Biologics

Biologics

Asthma

Biologics: I, Eat, Donuts, To stop asthma

IgE, Eosinophils, TSLP

Oh My Benevolent Rhino Doesn’t Tease

IGE – Omalizumab (Xolair), anaphylaxis risk in first couple doses

Eosinophils – IL-5 (MRB / NCF) Mepolizumab (nucala) / Reslizumab (Cinqair) / Benralizumab (Fasenra) IL4 / IL-13 dupilumab (Dupixent)

TSLP – Tezepelumab (Tezspire)

XO XO

Xolair is omalizumab

My Benevolent Rhino

M Nu Calm – Mepolizumab nucala, Rescue the Cinq reslizumab Cinqair, Ben erases fast attending who teaches fast and doesn’t share his materials he erases them and acts like he is 5

Dupilumab (Dupixent) IL4-13 acts on 2 used every 2 weeks

Tezepelumab (Tezspire) total all 4 see every 4 weeks IL4, IL13, IL 5, IgE

Omalizumab targets IGE and is indicated for allergic asthma. requires evidence of sensitization to perennial aeroallergens and IgE w/in dosing range. Omalizumab dosing is based on body weight and total IgE level

Mepolizumab IL-5 monoclonal antibody used in eosinophilic asthma reduces asthma exacerbations and oral corticosteroid dependence subcutaneously every 4 weeks

Reslizumab IL-5 administered intravenously for severe eosinophilic asthma carries risk of anaphylaxis

Benralizumab IL5 causes near complete eosinophil depletion via ADCC after loading dose can be administered q8wks

benralizumab is afucosylated which enhances binding to CD16a on NK cells and increases ADCC potency causing near complete eosinophil depletion w/in 24 hours via apoptosis unlike the other IL-5 (mepolizumab / reslizumab) which causes a gradual reduction

The higher the baseline blood eosinophil count the greater the reduction in asthma exacerbations w/in anti-IL5 and IL-5R biologics

Dupilumab IL4 13 useful in patients with asthma and nasal polyposis or atopic dermatitis and can cause transient eosinophilia after initiation

Tezepelumab TSLP upstream epithelial cytokine effective regardless of eosinophil count or IgE level used in severe uncontrolled asthma w/o classic T2 biomarkers

Baseline FeNO predicts response well for dupilumab and tezepelumab but less so far anti IL-5 agents

asthma w/ allergy and IGE consider omalizumab

Asthma w/ high eosinophils consider IL-5 IL-5R biologics

Asthma w/ eczema and nasal polyps consider dupilumab

asthma w/o T2 biomarkers consider tezepelumab

BIOMARKER THRESHOLD

mepolizumab blood eosinophils < 150/uL may work at lower thresholds if > 2 exacerbations per year

reslizumab require baseline eosinophils > 400 highest threshold among anti-IL5 biologics can be used IV

dupilumab eosinophils > 150 and FeNO > 25 ppb

tezepelumab effective regardless of eosinophil count useful for nonT2 or low eosinophil severe asthma

Mnemonic Word	Generic	Brand	Target	Route	Frequency	Age
Oh	Omalizumab	Xolair	IgE	SC	Q2-4 wks	≥6y
My	Mepolizumab	Nucala	IL-5	SC	Q4 wks	≥6y
Benevolent	Benralizumab	Fasenra	IL-5Rα	SC	Q8 wks*	≥6y
Rhino	Reslizumab	Cinqair	IL-5	IV	Q4 wks	≥18y
Doesn’t	Dupilumab	Dupixent	IL-4Rα	SC	Q2 wks	≥6y
Tease	Tezepelumab	Tezspire	TSLP	SC	Q4 wks	≥12y