Using Nucala and Cinqair to Treat Severe Asthma

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Asthma is a common chronic disease affecting up to 12 percent of the population and is especially common in the United States and other Westernized countries. Asthma is characterized by recurrent episodes of wheezing, coughing, shortness of breath and chest tightness, with symptoms ranging from mild or intermittent to severe and life-threatening.

People with severe asthma can have a significant decrease in quality of life and can experience exacerbations resulting in the need for oral corticosteroids, emergency room visits, and hospitalizations.

There are a number of different asthma medications available to control asthma. Most commonly these include inhaled corticosteroids, long-acting bronchodilators, and leukotriene modifier drugs, such as Singulair. People with severe allergic asthma require the use of Xolair. Despite these various controller medications, however, many asthmatics continue to have frequent exacerbations requiring the use of oral or injectable corticosteroids. 

Xolair was the first commercially available biologic medicine for the treatment of moderate to severe asthma. It is a monoclonal antibody directed against IgE. This means that an antibody was produced in a laboratory setting against IgE antibody—a “trigger switch” for allergic reactions. When an asthmatic has allergic triggers, such as pet dander or dust mite, and symptoms aren’t controlled by usual medicines like inhaled corticosteroids, Xolair can be used to reduce asthma symptoms and exacerbation rates.


A number of different biologic asthma drugs are in production to address various types of asthma that may not respond to usual therapies or Xolair. Two biologic drugs were approved in late 2015 and early 2016 for the treatment of severe asthma characterized by high amounts of blood or sputum eosinophils.

Nucala (mepolizumab) is a monoclonal antibody that targets IL-5, a signaling chemical made by the body that causes the production, growth, and activation of eosinophils. Eosinophils are white blood cells that can cause tissue damage, inflammation, and muscle constriction in the lungs of asthmatics. 

Nucala works by counteracting the effects of IL-5, resulting in a decrease in the amount of sputum and blood eosinophils. Initial studies with mepolizumab failed to show any benefit of this effect in most people with asthma. However, people with severe asthma and high levels of sputum or blood eosinophils seemed to get better with the use of mepolizumab.

Specifically, people with this type of asthma were able to reduce their dose of oral corticosteroids taken to control their asthma, had overall improvement in asthma control (fewer asthma symptoms,) and had fewer asthma exacerbations over time. Some studies even showed that there was improvement in lung function measurements while taking Nucala.

Nucala is indicated for the treatment of severe, eosinophilic asthma in people 12 years of age and older who are not responding to usual asthma therapies. The dosage is the same for all people, regardless of age, weight or eosinophil level—which is 100 milligrams delivered subcutaneously as an injection every four weeks.

Side effects for Nucala are similar to those for placebo injections, although there is always a concern for anaphylaxis as a side effect with biologic injected medications. The rate of anaphylaxis was one percent of Nucala injections, but two percent for those receiving placebo injections. While Nucala doesn’t have a black box warning for anaphylaxis, people receiving Nucala injections should probably be monitored for an allergic reaction for a period of time by a physician experienced in treating anaphylaxis.


Cinqair (reslizumab) works in a very similar fashion as Nucala—it is also a monoclonal antibody against IL-5, but is a slightly different molecule. Cinqair also acts to decrease the amount of sputum and blood eosinophils, improves asthma symptoms and lung function, and reduces exacerbations in asthmatics with high sputum and blood eosinophils. Cinqair seems to be especially useful in a subgroup of asthmatics with nasal polyps since nasal polyp growth seems to be driven by IL-5.

Cinqair is indicated for the treatment of severe, eosinophilic asthma in people 18 years of age and older who are not responding to usual asthma therapies. The dosage is weight-based and delivered as an intravenous infusion every four weeks. The rate of anaphylaxis in people receiving Cinqair is 0.3 percent and therefore has a black box warning similar to Xolair.

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  • Nucala Package Insert

  • Cinqair Package Insert

  • Patterson MF, Borish L, Kennedy JL. The Past, Present and Future of Monoclonal Antibodies to IL-5 and Eosinophilic Asthma: A Review. Journal of Asthma and Allergy. 2015; 8:125-134.