Welcome to the first episode of our podcast series, “Allergy, Asthma & Immunology Innovations Podcast.” This podcast episode is “Biologic Therapies for Asthma.” It explores biologic medications and how they can help people with moderate to severe asthma.”

The podcast is a joint collaboration between Allergy & Asthma Network and The Itch Podcast. It’s hosted by The Itch Podcast’s Kortney Kwong Hing and allergist/immunologist Payel Gupta, MD. Allergy & Asthma Network thanks AstraZeneca for their funding support to make “Biologic Therapies for Asthma” possible.

You can also listen to or download the podcast on ItchPodcast.com for listening anytime, anywhere. The podcast can be downloaded at:

Timestamp: Episode 1 Biologic Therapies and Asthma

2:00 – What is a biologic medication? How do they work?

4:12 – An overview of the first biologic for allergic asthma: omalizumab (Xolair)

7:38 – Is omalizumab right for you? What you need to know

10:40 – Biologics are injectable medications – administered in doctor’s office or at home

12:44 – Are biologics lifelong medications? Can they cure asthma?

15:40 – Biologics for eosinophilic asthma and Type 2 inflammation: how they work

19:35 – Mepolizumab (Nucala) for eosinophilic asthma

22:14 – Discussing biologics with your doctor, Shared Decision-Making, and health insurance

23:42 – Factors that can determine which biologic is right for you, including patient preference for location

26:20 – Reslizumab (Cinqair) for eosinophilic asthma

28:15 – Benralizumab (Fasenra) for eosinophilic asthma

29:30 – Dupilumab (Dupixent) for eosinophilic asthma

33:14 – Tezepelumab-ekko (Tezspire) for severe asthma

35:12 – Why it’s important to understand the science behind biologics

Episode 1 Recap: Asthma and Biologics

Kortney Kwong Hing and Dr. Payel Gupta dive into the world of asthma and biologics in this podcast. They begin by defining what a biologic medication is and how it’s developed. They examine how biologics interact with the body to improve asthma symptoms.

Biologics treat moderate to severe asthma that is not well-controlled by controller medications. They target the source of asthma symptoms rather than treat the symptoms.

Kortney and Dr. Gupta then explore the various biologic options available, who is eligible to receive them, and how they are administered. The six available biologics (as of July 2023) for asthma include:

  • Omalizumab (Xolair)
  • Mepolizumab (Nucala)
  • Reslizumab (Cinqair)
  • Benralizumab (Fasenra)
  • Dupilumab (Dupixent)
  • Tezepelumab-ekko (Tezspire)

Omalizumab was the first-ever biologic medication. It was introduced in 2003. Omalizumab is prescribed to people who are diagnosed with allergic asthma triggered by perennial allergens (not seasonal) and high IgE levels in the blood.

Mepolizumab, reslizumab, benralizumab and dupilumab treat eosinophilic asthma. This is a type of severe asthma that involves high levels of eosinophils – white blood cells that can cause airway inflammation. The medications work by blocking eosinophil production.

Tezepelumab-ekko is the sixth biologic medication. It works by blocking symptoms at the top of the inflammatory cascade by targeting the thymic stromal lymphopoietin (TSLP), a cytokine that causes inflammation.

Throughout the podcast, Kortney and Dr. Gupta emphasize the importance of understanding the science behind biologics when discussing them with doctors. They explore the important role of Shared Decision-Making between patients and doctors in deciding on an appropriate treatment plan. They explain that insurance coverage and preferences can influence the choice of biologic medication.

People with moderate to severe asthma should talk with an asthma specialist about biologic medications. Work together with a doctor through Shared Decision-Making to determine if biologic medications are right for you.

Mockups of the Biologic Meds website on desktop computer, laptop, tablet, and phone.

Learn about Biological Medications: What they are, how they work, and who might benefit ➤


Full Transcript

Kortney Kwong Hing: You’re listening to The Itch, a podcast exploring all things allergy, asthma and immunology. I’m your co-host Kortney, a real-life allergy, asthma and eczema girl.

