What a Review Says About Biologics for Allergic Bronchopulmonary Aspergillosis, Asthma, CF

With the introduction of several biologics for the treatment of allergic bronchopulmonary aspergillosis (ABPA) once patients with cystic fibrosis (CF) or asthma have failed to respond to or develop side effects to systemic steroid treatment, researchers have performed a literature review of the evidence supporting the strategy.

The review of 32 studies, all but 1 of which were descriptive in nature, revealed that biologic treatment—omalizumab, mepolizumab, dupilumab, or benralizumab—tended to favor patients with ABPA and asthma than those with CF.

The researchers caution that “the biggest limitation is that there is substantial heterogeneity among studies, a high risk of bias inherent in these types of descriptive studies and significant differences in sample size, making it inappropriate to attempt to do other statistical analysis on the results. Therefore, this article has a narrative purpose, in which no robust conclusions can be drawn.”

Omalizumab

The majority of the literature available on the use of biologics for patients with asthma who developed ABPA came from treatment with omalizumab. Across the available studies of these patients, 11 of 27 patients achieved more than a 35% reduction in total IgE values—typically considered a success of treatment—between 5 months and 3 years of follow-up. Among 10 patients, 85.7% has eosinophil counts drop below 500cells/μL following treatment. There were also 18.2% of patients across 5 studies who had no exacerbations between 9 months and 1 year following the initiation of treatment and 70 who had a reduced and 67.3% who had a reduced frequency of exacerbations between 3 months and 3 years of treatment.

Results were not as promising in patients with cystic fibrosis receiving treatment for ABPA. There were just 2 studies available, both of which assessed the utility of omalizumab. One of these studies has data on IgE levels, showing that the treatment led to a median of 437.5 IU/mL after 8-27 months of follow-up. The other study included data on exacerbations, finding that all but 1 patient had acute pulmonary exacerbations, with a median of 3.5 exacerbations.

Mepolizumab

Among 4 patients with asthma being treated for ABPA with mepolizumab, 66.5% had a reduction in total IgE values over 5-14 months of follow-up. Among 38 patients, all had eosinophil counts below 500 cells/μL after treatment. Only a few studies accounting for 21 patients looked at the impact of treatment on annual acute exacerbations, with 1 study reporting 0 exacerbation per year among the 20 patients after treatment and with the rest of the studies showing 25% of patients having an improvement in the rate of exacerbations.

Dupilumab

There were 2 studies that assessed dupilumab in 21 patients with asthma being treated for ABPA. IgE levels reached 384 IU/mL after 3-4 months of follow-up in 1 study and were reduced by more than 35% in the second study after 13 months of follow-up. The treatment also reduced annual exacerbation rates in 95% of patients.

Benralizumab

There were just 2 case reports detailing the impact on benralizumab in patients with asthma being treated for ABPA, which similarly revealed decreases in IgE and eosinophils, as well as a drop in the frequency of exacerbations.

Reference

Eraso I, Sangiovanni S, Morales E, Fernández-Trujillo L. Use of monoclonal antibodies for allergic bronchopulmonary aspergillosis in patients with asthma and cystic fibrosis: literature review. Ther Adv Respir Dis. 2020;14:1-16. doi: 10.1177/1753466620961648