Division of Allergy and Immunology, Department of Internal Medicine, University of South Florida Morsani College of Medicine, Tampa, Fla.
Section of Pulmonary and Critical Care Medicine, Baylor College of Medicine, Houston, Texas.
J Allergy Clin Immunol Pract. 2021 Mar;9(3):1081-1088. doi: 10.1016/j.jaip.2020.10.048.
Five biologic medications are approved in the United States for the treatment of asthma that is not well controlled with other therapies. All target asthma with elevated type 2 inflammatory markers, such as elevated eosinophils, fractional exhaled nitric oxide, or total and specific IgE. Asthma severity, phenotype, age, biomarkers, treatment goals/outcomes, comorbid conditions, safety, and cost should all help guide the initial biologic choice. In addition, a shared decision-making process with the patient is needed to optimize adherence, with special attention to patient preference regarding outcomes, safety concerns, and medication administration options. After a biologic agent is initiated, sufficient time is needed to monitor efficacy and response. For patients who do not respond favorably, patient-, disease-, and medication-related factors should be considered and remedied, if possible. Persistent suboptimal responders necessitate a reexamination of asthma phenotype, biomarkers, and the suspected immune response pathways. For some patients, a change in biologic therapy or other therapeutic options may be warranted. In this review, we examine the clinical approach for choosing an initial biologic for the treatment of asthma, the assessment of response to biologics, and the process of troubleshooting and adjusting biologic treatment for those patients with suboptimal responses.
五种生物制剂已获美国批准用于治疗经其他疗法治疗后仍控制不佳的哮喘。所有生物制剂均针对伴有 2 型炎症标志物升高的哮喘，如嗜酸性粒细胞、呼出气一氧化氮分数、总 IgE 和特异性 IgE 升高。哮喘严重程度、表型、年龄、生物标志物、治疗目标/结果、合并症、安全性和成本均应有助于指导初始生物制剂选择。此外，需要与患者进行共同决策过程，以优化治疗的依从性，特别要关注患者对结果、安全性问题和药物管理选择的偏好。开始使用生物制剂后，需要足够的时间来监测疗效和反应。对于反应不佳的患者，应考虑并纠正与患者、疾病和药物相关的因素（如果可能的话）。持续治疗反应欠佳者需要重新检查哮喘表型、生物标志物和疑似免疫反应途径。对于某些患者，可能需要改变生物治疗或其他治疗选择。在这篇综述中，我们探讨了选择初始生物制剂治疗哮喘的临床方法、对生物制剂反应的评估以及对治疗反应不佳患者进行故障排除和调整生物治疗的过程。
