Patients with severe asthma tend to have poor control despite numerous medications. This may result in emergency room visits, hospitalizations and urgent visits with physicians. One way to measure asthma control is how many exacerbations (flare ups) a person has per year. Another indication of control is quality of life, how often a person needs to take their rescue inhaler, how often someone awakens at night due to asthma, how often activities are missed or avoided. The requirement for systemic steroid (cortisone) medicines given by mouth or injection is another indicator of asthma control. Though systemic steroids can be very helpful in short courses, prolonged use has many side effects. A new class of medicine, a Biologic, holds the hope of improving the lives of patients with severe asthma.
Biologics are not synthesized chemicals like most medications. Biologics are proteins that are made in cell cultures. These proteins are G antibodies, the most common antibodies humans use for fighting infections. An antibody sticks to a particular protein on the surface of a bacteria or virus and activates the immune system to protect against or fight infection. Biologics are mono clonal (recognize only one protein) antibodies that are designed to affect a particular protein in the body. There are many biologics used in medicine to treat auto immune disease (Rheumatoid arthritis, Psoriasis and Psoriatic arthritis, etc), cancer and other conditions. This is an exciting time as new biologics with unique capabilities are being developed for many diseases. For example, several are in development now for prevention of migraine headaches.
15 years ago the first Biologic for asthma, Xolair, was introduced in the United States. Xolair functions by binding to E (allergic) antibody, the mediator of allergic asthma and nasal and eye allergy. When antibody E is bound a person has a marked reduction in all manifestations of allergy, especially allergic asthma. Xolair can be thought of as a universal allergy shot as it is effective for allergy to all inhaled substances. Xolair is administered every 2 to 4 weeks in a physician’s office with an observation period afterward for safety. The primary side effect of Xolair is an allergic reaction similar to that seen with routine allergy shots. These reactions are treated with an injection of epinephrine. We have many patients on Xolair injections for asthma, some for as long as 10 years. With a 15 year track record of safety, we feel confident in recommending Xolair to the appropriate patients with severe asthma. Coincidentally, Xolair has been found to be effective in people with chronic (more that 6 weeks) spontaneous (no known cause) hives and giant swelling.
Recently three new Biologics have become available for severe asthma. These include Nucala, Fasenra and Cinqair. These target eosinophils, a destructive white blood cell that causes serious inflammation in the lungs of patients with asthma. Eosinophils normally function to destroy parasites like tropical worms or amoeba but can turn against the fragile lining of the airways in asthma. Some patients with severe asthma are not allergic and antibody E is not felt to cause problems. In these patients, one of these newer biologics might be helpful. These are given in the office on a monthly or every 2 month schedule and tend to have few side effects. We have some patients on Nucala and Fasenra who have had relatively remarkable improvements when their asthma was previously poorly controlled with conventional therapy.
In the near future another biologic, Dupixent, will likely be approved for asthma. Dupixent is already being used for eczema.
If you or a friend or family member have significant asthma that is not well controlled, consider calling 512-345-7635 for a consultation visit.