Prim. MUDr. Gustáv Ondrejka: Biological treatment of asthma eliminates the need for systemic corticotherapy
Despite advances in the therapy of bronchial asthma, a portion of patients still do not achieve the desired control of the disease. The introduction of biological treatment marked a significant milestone in management, improving the prognosis for patients previously dependent on long-term systemic corticotherapy with all its negative impacts. The recently approved reimbursement for dupilumab expands treatment options for patients with severe asthma, relieving patients of common asthma comorbidities. The current perspective on the treatment of bronchial asthma is provided by the head of the Pulmonary Department at KNTB Zlín, which includes the Center for the Diagnosis and Treatment of Severe Forms of Bronchial Asthma, Prim. MUDr. Gustáv Ondrejka, Ph.D.
What is the current situation regarding asthma? Where do you see the main challenges and what has already been achieved?
The bad news is that the number of people suffering from allergies continues to rise. According to estimates by the World Health Organization, around 50 percent of the population will suffer from some form of allergy by 2050. Today, half of the patients with allergies are under 19 years of age.
This situation is mainly due to the interaction of genetic factors with environmental allergens. With climate changes, previously unknown allergens are appearing. The introduction of non-native plant species, for example in the food industry, is changing the spectrum of allergies. Air pollution and the associated increase in bronchial reactivity also have a significant impact, leading to the development of chronic respiratory diseases, including asthma.
On the positive side, there has been significant development in diagnostic and therapeutic methods in the last decade. Until recently, many patients were treated long-term with systemic corticosteroids. Gradually, topical treatments and fixed combinations were developed, leading to a significant reduction in the side effects of therapy.
What does the diagnosis of asthma bronchiale mean for a patient today?
Given that it is a chronic respiratory disease, patients must expect long-term, often lifelong treatment. The positive aspect is that we have effective and safe treatment modalities. If properly managed, patients can live full lives with minimal restrictions. Of course, some patients have a complicated course of the disease. However, even for them, modern treatments are available that allow them to live a good quality life.
What is the foundation of modern asthma treatment?
Current treatment is based on the Global Initiative for Asthma (GINA) concept, summarizing the knowledge of experts from around the world. Treatment management includes preventive measures, such as eliminating allergens and promoting a healthy lifestyle, as well as stepwise pharmacotherapy. We start with low doses of topical medications, and if there is insufficient response, other drugs such as inhaled corticosteroids (ICS), long-acting beta-agonists (LABA), and long-acting muscarinic antagonists (LAMA) are added. Importantly, in the last, 5th stage of treatment, where patients with severe refractory asthma belong, systemic corticosteroids are no longer the drug of choice. Biological treatment, which is effective and has fewer undesirable side effects, takes precedence. It allows for reducing doses of systemic corticosteroids and sometimes even their complete discontinuation.
One of these biologics is dupilumab, which received reimbursement for severe asthma indication in March 2022. What do you see as its main benefits?
In general, the benefit of biological treatment is the reduction in the number of asthma exacerbations and, above all, the ability to avoid systemic corticotherapy or at least significantly reduce corticosteroid doses. The advantage of dupilumab is that it targets different structures compared to the existing biologics used in asthma treatment. It is an interleukin-4 receptor inhibitor. By blocking the cytokine mediator pathway that activates TH2-type inflammation, which plays a significant role in the pathophysiology of asthma bronchiale, as well as chronic allergic rhinitis and atopic dermatitis. Thus, the use of dupilumab also improves the manifestations of these common comorbidities.
To which patients is dupilumab specifically designated?
As mentioned earlier, biological treatment is intended for patients who did not achieve the desired control of the disease within the previous 4 stages of treatment. It is also suitable for patients with asthma comorbidities.
What is the current prognosis for asthma? And what are the most common reasons for poor disease control?
In difficult-to-treat asthma, we distinguish two groups of patients. The first comprises patients with severe refractory asthma that does not respond to conventional treatment. These patients significantly benefit from biological treatment. The second group consists of patients whose disease is influenced by other chronic comorbidities such as COPD, cardiovascular diseases, or diabetes mellitus, including conditions caused by long-term corticosteroid use. Of course, poor disease control can also be due to inadequate patient cooperation.
What is the main difference between asthma in pediatric, adult, and geriatric patients?
In children and younger individuals, there is a high prevalence of atopy. Asthma develops gradually and can progress to severe refractory states. In older individuals, environmental factors such as emissions or infectious agents, including COVID-19, play a significant role. Additionally, internal comorbidities like diabetes and cardiovascular diseases gradually add up, which can worsen asthma. Therefore, the need for their therapy becomes significant.
Is biological treatment suitable for these older patients with comorbidities?
Yes, we also have senior patients with multiple comorbidities who significantly benefit from biological treatment.
MUDr. Andrea Skálová
editor for proLékaře.cz
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