real Stepwise-Approach for
Personalised Management

44. Stepwise-Approach:
◦ When confirming diagnosis of severe asthma, critical to:
◦ Assess Adequate Use of ICS
◦ Assess inhaler technique and adherence
◦ Issues with ICS account for 50% to 80% of uncontrolled asthma
◦ Assess coexisting conditions, risk factors, and triggers
◦ Review FeNO after ICS therapy
Israel E, et al. N Engl J Med. 2017;377:965-976.

45. ICS Add-On Therapy
◦Corticosteroids
Avoid daily Oral Steriods / systemic toxicity
◦Consider nonbiologic add-ons: LABA, macrolide, leukotriene
modifier
◦Assess for targeted treatment with biologic agents

46. Additional Nonbiologic Treatment Options
◦Active against atypical bacteria and have anti-inflammatory
activity
◦ Macrolide antibiotics, add-on therapy: azithromycin (oral)
◦ Ketolide antibiotic: telithromycin
Gibson PG, et al. Lancet. 2017;390(10095):659-668.

47. AMAZES Study
Effect of azithromycin on asthma exacerbations
◦ N=420
◦ Randomly assigned (1:1) to receive azithromycin 500 mg or placebo 3 times per week for 48 weeks
◦ Azithromycin reduced asthma exacerbations; significantly improved asthma-related quality of life
◦ Reported beneficial in eosinophilic and noneosinophilic subtypes
Gibson PG, et al. Lancet. 2017;390(10095):659-668.

48. Bronchial Thermoplasty
◦ For adult patients whose asthma remains
uncontrolled.
◦ Note: little understood regarding appropriate
patient selection
◦ Method to decrease smooth muscle mass by
applying excess heat in the airways with radio-
frequent energy

49. Bronchial Thermoplasty
◦Asthma Intervention Research2 (AIR2) Trial
◦ n=288 adults
◦ Safe therapy
◦ Study shown to improve asthma quality of life and reduce
exacerbations
◦ 5 year long-term study showed sustained reduction in
exacerbations, ER visits and hospitalizations
◦ Real world studies have shown sustained efficacy out to 3 years
Goorsenberg AWM, et al. Respiration. 2018:1-7.

50. WHATS MORE EMERGING ?

51. Tezepelumab—Phase 2b Clinical Trial Data
◦ Tezepelumab, TSLP inhibitor
◦ Study (n=584) showed reduced blood eosinophil counts, FeNO levels, and total serum IgE levels
◦ Low dose (70 mg once every 4 weeks), medium dose (210 mg once every 4 weeks), or high dose (280 mg
once every 2 weeks)
◦ Reduced exacerbations across all patient groups both type 2 and non-type asthma by ~70%
◦ More Patients in tezepelumab groups were demonstrated to achieve well-controlled (27.2% in tezepelumab
overall vs 14.9% in placebo) or partially controlled (22.0% in tezepelumab overall vs 19.1% in placebo) asthma
at 52 weeks vs placebo
◦ Recruiting patients for tezepelumab, phase 3 (ClinicalTrials.gov; NCT03347279)
Corren J, et al. N Engl J Med. 2017;377(10):936-946. Corren J, et al. J Allergy Clin Immunol. 2018;141(2):AB80. ClinicalTrials.gov; NCT02054130.

52. Emerging Target-Specific Therapies
◦ CRTh2 oral inhibitors in development
◦ Fevipiprant, ARRY 502, BI-671800, OC000459
◦ Promising results in cellular, functional, clinical outcomes; acceptable safety
◦ Shows decrease in PGD2-mediated eosinophil migration
◦ Improve lung function and symptoms in patients with eosinophilic asthma
◦ CxCR2 antagonist decreases IL-8 levels; shown promise in early trials
◦ Navarixin reduced sputum and blood neutrophils; trend toward better asthma control based on ACQ, but no
significant change in FEV1
◦ IL-6—potential biomarker of systemic inflammation along with C-reactive protein; shown to be increased in a
subset of patients with severe asthma, particularly severe asthma associated with obesity
◦ IL-17 Brodalumab didn’t achieve clinical benefit but perhaps not the right patients were selected
◦ IL-33—no data yet, but in clinical development
◦ IL-25—no data, yet
ACQ, Asthma Control Questionnaire; CRTh2, chemoattractant receptor homologue expressed on Th2 cells (alternative name DP2); FEV1 , forced expiratory volume in
one second; PGD2, Prostaglandin D2
George L, et al. Ther Adv Chronic Dis. 2016;7:34-51; Santus P, et al. Expert Opin Investig Drugs. 2016;25(9):1083-92; Naik SP, et al. J Asthma. 2017;54(6):584-593.

53. FINALLY,

54. What is your approach to treating patients
with severe asthma?
◦Treat with personalized approach
◦Identify asthma type by phenotype or endotype
◦Treat with the most appropriate therapeutic strategy based
on underlying asthmatic mechanism of inflammation

55. What are the strategies to maximize standard
medical therapies in asthma management?
◦Biologics (novel therapies)
◦Bronchial Thermoplasty

56. What can we achieve with biologics?
◦Reduced exacerbation
◦Reduced steroid dose and side effects
◦Improved symptoms and quality of life
◦Disease modification to prevent asthma over long term

57. Which therapy is best for a specific patient?
How do you choose between biologics?
• Biomarkers help predict therapeutic responses
◦ Phenotype patients and choose most appropriate therapy
◦ Goal of personalized or “precision medicine”
◦ Potential need to measure different biomarkers to determine
endotype/phenotype
George L, et al. Ther Adv Chronic Dis. 2016;7:34-51.

58. What are the long-term health risks with
biologic therapy?
◦Real, long-term consequences of eosinopenia are not
known
◦Do not know if biologics provides long-term safe control of
severe refractory eosinophilic asthma
Cazzola M, et al. Expert Opin Drug Saf. 2018;17(4):429-435.

59. Persistent Questions
◦ How do we decide between biologics that target same pathways?
◦ How do we decide between biologics for patients that meet criteria for different therapies?
◦ How long should we treat?
◦ Should we be combining biologics?
◦ Should we be giving biologics earlier in treatment ?

60. Takeaways
◦ Today we have a better understanding of underlying disease mechanisms
◦ Use biomarkers and endotypes to personalize treatment approach
◦ Advances in treatment of severe asthma include:
◦ Evidence-based treatment guidelines
◦ Evidence about phenotypic patterns
◦ Increased understanding of biomarkers and use in treatment selection
◦ Screen patients to choose the right therapy for the right patient
◦ Biomarkers are needed to identify most appropriate therapeutic strategy to a specific patient

61. THANK YOU