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Which Child with Asthma is a Candidate for Biological Therapies?
1Imperial College & Royal Brompton Harefield NHS Foundation Trust, London SW£ dNP, UK.
Insights
Biological therapies for severe asthma in children show promise but require more research. Current options like omalizumab are effective, but more data is needed for mepolizumab and specific biomarkers to guide treatment in pediatric severe asthma.
Area of Science:
- Pediatric Pulmonology
- Immunology
- Allergy
Background:
- Monoclonal antibodies targeting Type 2 airway inflammation have improved adult asthma care.
- The evidence base for these therapies in children, particularly severe asthma, is less developed.
- Current pediatric biologics target the T helper (TH2) pathway, but eosinophil roles and TH2-driven pathways may differ in children.
Purpose of the Study:
- To review the current landscape of biologic therapies for severe pediatric asthma.
- To highlight the limitations in current evidence, particularly regarding efficacy and biomarkers in children.
- To emphasize the need for further research to optimize treatment strategies for severe pediatric asthma.
Main Methods:
- Review of existing literature on monoclonal antibody therapies for pediatric severe asthma.
- Analysis of current evidence for omalizumab and mepolizumab in children.
- Discussion of the challenges in diagnosing and treating severe pediatric asthma, including phenotypic differences and biomarker utility.
Main Results:
- Omalizumab shows good efficacy in children with severe asthma and multiple exacerbations.
- Mepolizumab has available pediatric safety data, but efficacy data is lacking.
- Paediatric severe asthma may not always be TH2-driven, and phenotypes can be less stable than in adults.
- Biomarkers used in adults may be less reliable for guiding therapy in children.
Conclusions:
- While omalizumab is a viable option for severe TH2-driven pediatric asthma, more efficacy data is urgently needed for mepolizumab.
- Protocolized assessment is crucial for children evaluated for biologics, as most asthma is manageable with inhaled corticosteroids.
- Further research into pediatric-specific biomarkers is essential to guide the appropriate use of powerful biologic therapies in children with severe, refractory asthma.
Abstract:
In asthmatic adults, monoclonals directed against Type 2 airway inflammation have led to major improvements in quality of life, reductions in asthma attacks and less need for oral corticosteroids. The paediatric evidence base has lagged behind. All monoclonals currently available for children are anti-eosinophilic, directed against the T helper (TH2) pathway. However, in children and in low and middle income settings, eosinophils may have important beneficial immunological actions. Furthermore, there is evidence that paediatric severe asthma may not be TH2 driven, phenotypes may be less stable than in adults, and adult biomarkers may be less useful. Children being evaluated for biologicals should undergo a protocolised assessment, because most paediatric asthma can be controlled with low dose inhaled corticosteroid if taken properly and regularly. For those with severe therapy resistant asthma, and refractory asthma which cannot be addressed, the two options if they have TH2 inflammation are omalizumab and mepolizumab. There is good evidence of efficacy for omalizumab, particularly in those with multiple asthma attacks, but only paediatric safety, not efficacy, data for mepolizumab. There is an urgent need for efficacy data in children, as well as data on biomarkers to guide therapy, if the right children are to be treated with these powerful new therapies.
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