Treating Severe Asthma With Biologics

For many people who live with asthma, their symptoms are managed by identifying and avoiding triggers, taking daily oral medications, and using a quick relief inhaler. However, for some people, these measures aren’t enough to manage their day-to-day asthma symptoms, and they need stronger medications. This is the case for 5% to 10% of the people living with asthma.

In recent years, new drugs called biologics have been approved for treating moderate-to-severe asthma. Biologic therapies offer new ways of treatment because they target specific antibodies (blood proteins) responsible for causing asthma.

What Are Biologics?

Biologics are powerful medicines made of tiny components, including sugars, proteins, DNA, whole tissues, or cells. They come from all sorts of living sources—mammals, insects, plants, bacteria, and more.

Biologic drugs are the latest and most advanced treatments available today for the treatment of numerous diseases and conditions. Many of these are making it possible to treat illnesses that previously were considered untreatable. They treat inflammatory conditions by addressing the issue at the immune system level, which is the root cause of many diseases. But because these drugs come from a variety of sources, they are more complicated. In fact, they take a lot more work to produce, and once they are formulated, they are more susceptible to light and temperature and should be managed safely and kept correctly.

How Biologics Help With Asthma

Healthcare providers will prescribe biologics for people with severe asthma whose symptoms aren’t being controlled by inhaled corticosteroids, short-acting beta agonists, and other standard asthma medications. A biologic drug can help to manage shortness of breath and coughing. It may also reduce and prevent asthma attacks and lessen the intensity of attacks that do happen. When given for people with asthma, these drugs work by targeting different molecules and proteins in the body that contribute to symptoms.

According to a 2016 report in the journal Current Opinion in Allergy and Clinical Immunology, the primary benefit of biologics is to significantly decrease the frequency of "asthma exacerbation, emergency room visits, hospitalization, and need for oral steroids.” Further, biologics can improve life quality for people with the condition, and some biologics have even improved lung function in people with severe asthma.

Biologic Types for Severe Asthma

There are currently six approved biologics for the treatment of severe asthma. Xolair targets allergy antibodies known as immunoglobulin E (IgE), and the other four biologics (Dupixent, Nucala, Fasenra, and Cinqair) target pathways that affect eosinophils, a cell involved in allergic inflammation. Tezpire is approved for any phenotype of asthma.

IgE is an alleric antibody that occurs naturally in the body. IgE is naturally produced by B cell lymphocytes—a type of white blood cell. IgE also increases when someone is exposed to an allergen, such as cat, dust-mite or pollen and triggers an allergic reaction, which may include increased symptoms that results in an asthma attack.

Eosinophilic asthma (EA) is a severe kind of asthma, marked by high white blood cell levels. EA represents the majority of asthma, including approximately 80% of children and 60% of adults. The cells—called eosinophils—usually fight infections and bacteria. However, in people with EA, they cause inflammation and swelling in the airways and respiratory system.

The more eosinophilic cells there are, the more severe asthma symptoms will be. Unfortunately, EA is also difficult to treat and can significantly alter a person’s quality of life.

Biologic Therapy Drugs

There are many new biologic therapy options available to treat severe asthma. They work by disrupting the pathways that lead to inflammation in the body that causes asthma symptoms. Xolair and Nucala are approved for patients as young as six years old, while Dupixent is approved for children as young as 6 years old, and Fasenra are approved for patients as young as 12 years old. Cinqair is approved for adults 18 years and over. 

Xolair (omalizumab): Xolair was approved in 2016 by the U.S. Food and Drug and Administration (FDA) for adults and children ages 6 and up, who have poorly controlled asthma and allergies to year-round allergens like dust mites, pet dander, or cockroach debris. It works by blocking IgE proteins on immune cells and prevents them from releasing their chemicals. The medication is available as a subcutaneous (shots given under the skin) injection taken once or twice a month, depending on the dose prescribed. Studies show it can reduce the number of asthma attacks, prevent hospitalizations, and reduce the need for other asthma treatments, especially steroids.

Dupixent (dupilumab): Healthcare providers prescribe Dupixent for people with eosinophilic asthma that is poorly controlled. It works by blocking inflammatory cells responsible for asthma symptoms. The medication is given once every other week. You will receive the first dose Dupixent at the healthcare provider's office so that you will learn how to inject it. After the initial doses, you can administer the injections at home on your own.

Nucala (mepolizumab): Nucula is prescribed for people with eosinophilic asthma, which is a type of severe asthma. Eosinophils are a type of white blood cells that can cause inflammation and swelling in the airways and respiratory system. The more eosinophils in the blood, the more severe the symptoms of asthma can be. Nucala works by reducing the number of eosinophils in your blood.

Fasenra (benralizumab): Fasenra is prescribed for treating eosinophilic asthma and works by reducing the number of eosinophils in the blood. It is an injection treatment, taken once every four weeks for the first three doses, and then taken once every eight weeks.

Cinqair (reslizumab): Cinqair is also a medication for people with eosinophilic asthma. Similarly to other biologics for asthma, it works to reduce the number of eosinophils blood cells. It is given as an intravenous (IV, or through the vein) infusion once every four weeks. Infusion treatments are usually done at an infusion center. After you receive a dose of medication, the staff at the infusion center will monitor you for a period of time to make sure you don’t have any adverse reactions to the medications.

Side Effects of Biologics

Biologic drugs are generally safe, but side effects are possible. Side effects of biologic drugs depend on the specific drug and the way in which it is administrated.

While rare, some biologic drugs can cause allergic reactions called anaphylaxis, which may include:

• Hives or a rash 
• Swelling in the face, mouth, or tongue
• Shortness of breath
• Low blood pressure
• Wheezing
• Problems with swallowing
• Dizziness and/or fainting

Other biologics can increase a person’s risk for infections. Biologics given by injection can cause injection site irritation or swelling, while biologics given by IV can cause infusion reactions.

Injection site reactions may include redness, swelling, pain, and itching. Infusion reactions include pain, swelling, redness at the IV site, headache, flushing, nausea, and rash.

Other common side effects of biologics include:

• Cold-like symptoms
• Headaches
• Fatigue
• Nausea
• Sinus infection

A Word From Verywell

Biologic therapy may not work for everyone and it may require the use of other treatments as well. It is likely your healthcare provider will initially introduce a biologic to treat your asthma as part of your treatment plan to see if it helps manage symptoms. If you are able to find a biologic that works for you, this may cut down the number of asthma attacks you experience. It is also possible that you may eventually be able to cut back on the number of other treatments you take, including corticosteroids.

Biologic drugs are expensive and may cost thousands of dollars per year. Because of the high cost, your healthcare provider and other healthcare providers (pharmacist or nurse) will work with your insurance company to make sure a biologic is covered prior to your starting the treatment. And it may take a few months to see if the biologic is helping. Your healthcare provider will give you a timeframe for how long you will be on a biologic if your asthma is under control.