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Dr Neal Jain Discusses the Use of Dupilumab in Oral Steroid–Dependent Asthma


Patients who have oral corticosteroid–dependent asthma are recommended to use dupilumab, which reduces the use of oral steroids, explained Neal Jain, MD, FAAP, FAAAAI, of Arizona Allergy & Immunology Research.

Patients who have asthma and are oral corticosteroid dependent are recommended to use dupilumab, which has been shown to reduce the use of oral steroids, explained Neal Jain, MD, FAAP, FAAAAI, director of research at Arizona Allergy & Immunology Research and a co-owner of Arcadia Allergy & Asthma and San Tan Allergy & Asthma.


What role might guidelines play in the use of dupilumab? What is the recommendation?

Yeah, so fortunately, there have been guidelines put out by the Global Initiative for Asthma or GINA, as most people know it, and those have been updated annually, not only for asthma in general, but there's also been this sort of pocket guide for the evaluation and management of difficult-to-treat and severe asthma that's been put out by GINA. And that really is a nice guide that I think provides a nice algorithm for individuals that are managing severe asthma or difficult-to-treat asthma. And it walks you through, you know how you go through the evaluation of an individual, evaluating specifically for those type 2 biomarkers, including eosinophils and potentially exhaled nitric oxide, and potentially others to determine if someone does have type 2 inflammation and fits the sort of criteria for difficult to treat for severe asthma.

Obviously, you have to adjust for and look for things like nonadherence and other factors prior to sort of saying that someone truly has severe asthma. But after you've done that, you identify someone as having type 2 inflammation they do recommend, dupilumab or anti–[interleukin]-4 therapy is one of the options that can be considered and used and individuals that have difficult to treat asthma, severe asthma, and in particular, oral steroid–dependent asthma.

What is the importance of reducing oral corticosteroid dependency in patients with asthma, as dupilumab has been shown to do in studies?

Yeah, so I mean, we are unfortunately, learning more and more about the potential negative impact of oral steroids not only used chronically but even in intermittent bursts, and the role that those steroids may have on long-term outcomes, including things like osteoporosis, glucose metabolism, waking eye issues. So, there's a number of things that can occur from chronic oral steroid use, and a number of negative health outcomes that can result from oral steroid use. And certainly, in those that are oral steroid dependent, those risk factors are amplified, and we oftentimes see them.

So, you know, and historically, we really haven't had great options that we've had available for us. If you look back at the initial omalizumab studies, the Xolair studies, they weren't actually able to demonstrate efficacy in patients that had oral steroid–dependent asthma. So, it's nice, now that we have a couple of options for patients that have oral steroid–dependent asthma. In particular, you know, one that is in the label for dupilumab is that…it is a medication indicated for those [with] oral steroid–dependent asthma, and has been shown regardless of biomarkers to reduce the need for oral steroids in those individuals that have oral steroid-dependent asthma.

So, you know, it's a necessary tool, one that we've, you know, really eagerly been anticipating to use, and we fortunately had a lot of good success early on, and those that have oral steroid–dependent asthma.

And I think it's also important to note that a lot of our oral steroid–dependent asthmatics, probably about 20% or more, also have comorbid, chronic rhinosinusitis with nasal polyps. It's oftentimes difficult to ascertain in those individuals that have comorbid disease, how much of their oral steroid dependency is coming from their upper airway versus their lower airway, because they're oftentimes on oral steroids and they'll describe feeling short of breath and having difficulty with control of their asthma when they're off of oral steroids and you can't tell if that's really coming from their upper or lower airways.

And when we've oftentimes maybe had success in controlling the asthma component with other biologics, we often see that their nasal polyposis and chronic rhinosinusitis actually worsens upon withdrawal of oral steroids. And dupilumab has been nice because we've actually been able to get people on much lower doses and sometimes off their oral steroids with control both of their upper and lower airway disease. So, it really is a nice entry into the market for those individuals.

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