Biologic Therapies for Severe Asthma in School-Age Children

Children with severe asthma incur substantial disease-related morbidity. Despite treatment with inhaled corticosteroids and additional controller medications, many patients continue to experience recurrent exacerbations, impaired lung function, and diminished quality of life. Most children with severe asthma demonstrate evidence of a phenotype consistent with ongoing type 2 inflammation. Fortunately, the advent of biologic therapies, monoclonal antibodies that target specific pathways relevant to asthma pathogenesis, has allowed most children with severe asthma to experience marked improvements in disease control and clinical outcomes. Four biologic medications that target various aspects of type 2 inflammation-specifically omalizumab, mepolizumab, benralizumab, and dupilumab-are currently approved by the United States Food and Drug Administration for use in children 6-11 years of age with specific phenotypes of severe asthma. The selection of the most appropriate biologic for a patient's phenotype is driven by a biomarker-based approach, including assessments of blood eosinophil counts, fraction of exhaled nitric oxide levels, and allergic sensitization and total immunoglobulin E levels. These biologic medications have been demonstrated to significantly reduce the rates of asthma exacerbations between 27% and 59% relative to placebo, although they vary in their impact on lung function. The overall safety profiles of these biologics have been reassuring. This review discusses the role of biologics in childhood asthma, including the strategy for phenotyping patients, summarizes the data supporting the efficacy and safety of biologics in this population, and presents an approach for choosing a biologic and monitoring patient outcomes.