Payel Gupta, MD: And I’m your second host, Dr. Payel Gupta, a board-certified allergy, asthma and immunology doctor. Kortney and I hope to balance each other out so that we get you all the information that you want and need about allergies, asthma and immunology.

Kortney: Hello. Today is the first episode of a new podcast series that we had in partnership with Allergy & Asthma Network. It’s called the Allergy, Asthma, Immunology Innovations Podcast. To kick off this series, we are going to be talking about biologic medications for asthma. We’re going to be diving into an overview of what biologic therapy is, which biologics are available for asthma treatment, how they work and whether they are right for you or a loved one. Before we get started, we wanted to thank AstraZeneca for their funding support to make this podcast possible. This podcast was also medically reviewed by Dr. Dipa Sheth.

As you guys might know, asthma is not a new topic for this podcast, and we actually have talked about different asthma treatments in the past all the way back in Episode 13. So if you’re interested in those forms of treatment, definitely go check out that episode.

Throughout today, we’re going to be using terms like moderate and severe asthma. If you don’t know what we’re talking about, we covered this in Episode 10. We go over all of the categories of asthma. Now, on to today – biologics.

Dr. Gupta: Yes, the biologics. We are going to talk about six biologics today, but first, let’s talk about the definition of what a biologic is. It’s a drug that is produced from a living organism or contains components of living organisms. What’s interesting to me is that blood is actually considered a biologic. So if you’ve ever donated blood, you have given someone a biologic medication.

Kortney: That means that if you technically get a blood transfusion, you’re getting a biologic.

Dr. Gupta: Yes. So the basic definition is that a biologic is a drug that comes from a living organism, and you are a living organism. So in contrast to most drugs that are chemically synthesized, biologics are not chemically synthesized and are coming from a living organism, as I’ve said. The types of biologic medications that we have right now for asthma are all what we call monoclonal antibodies. So let me break down the words. Mono means one and clonal means cloning or creating a copy. Essentially, these medications are the clone of one antibody that we want to use.

Kortney: Okay, so let me just summarize this so we all have a very clear understanding. What you’re saying is that the medication we call Biologics and the medication that you would be taking is a clone of one type of antibody, and that is made in a lab. We’re cloning an antibody in the lab, and that’s the medication.

Dr. Gupta: Yes, that’s what’s happening.

Kortney: And are all asthma biologics made of antibodies?

Dr. Gupta: Yes. Right now, the biologics we have are all monoclonal antibodies. We have discussed antibodies before, and essentially an antibody is a protein that sticks to another protein that’s called an antigen. Each biologic targets a different protein or antigen to help control the inflammation and asthma. We will go through the different biologics today and discuss how each one works and what proteins they are each affecting in the body to help people with asthma.

Kortney: We’re going to cover six biologics, right, Dr. G? Which one would be the best to start with?

Dr. Gupta: Well, I thought it would be a good idea just to go in chronological order. The first biologic that came out to the market was omalizumab in 2003. The brand name for this medication is Xolair. It is also used in the treatment of hives or urticaria and also nasal polyps. So this one is specifically for moderate to severe allergic asthma. And in order to be on this medication, you have to have allergic asthma. And the allergen needs to be what we call a perennial or year-round allergen. So something like dust mites, mold, or animal allergies are considered perennial or year-round allergens. And it is then approved for people with only seasonal allergic asthma. So in addition, you have to have an elevated IGE level in your blood, which most allergic people will have.

Kortney: Okay, so you can’t have seasonal allergies to be on omalizumab, but you have to have an elevated IGE level to be a candidate. Can you explain to us a little bit about why that IGE level is important?

Dr. Gupta: Yes. So Xolair actually inhibits the binding of IGE to the IGE receptor. So if you remember, IGE is the allergy antibody, essentially, and the receptor for this antibody is on the surface of mast cells and basophils. So the receptor is called FC Epsilon R1. And when IGE binds a receptor on the mast cells and basophils, it causes the release of things like histamine and other inflammatory mediators. Mast cells are very similar to basophils in that they both contain inflammatory mediators that cause an allergic reaction.

