Immunomodulators for Asthma

In This Article

Immunomodulators are medications that, among other things, lessen the inflammatory process related to asthma. These injectable treatments—including Xolair (omalizumab), Dupixent (dupilumab), and others—are approved for the management of moderate and severe cases. Immunomodulators function as controller medications that help prevent asthma symptoms and are not effective for the acute relief of an asthma attack.

Several diseases can be treated with immunomodulators. For asthma, these drugs are typically used as an add-on therapy along with other asthma treatments. Your doctor may prescribe one for you if your symptoms have been persistent despite standard asthma treatment.

What Are Immunomodulators?

Biologics are a type of treatment made from living organisms. Asthma biologics are in a subtype of biologics called immunomodulators (immunotherapy), so named because they act on the immune system.

Immunomodulators are also used for diseases such as rheumatoid arthritis and inflammatory bowel disease (IBD). The specific immunotherapies used for asthma are monoclonal antibodies—specialized immune proteins that bind to a particular target in the body.

How They Work

Each type of immunomodulatory biologic drug targets a very specific aspect of the inflammatory response. Once a monoclonal antibody does this, it flags your immune system to kick in and destroy the target substance. This process helps alleviate the effects of the disease that's being treated.

Inflammation in asthma is the result of immune cells and proteins that induce a cascade of events in the lungs, with the final result being obstruction of the airways. Bronchoconstriction (narrowing of the airways) can be triggered by an excessive immune response to an inhaled substance or without any trigger at all.

Immunomodulators target one or more of the substances in this immune process to temper the inflammatory allergic response and limit asthma symptoms. Some of the key actors mitigated by these drugs include:

  • Immunoglobulin E (IgE): People with allergic asthma tend to have higher levels of IgE, an antibody overproduced during an allergic reaction, than the general population.
  • Cytokines: These are 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 cascade that produces asthma symptoms. 
  • Eosinophils: A higher-than-normal eosinophil count is consistent with an inflammatory condition such as allergic asthma. Interleukin cytokines, in particular, are involved in the overproduction of these white blood cells.

The treatment offered by immunomodulators is more focused than that of inhaled or oral corticosteroids, which cause broad immune suppression.

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 doctor 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 treatments. But when traditional asthma treatments alone don't produce adequate results, these add-on biologics have been shown to yield the following benefits:

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

Immunomodulators may be effective enough that your need for other asthma treatments is reduced. In fact, biologics have been associated with as much as a 25% decrease in corticosteroid use.

Types Used for Asthma

Five biologics have been approved by the U.S. Food and Drug Administration (FDA) as add-on asthma treatments. They don't all function the same way, and each is designed to target a slightly different aspect of the inflammatory process.

Your doctor will consider your medical history, symptom severity, blood tests, physical examination, age, and body weight when determining which biologic could be most effective for you, and at what dose.

Xolair (omalizumab)

Xolair (omalizumab) was the first biologic approved for use in asthma treatment. It is approved for adults and children age 6 and older who have moderate to severe asthma that doesn't adequately improve with inhaled steroids and who have a positive skin test or blood allergy test.

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

Omalizumab is administered via subcutaneous (under the skin) injection by a healthcare professional every two to four weeks and is dosed according to IgE levels and body weight.

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

These medications target IL-5 and the overproduction of eosinophils to aid in asthma maintenance.

  • Mepolizumab is indicated for severe asthma for adults and children age 12 and older who have a high eosinophil level with their asthma. It is injected subcutaneously by a healthcare professional at a fixed dose of 100 milligrams (mg) every four weeks.
  • Reslizumab is approved for adults age 18 and over who have severe asthma and a high eosinophil level. It is administered intravenously (IV, by vein) by a healthcare professional every four weeks at a dose of 3 mg/kg.
  • Benralizumab is approved for the treatment of severe asthma for adults and children age 12 and older who have eosinophilic asthma. A 30-mg dose of benralizumab is injected subcutaneously by a healthcare professional every four weeks for the first three months and then every eight weeks.

Dupixent (dupilumab)

This drug also targets eosinophil overproduction but does so via the IL-4 and IL-13 pathways. It is approved for treating moderate to severe eosinophilic asthma in adults and children age 12 and older.

Dupilumab is injected subcutaneously at either an initial dose of 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 you can learn to inject the medication yourself.

Regardless of which immunomodulator you use:

  • Be sure to follow package instructions.
  • Store the medication in its original container.
  • Keep it refrigerated and away from light, but do not freeze it.
  • Discard unused or expired medication.

Potential Side Effects

While biologics for asthma are generally well tolerated, you could experience some side effects, including:

  • Injection site pain
  • Fatigue
  • Headache
  • Sore throat
  • Muscle aches (with omalizumab)
  • Back pain (with mepolizumab)

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 doctor may reduce your dose cautiously after you start taking biologics for your asthma control. This reduction has to be done gradually and with medical supervision.

A Word From Verywell

While the clinical results assessing the effects of biologics in the treatment of asthma have been promising, immunomodulators are currently only approved for limited use as an add-on therapy for moderate or severe asthma with inadequate response to steroids—and have only been proven effective for eosinophilic asthma or high IgE asthma.

As you learn more about managing your asthma, you should discuss your options with your doctor, who will be able to answer your questions about immunomodulators and whether they may be suitable treatments for your asthma.

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Article Sources
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