Three-step algorithm for biological therapy targeted IgE and IL-5 in severe asthma

Area of Science:

• Pulmonology
• Immunology
• Pharmacology

Background:

• Severe asthma treatment has new biological therapies targeting IgE and IL-5.
• Existing therapeutic algorithms lack guidance for atopic/eosinophilic asthma patients.
• Optimal selection between Anti-IgE and anti-IL-5 remains a challenge in overlapping severe asthma phenotypes.

Purpose of the Study:

• To propose a novel three-step algorithm for selecting biological therapy in severe asthma.
• To address the challenge of choosing between Anti-IgE and anti-IL-5 in patients with overlapping atopic and eosinophilic features.
• To provide a biomarker-driven approach for personalized severe asthma management.

Main Methods:

• A three-step algorithm incorporating blood eosinophils, FeNO, and atopy testing.
• Inclusion of a 14-day oral steroid trial (prednisolone) for specific patient subgroups.
• Assessment of treatment response based on changes in asthma symptoms, lung function, blood eosinophils, and FeNO.

Main Results:

• The algorithm categorizes patients based on initial biomarker measurements (eosinophils, FeNO) and atopy status.
• A steroid trial differentiates between "truly steroid resistant" and potentially responsive cases.
• Anti-IgE is suggested for non-steroid resistant cases with dominant allergic inflammation, while anti-IL-5 is recommended for steroid-resistant eosinophilic inflammation.

Conclusions:

• The proposed three-step algorithm, including a steroid trial, offers a structured approach to biological therapy selection in severe asthma.
• This algorithm may serve as a basis for companion diagnostics in molecularly targeted therapies.
• Further validation studies are necessary to confirm the algorithm's clinical effectiveness.