Kortney: This is a pretty dense episode, and I think I’m going to parrot a lot of what you say, Dr. G, just so that I can be sure I’m on the same page as you. And I feel like hopefully if I’m on the same page as you, the audience will also be on the same page as you. I hope you guys don’t mind that I’m going to be a little bit repetitive today, but I find that doing this research was really overwhelming, and so I feel like I just want to say it again.

Let’s go back to Xolair. Xolair is also known as omalizumab. If I understand it correctly, what it does is it stops the IGE from binding to the mast cell or the basophil, and that stops the release of histamines or inflammatory mediators, which in turn stops an allergic reaction or inflammation that could cause asthma.

Dr. Gupta: Yes. The only other thing is that the anti-IGE antibody is the omalizumab or Xolair. And so it inhibits the IGE functions by blocking the IGE that’s floating around in the serum and also by inhibiting their binding to the FCE R1 receptor on mast cells and basophils. So by reducing serum IGE levels and the IGE receptor expression on inflammatory cells, we get limited release of mediators that then causes a reduction in the amount of inflammation in the airways for people with allergic asthma.

Kortney: When you’re talking about serum, are you talking about IGE that’s floating around in our blood?

Dr. Gupta: Yes, exactly. Now, for people to be prescribed Xolair, they need to have severe asthma and take a blood test to see if their IGE levels are high enough.

Kortney: Do they also need to take an allergy test to ensure that their triggers are actually year round?

Dr. Gupta: Yes. So they do need to get a blood test to make sure that they have year-round allergies or a skin prick test. Remember from our previous episodes, we diagnose an environmental allergy by doing either a skin prick test or a blood test. They do need to have both of those things, an elevated IGE level and the perinatal positive allergen.

Then let’s go into what type of asthma it’s used for – again, moderate to severe asthma that isn’t being controlled with normal controller medications. Those normal controller medications would be things like inhaled corticosteroids, long-acting beta-agonists, and anticholinergics or muscarinic antagonists that we have previously talked about. These patients continue to have symptoms despite using these medications on a daily basis and also sometimes need to use oral corticosteroids because they’re having such a severe exacerbation and they need to continuously use their albuterol inhaler to have relief of their symptoms.

So if a doctor determines that someone has uncontrolled asthma, then they will send the patient for the allergy testing and the total IGE and also look at their eosinophil count, which we will discuss later for the other biologic treatments.

Kortney: If omalizumab is a controller medication, which I think from my understanding, that would be what it is, does that mean that someone who is on omalizumab or Xolair no longer needs to take their controller inhaler? And do they still need to carry an emergency inhaler?

Dr. Gupta: Yes. Xolair is a controller medication, you’re absolutely right. Our goal is obviously to always have every patient on the lease medication possible. And so we will try to reduce the other inhalers that a patient is on, but because each medication does something different, sometimes it’s not possible to do that. And patients really do need a combination of all of those medications to control their asthma.

But once you stop the underlying inflammation with omalizumab, then ideally patients will reduce the need for those other controller inhalers over time.

I want to just give a quick reminder that you always need to carry your rescue inhaler when you have asthma. Using Xolair or any medication doesn’t mean that you can’t have an asthma attack. Always have your rescue inhaler if you have asthma, period.

Kortney: Unlike the controllers that we just talked about, that are taken by the spray, how are biologics taken?

Dr. Gupta: Yes. So first of all, an important note is that all biologics are injectable medications. So some can be given at home and some need to be given in the office.

