Immunomodulators for Asthma

Immunomodulators are injectable medications used to decrease inflammation caused by asthma and other conditions (among them, rheumatoid arthritis and Crohn's disease). They are a type of biologic drug, which means they are made from the cells of a living organism.

Biologic immunomodulators for asthma are prescribed as "add-on" controller medications for helping prevent asthma symptoms when other such medications—namely, inhaled or oral corticosteroids—are not working well enough; they are not effective for relieving symptoms of an asthma attack that's in progress. Most immunomodulators are administered by a healthcare provider at a healthcare provider's office or infusion center.

There are five biologic immunomodulator medications approved by the Food and Drug Administration (FDA) to treat moderate to severe asthma:

• Xolair (omalizumab)
• Dupixent (dupilumab)
• Nucala (mepolizumab)
• Cinqair (reslizumab)
• Fasenra (benralizumab)

How They Work

The biologic immunomodulators used to treat asthma are monoclonal antibodies—manmade proteins that work much like the antibodies produced by the immune system to help fight off a bacterial or viral infection.

Each such drug targets a specific aspect of the inflammatory response. Inflammation caused by asthma occurs when immune cells and proteins induce a cascade of changes in the lungs that ultimately lead to bronchoconstriction, narrowing of the bronchi and bronchioles (airways). It can be triggered by an excessive immune response to an inhaled substance or without any trigger at all.

The substances targeted by immununomodulators that treat asthma are:

• Immunoglobulin E (IgE), an antibody overproduced during an allergic reaction. People with allergic asthma tend to have higher levels of IgE than the general population.
• Cytokines, signal molecules that amplify the immune response. In some people who have severe asthma, the cytokines interleukin-4, -5, and -13 (IL-4, -5, -13) are major factors in the inflammatory sequence that produces asthma symptoms.
• Eosinophils, white blood cells involved in the production of mucus and fluid that can trigger bronchospasms

In general, asthma immunomodulators are approved for IgE asthma or eosinophilic asthma. While blood tests might show high IgE or eosinophils, these levels are not consistent, and your healthcare provider may diagnose you with eosinophilic asthma or IgE asthma based on the pattern of your signs and symptoms rather than relying strictly on blood tests.

Benefits

Immunomodulators cannot replace other asthma medications and management strategies. But when traditional treatments aren't effective enough, an add-on biologic may offer:

• More effective control of asthma symptoms
• Less need for inhaled and oral corticosteroids
• Fewer asthma exacerbations and attacks and, as a result, fewer emergency medical interventions
• Improvement in forced expiratory volume (FEV) results, a breathing test for lung function
• Better quality of life

Comparing Immununomodulators

The five biologics approved by the FDA as add-on asthma medications work in sightly different ways: Each is designed to target a slightly different aspect of the inflammatory process.

They are not all given in the same way, either, nor are they all appropriate for the same people. Your healthcare provider will consider your medical history, symptom severity, blood tests, physical examination, age, and body weight to determine which biologic is likely to be most effective for you and at what dose.

Xolair (omalizumab)

Xolair (omalizumab) was the first biologic approved for asthma treatment. It is approved for adults and children age six and older who have moderate to severe asthma that doesn't adequately improve with inhaled steroids and who have a positive skin prick test or blood test for specific allergens.

It binds with IgE to lower IgE levels and block the production of inflammatory substances.

Omalizumab is administered via subcutaneous (under the skin) injection every two to four weeks and is dosed according to IgE levels and body weight. It can be administered at home after in-office training.

Nucala (mepolizumab), Cinqair (reslizumab), and Fasenra (benralizumab)

These medications target IL-5 and the overproduction of eosinophils.

• Nucala is indicated for severe asthma for adults and children 12 and older who have a high eosinophil level with their asthma. It is injected subcutaneously by a healthcare professional or self-administered after in-office training at a fixed dose of 100 milligrams (mg) every four weeks.
• Cinqair is approved for adults 18 and over with severe asthma and a high eosinophil count. It is administered intravenously (through a needle into a vein) by a healthcare professional every four weeks at a dose of 3 mg per kilogram (kg) of body weight.
• Fasenra is approved to treat severe asthma in adults and children 12 and older who have eosinophilic asthma. A 30-mg dose is injected subcutaneously by a healthcare professional or self-administered after in-office training every four weeks for the first three months and then every eight weeks.

Dupixent (dupilumab)

This drug targets eosinophils via the IL-4 and IL-13 pathways. It is approved for treating moderate to severe eosinophilic asthma in adults and children 12 and older.

Dupixent is injected subcutaneously at an initial dose of either 400 mg (two 200-mg injections) followed by a 200-mg dose every two weeks, or an initial dose of 600 mg (two 300-mg injections) followed by a 300-mg dose every two weeks. It can be injected by a healthcare professional or self-administered.

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Potential Side Effects

Biologics for asthma are generally well tolerated, but as with any medication, there is some degree of risk of side effects. Among the most common:

• Injection site pain
• Fatigue
• Headache
• Sore throat
• Muscle aches (with Xolair)
• Back pain (with Nucala)

Warnings and Interactions

Biologics can cause an allergic reaction. They should not be used if you have a severe infection—especially a parasitic infection, because the body typically fights parasites with IgE and eosinophils.

If you are taking steroids, your healthcare provider may reduce your dose cautiously after you start taking biologics for your asthma control. This will need to be done gradually and with medical supervision.

A Word From Verywell

The results of clinical studies assessing the safety and effectiveness of biologics for helping to control asthma and ward off exacerbations and asthma attacks have been promising—so much so that there are other such drugs being researched.

It's important to know, however, that these drugs are initially approved only to treat moderate to severe eosinophilic asthma or allergic asthma for people with a high IgE count.

If you are prescribed a biologic medication, show up for injections or infusions as directed, and maintain an ongoing dialogue with your healthcare provider about your symptoms so they can monitor the effectiveness of your overall asthma treatment and make any changes that might be necessary to keep you as symptom-free as possible.