Weighing the Pros, Cons of At-Home Use of Biologics for Asthma

When the first biologic to treat asthma was approved by the FDA in 2003, it needed to be administered subcutaneously in the physician’s office. Now, there are 3 options available for at-home use: mepolizumab, benralizumab, and dupilumab.

During a session at the CHEST 2020 annual meeting, Diego J. Maselli, MD, FCCP, associate professor of medicine, Division of Pulmonary Diseases and Critical Care, University of Texas Health San Antonio, and director, Severe Asthma Program, University Health System, highlighted the pros and cons of in-office and at-home administration of biologics to treat asthma.

However, physicians are faced with a dilemma: where does the therapy get administered and how do they choose what is best for their patient?

The benefits of using biologics to treat asthma in office is that there is increased compliance to the medication, increased provider interaction so patients can ask questions, and, to some extent, improved asthma care.

“Providers can look at [the patient] and see how they’re doing and evaluate their asthma control,” Maselli explained.

In addition, when biologics are administered in the physician’s office, patients can be monitored for side effects, which is particularly beneficial with the first few doses, he said.

However, there is more convenience when the biologics are administered at home. Patients don’t need to worry about traveling to the office, parking, and waiting to be seen. When they have the option to take the biologic at home, patients don’t have to worry about the office visit interfering with school, work, or other important responsibilities.

“Some of our patients, as you know, they work or go to school, and they're very busy,” Maselli said. “And sometimes the only time that they have is on the weekends. So, even though some clinics are open Saturdays, it's still troublesome for some of them to find time to get these shots.”

A study published in February looking at the average distance and time to an administration clinic compared with a regular primary care physician (PCP) office found that patients in rural New England spent considerably more time driving to the clinic to receive their biologic than they would to see their PCP.¹ The study looked specifically at patients being treated with omalizumab or mepolizumab. Patients receiving omalizumab spent an average of 59 minutes driving to the clinic compared with 19 minutes to the PCP’s office. Patients receiving mepolizumab spent an average of 46 minutes driving to the clinic compared with 21 minutes to the PCP’s office.

Dupilumab is the only biologic that was approved from the start for at-home use; the other biologics gained approval for self-administration at home years after their initial approval. As such, there were some concerns about how patients currently receiving the biologic at the clinic would handle switching to administering the biologic at home, Maselli said.

However, home use is accepted well by patients. A study² of mepolizumab home use showed that 86% of patients found the biologic very or extremely easy to self-administer using the autoinjector at home; 88% felt very or extremely confident in using the autoinjector at home; and 75% reported feeling no or a little anxiety about self-administering at home. Furthermore, when patients were shown a pictogram of how to use the autoinjector and when clinicians spent a little time to highlight the features of the injector, confidence and ease increased and anxiety decreased.

“So, this just highlights the importance of having a good education, particularly when we're starting a patient from the normal injections,” Maselli said. “And they're not used to having injections, so that they can feel comfortable doing it at home.”

The fact that the safety of the biologics is similar at home and in the clinic is important with the coronavirus disease 2019 (COVID-19), because patients with asthma are at risk for poorer outcomes if they are infected. There has been some discussion about stopping biologic treatment, but current guidance is for patients to continue the therapy, he said. If biologic therapy is stopped, patients could experience exacerbations and end up in the hospital where they could potentially get infected with COVID-19.

Overall, the place of administration needs to be considered on a patient-by-patient basis, Maselli said.

“It's important to know that these medications, fortunately, are a good option for patients,” he said. “They appear to be safe; they appear to be effective and well accepted by the patients, which is important. So, we have that [at-home] option for our patients.”

Reference

1. Shaker M, Briggs A, Dbouk A, Dutille E, Oppenheimer J, Greenhawt M. Estimation of health and economic benefits of clinic versus home administration of omalizumab and mepolizumab. J Allergy Clin Immunol Pract. 2020;8(2):565-572. doi:10.1016/j.jaip.2019.09.037

2. Bernstein D, Pavord ID, Chapman KR, et al. Usability of mepolizumab single-use prefilled autoinjector for patient self-administration. J Asthma. 2020;57(9):987-998. doi:10.1080/02770903.2019.1630641