Omalizumab can be given in the office or it can be done at home. But every patient that is started on omalizumab needs to start the initial doses in the office to make sure that they’re able to tolerate the medication. Xolair or omalizumab in particular needs to be given in the office initially because it can sometimes cause an anaphylactic reaction in people. So this is very rare, but it can happen. So anyone on Xolair will also be given an epinephrine device. But this only needs to be carried on the day that you’re given the Xolair injection and not every day, which is different when you consider food allergies and the need to carry epinephrine, for example, all the time. So most allergists will have patients wait in their office for two hours after the first three doses, and then that time will decrease to 30 minutes if there haven’t been any reactions. What’s interesting is that for patients who are getting omalizumab for their urticaria, the risk for anaphylaxis with the medication is lower than that for patients who are getting it for asthma.

Kortney: And how often do these patients need to get injections?

Dr. Gupta: So the dose depends on the patient’s IGE level and also on the weight of the person. So it’s given every two to four weeks, depending on those two factors.

Kortney: What’s the youngest age someone can start it?

Dr. Gupta: So first, every biologic does have its own age cut-off. And so we’ll be discussing that for each one. And for omalizumab, it is approved in asthma patients who are 6 years old and older.

Kortney: Is this a lifelong treatment? And if it’s not, how do you assess a patient who has been on omalizumab and wants to know if they can come off of it?

Dr. Gupta: So this answer will actually hold true for all biologics. We have to see how that person does and determine the course. So technically, there is no stop point. So with my asthmatics, once they are doing better for at least one year, then only will I consider sometimes extending the time between shots to see if the person can tolerate it. But again, this has to be done cautiously and after talking to the patient and doing what we call shared decision making, making sure that the patient understands the pros and cons before doing anything. So the answer to that question is complicated, and I think different doctors will do it in different ways.

But for the most part, a lot of patients may stay on this medication, and definitely, if it has made a big difference in their moderate to severe asthma. And another reminder is that biologics actually do not cure asthma. There is no cure for asthma. It’s a chronic condition.

Kortney: That’s a good thing to remember, that there’s not a cure for asthma, this is just something that’s helping you control it, essentially. So beyond the potential for anaphylaxis, what are the other side effects of omalizumab?

Dr. Gupta: As far as side effects, we are talking about the most commonly described side effects for all of these biologics. The list may be longer, but we will put a link to all the medication websites for reference.

I also want to say, even for the mechanism of action and all of these things that we’re talking about, we’ll also have a diagram for each of these medications so that you can refer to that as you’re listening to this podcast because I think it is a lot. As for the side effects, some common ones are itching or mild rash at the site of the injection. You could get joint pain, bone fractures, arm or leg pain, nausea, dizziness, feeling tired, ear pain, or cold symptoms such as a stuffy nose, sneezing, sinus pain, cough, sore throat, etc. I haven’t seen many of these in my patients, but they were seen in the studies.

The other issue that has come up with omalizumab is the risk of cancer or malignancy, but the data is unclear on this. However, if a patient has a history of cancer, then we usually consider an alternative to Xolair if we can.

Kortney: Great. Those were some possible symptoms. But like you said, we’re going to link all of that. If you guys are like, ‘Oh, there’s only a few?’ There’s still some stuff that you probably need to read if you’re going to go on certain biologics, you want to definitely talk to your doctor about. I think that’s a pretty comprehensive overview of Xolair therapy because if we get any more information about it, our brains will explode at this point.

So let’s jump into the other five that we’re going to talk about. What type of asthma are they targeting?

Dr. Gupta: Yes. So there are four biologics that are in this next category for eosinophilic asthma. So in this form of asthma, we have found that reducing the number of eosinophils can help someone’s asthma. And the medications that have been created essentially use, again, monoclonal antibodies to do this in different ways.

Kortney: I think it would be really nice for the audience to get a little bit of an understanding of what are eosinophils before we jump into all of these four medications, because we have a clear understanding of allergens like you just described, but now we’re jumping into a completely different thing. So can you tell us a little bit about what are eosinophils?

Dr. Gupta: Yeah. So eosinophils are a normal part of the body’s immune system. They are a type of white blood cell, and eosinophils are considered to be associated with what we call Type 2 inflammation. So Type 2 inflammation is characterized by an immune response that involves various cells and molecules that are associated with allergies and asthma. So eosinophils play a really significant role in Type 2 inflammation. In people with asthma, they can contribute to inflammation in the lungs. So the number of eosinophils can be associated with poor asthma control and more asthma attacks for some people with asthma. So again, this is what we call eosinophilic asthma.

Kortney: Does this mean that the antigen that’s being targeted for eosinophilic asthma are the eosinophils?

Dr. Gupta: Yes and no. The goal is to reduce the number and functioning of eosinophils because the eosinophilic again causes inflammation that leads to asthma symptoms in these patients. But each of the biologics do this in a different way by targeting different allergens in the body that affect the eosinophils, that affect the number of eosinophils, the production of eosinophils, the functioning of the eosinophils.

Kortney: Basically, we want to reduce the number of eosinophils that cause inflammation. And the next four biologics that we’re going to talk about differ because of how they target antigens that impact the eosinophils. Just want to be 100 % clear before we move on and break each one down.

But actually, I have one more question. I’ve read the warnings for many of these biologics, and they all mentioned that you have to tell your doctor if you’ve experienced a parasitic infection. I’m just curious as to why that would be.

Dr. Gupta: Yes. As I said before, eosinophils are an important part of our body’s immune system, and they actually help fight off parasitic infections. Therefore, if you have a parasitic infection, we wouldn’t want to decrease eosinophil function, capacity, and growth so that the body could actually fight off the parasite.

But we have seen in studies that in areas where parasites are more common, that the medications that reduce the eosinophils don’t cause people to get parasitic infections or to get worse parasitic infections, etc. It’s just that if the patient already has a parasitic infection, we want to make sure that the patient has overcome that infection before we start them on a biologic that reduces the number or function of the eosinophils.

Kortney: I just want to emphasize that we actually aren’t going to cover what conditions you may have that would prevent you from going on a biologic in this episode, just like what we learned that having a parasitic infection would be one. Please remember when you are listening that you do need to talk to your doctor about your medical history. This is part of the Shared Decision- Making so that you can choose the right biologic for you. I just wanted to put that caveat in that this is one thing we won’t be talking about in this podcast, or else this podcast episode would literally be hours long.

Dr. Gupta: I was thinking that we could discuss each of the medications in the order that they came out to market. Starting with mepolizumab, also called Nucala in the United States. I’m going to use Nucala just because it’s easier to say. But Nucala is also approved for chronic rhinosinusitis with nasal polyps in adults whose disease is not controlled with nasal corticosteroids. And the way that it works is that IL5 is the protein or antigen that Nucala is targeting. So IL5 specifically causes the growth, development, activation, and survival of eosinophils. So if we want to reduce the inflammation caused by eosinophils, this is a good protein to target.

Kortney: So how exactly does it target the IL5?

Dr. Gupta: Yes. So it blocks the IL5 from binding to a receptor on the eosinophil, and therefore it causes a reduction in the production and survival of eosinophils.

Kortney: How does Nucala target IL5, Dr. G?

Dr. Gupta: Great question. And before we get into how it targets it, let me just talk a little bit about IL5. IL5 is a cytokine, which means it’s a chemical, essentially in our body, that’s responsible for eosinophil development. Il5 binds to the IL5 receptor on the surface of the eosinophil that creates a signal that promotes the growth, differentiation, recruitment, activation, and survival of eosinophils. So essentially it just allows the eosinophils to survive once that binding happens. And so blocking it allows us to reduce the production and survival of the eosinophils. And the way that the mepolizumab or Nucala does that is it blocks IL5 from binding to the receptor on the eosinophil. Then again, it results in the reduced production and survival.

Kortney: All right, that makes sense. How do you decide if a patient is a candidate for mepolizumab?

Dr. Gupta: All of these biologics for eosinophilic asthma have essentially the same criteria. It is specifically used for moderate to severe eosinophilic asthma. The eosinophils should be elevated and for asthma that is not responding to normal controller medications. So there are patients who need to use their rescue inhaler more often, have symptoms more often, and also may require oral steroids or emergency visits often. We do the blood work to check for the numbers of eosinophils, and if they meet the cutoff criteria, then we can start a discussion about which biologic to use.

Kortney: What does that discussion look like? So how do you decide which biologic you want to use with a patient?

Dr. Gupta: That’s a good question. So once we’ve determined that it is eosinophilic asthma, then we have these four options. And deciding which one to use, again, is done using shared decision making. This means that we go through each of the options that we have, how they’re given, how often they need to be taken, the side effects. Also, it can depend on what other conditions the patient suffers from.

So as we talked about with Xolair already and also with Nucala, these medications are also used for other conditions. So if the patient has one of these other conditions and the biologic also targets that other condition, then it might make more sense to use one over the other. So that’s how we do it. So it’s a lot of factors that we go through with the patient.

And then also, ultimately, it depends on insurance coverage. So insurance companies sometimes like one biologic over another, and that’s not based on anything I think rational, but it’s just more of, I think, a business decision on the end of the insurance companies, at least in the US. And so that also plays a factor into what the patient ultimately ends up being on.

Kortney: Is it ever a bit of a trial and error situation where you try a patient on one and then it’s not really working the way you hoped and then you try another one. And if that is the case, is there a timeline that you have?

Dr. Gupta: So again, we make the decision based on several factors on which medication to start, but then how a patient responds to that medication is always variable. We think that this medication might be the best for this patient based on multiple factors. But then once we start it, we just have to see how they’re responding to the medication. I think most physicians will give it several months to make sure that they’ve given an appropriate trial and then see how the patient is doing. So there’s no exact rule to this. And then for Nucala, it’s actually given every four weeks and you can take it at home or in the doctor’s office. So I have patients who would rather get it in the office because they don’t feel comfortable giving themselves injections, and then some would rather do it at home because of convenience issues. So it really just depends on what is comfortable for the patient. And we’ll mention this with the other biologics, but a lot of them now are either in the office or at home.

Kortney: Since you can do it at home, is it an auto-injector?

Dr. Gupta: Yes, it is an auto-injector that is fairly easy to use.

Kortney: They don’t have to get the needle and then get the liquidy stuff and then do it themselves. That’s good. I feel like that would also be something that would hinder someone wanting to do it at home. Now, what about the side effects? I guess since maybe you can do it at home, anaphylaxis isn’t one. But let me know if I’m just making sweeping guesses here.

Dr. Gupta: In general, you can have an allergic reaction to any medication. And so anaphylaxis would be possible with any medication. But with this particular medication, there was no indication that it was more often than just random chance or occurrence. And so there’s no indication for a patient to need an epinephrine device during administration. And the possible side effects listed are headache, feeling weak or tired, back pain, pain swelling, redness, burning, or itching, where the medicine was injected, and then a condition called shingles.

Kortney: Just curious, and tell me if this list might be too long and we should keep it out, but now I’ve planned it in my head, are there any conditions that someone might have that would preclude them from going on Nucala?

Dr. Gupta: No, there are no specific contraindications for Nucala that we worry about. And also it’s approved in patients as young as six years old.

Kortney: Great. I think that’s everything for Nucala or mepolizumab. So on to the next one. What do we have next?

Dr. Gupta: Yes. So the next one on the market is reslizumab, or Cinqair. This is another anti-IL5 biologic. It binds to the IL5 receptor and doesn’t allow IL5 to bind, which inhibits the eosinophil from proliferating, developing, and all of the other things that we discussed just earlier.

Kortney: How does this one differ from mepolizumab?

Dr. Gupta: Again, they’re both essentially IL5 inhibitors. Mepolizumab binds to IL5 and inhibits it from working. Reslizumab binds to the receptor that IL5 binds to on the eosinophil, and therefore doesn’t allow IL5 to work. It’s a little confusing, but a picture always helps. For listeners, it’s a good idea to refer to the diagrams we posted online. I think that makes sense. They both reduce the functioning of IL5 and therefore reduce the number of eosinophils that can cause inflammation.

Kortney: You made it very clear. It’s basically they’re targeting different parts that impact IL5’s ability to do its job.

D. Gupta: Yeah, that’s a great way to summarize it. And for other key points, it is only approved for those who are 18 years of age and older. So this medication, SIN care or reslizumab is an IV medication. So it needs to be given in a place where they administer IV medications. So it is different from the other three that we’re talking about.

Kortney: I can see how that would play into your Shared Decision-Making since this is given by IV. So how about the side effects? What do those look like?

Dr. Gupta: So the possible side effects listed are nausea, a light headed feeling like you might pass out, chest tightness, wheezing, trouble breathing, itching or rash, or swelling in your lips or tongue, or swelling in your lips or tongue. So there’s nothing else to worry about or scream for. Only if you have a reaction to it then should you not use it again. Nothing else that would be a red flag.

Kortney: Great. I think we’ve established a flow. So let’s continue. What’s number three?

Dr. Gupta: So benralizumab is the next one on the market. The trade name is Fasenra. And it also targets the IL5 receptor, but a different part of the receptor than reslizumab or Cinqair, and doesn’t allow it to bind and therefore work. So it’s approved in those that are 12 years of age and older with severe asthma. And this one is given in the office or at home, and it also has an auto-injector type device which is easy to use. It starts at every four weeks for the first three doses, and then you actually move to every eight week dosing.

Kortney: It’s really interesting to hear how these all differ so widely and all do the same thing, but just such a different method. So how about side effects?

Dr. Gupta: Yeah. So the side effects listed are headaches, sore throat, fever, and injection site reactions like pain, redness, itching, or small lump. And there’s no conditions for which you can’t get this medication.

Kortney: So we’ve got one more left for eosinophilic asthma. And I’m very excited to hear about this one because it’s actually one that I’m a candidate for, and I’m looking at going on eventually. So without further ado, Dr. G, what’s number four for eosinophilic asthma?

Dr. Gupta: Yes. So let’s talk about dupilumab, the trade name is Dupixent. This one is actually being used for several conditions. It was first approved for eczema and was used in those patients and then was approved for asthma and is now also approved for chronic rhinosinusitis with nasal polyposis, eosinophilic esophagitis, and a condition called prurigo nodularis. So it’s being used in several different conditions.

Kortney: Yeah, I was recommended dupilumab for my eczema, so I don’t know much about its role in eosinophilic asthma. Can you talk to us more about that?

Dr. Gupta: Dupilumab also has the recommendation to be used not only for eosinophilic asthma, but also in any patient that is on chronic oral corticosteroids for their asthma, which we call steroid dependent asthma. Dupilumab binds to the IL4 receptor. IL4 is another cytokine or protein, and when it is blocked, we see less of a Th2 response. So this includes less eosinophils being activated. It also prevents IGE from forming, and it does not allow IL13 to be released. IL13 is another protein or cytokine, and that has a role in mucus secretion and airway remodeling. So all of these things help with the prevention of asthma inflammation.

Kortney: It sounds like there are many different proteins at play in the role of eosinophil production, so that’s really been very interesting to learn. And that each biologic we’ve discussed, acts on a different part of that.

Dr. Gupta: Yes, exactly. A lot of them act on IL5, and then dupilumab acts on IL4 and IL13. Again, I think it will be helpful for people to see a picture and a chart because it’s a lot of information. But the bottom line is that they all ultimately help with inflammation caused by eosinophils.

Kortney: Great. That makes sense. And thank you for hitting upon inflammation again, because basically that’s the thing that we’re trying to prevent, right? It is all of this inflammation in the body. So to round out dupilumab, how often is this one given?

Dr. Gupta: So this one is given every two to four weeks, depending on the age, and can be given at home or in the office. And it’s for patients that are six years of age or older.

Kortney: So since I’ve talked about dupilumab and my journey just a teeny weeny bit, I know some of the side effects that it could potentially cause. I know that dry eye is something that they talk about when treating eczema, and I’m very curious to see if it’s the same if you’re a candidate for it because of asthma. So can we talk a little bit about the side effects?

Dr. Gupta: Yes, what we see is that patients with only asthma, and not asthma plus atopic dermatitis or eczema, don’t experience the dry eye side effect as often. But yes, you’re right. It’s specifically associated with dry eye or conjunctivitis for patients who use it for their eczema. Then the other possible side effects listed are injection-site reactions, which is true for really all of them, swollen or puffy eyelids, oral herpes, inflammation of the cornea, eye itching, other herpes simplex virus infections. There’s no other conditions that we have to worry about before prescribing dupilumab. But again, all of these, if you have a history of parasitic disease, then that would be one of the things that we would always monitor for, which I guess I haven’t mentioned when we talk about the other conditions that we would need to worry about.

Kortney: I think that’s it for eosinophilic asthma. How about the last biologic on the block. What are we talking about for biologic number six?

Dr. Gupta: Yes. So this one would be tezepelumab-ekko or Tezspire. So this biologic was just recently approved, and it doesn’t have to have a particular eosinophil count. You don’t have to have positive allergic triggers or be steroid dependent. So it is technically for any severe asthma patient who is 12 years of age and older and is not finding control with other therapies.

Kortney: Oh, this sounds like a good one to have in addition to the other asthma biologics that we’ve talked about before, in case one of them isn’t covered by insurance or you need to try a different one. How does this one work since it’s not like an eosinophilic asthma one, what’s the biologic work on?

Dr. Gupta: Yeah, that’s a great question. Tezepelumab-ekko binds to the TSLP, and it blocks its interaction with the TSLP receptor. So TSLP is a cytokine or protein or chemical that is at the start of the chain of events that can lead to the release of eosinophils, airway submucosal eosinophils, IGE, IL5, and IL13.

Kortney: Just so I’m clear, what I’m understanding is that this biologic is working higher up in the process that will eventually cause the inflammation.

Dr. Gupta: Yes. And this one is also an injectable and is given at home or in the office, and it’s given every four weeks. And the possible side effects listed are injection site reactions, pharyngitis, arthritis, back pain. And again, it’s recommended in patients that are 12 years of age or older.

Kortney: I think we covered everything, right, Dr. G?

Dr. Gupta: Yeah, I think those are all the biologics that are out in the market at this point.

Kortney: “At this point” is a good thing to add because I feel like they’re getting added all the time, or they’re learning that biologics have a lot more function than the first one that they have when they go on to the market.

I have to say this was a very dense episode, everyone. So if you stayed with us, thank you. The science geek in me has loved it. And as I said, since I have been talking to my doctor about going on a biologic, understanding the science behind these biologics is really important because when you sit there with your doctor, it can feel really overwhelming at what they’re telling you. But I think that Dr. G has done a really good job at simplifying the process and understanding what it will be doing in your body.

I just really want to say thank you, Dr. G, for making that super clear for us. Before we wrap up, I just want to know if there’s anything else that we should know when it comes to biologics?

Dr. Gupta: Well, I think I always like to end with just saying that this episode is really for people to understand what all the options are out there. So if you feel like your asthma is not controlled, if you feel that things just aren’t going the way that you’d like them to, these are other medications that can be considered.

So it’s really important just to be informed about them and to have a conversation with your provider to see if you might be a candidate for any of these. So informed Share Decision-Making is just very important. And that’s just really what we want to highlight here is, the more you know, the more you’re able to advocate for yourself and for your patients.

Kortney: I 100% can’t agree more. Well, thank you, everyone, for listening. We are super hyped with biologics right now, and we’re thinking about some smaller episodes that we’re going to release following this one because as you can tell, there’s so much more to talk about, and we are here to talk about it. So thank you again for listening and thank you for staying in on this deep dive.