Asthma: Diagnosis and Management ____________________________________________________________
The frequency of injections may be reduced, but the allergen dose may be increased for up to three to five years. Successful immunotherapy results in fewer symptoms and decreased need for medication to control allergies and allergy-related asthma. Immunotherapy is generally more successful in children than adults. Studies report that this preventive treatment is effective in reducing symptoms of allergic asthma if the allergies involve animal dander, house dust mites, pollen, or fungi; to date, research has not confirmed that the positive effects are lasting. Also, immunotherapy may be costly and time-consuming and may not result in a complete cure. Even without cure, lessen- ing an allergic reaction can result in better control of asthma and asthma-like symptoms. It may also provide additional time for medical interventions in cases of severe asthmatic reactions [8; 9; 13]. Several biologics for moderate-to-severe allergic and/or eosino- philic asthma are currently approved by the FDA. Omalizumab has become a widely used option for patients with persistent allergic asthma not adequately controlled with inhaled cor- ticosteroids, either alone or in combination with inhaled long-acting beta 2 agonist bronchodilators. Omalizumab is a humanized monoclonal antibody that binds circulating IgE antibody, which leads to a decrease in the release of media- tors in response to allergen exposure. It is approved for the treatment of adults and children older than 12 years of age in conjunction with inhaled corticosteroids and long-acting beta 2 agonists. The agent is administered subcutaneously every two or four weeks (depending on the dosage schedule), and the dose used is based on pretreatment IgE serum levels and body weight. Possible adverse effects of omalizumab use include injection site pain and bruising, viral infection, headache, and sinusitis. Allergic reactions (e.g., urticaria, anaphylaxis) occur in 0.1% to 0.2% of patients [9; 35; 41]. Several other biologics have been approved to treat moderate- to-severe allergic and moderate-to-severe asthma with levels of blood eosinophils (i.e., eosinophilic asthma). These therapies include three monoclonal antibodies that treat eosinophilic asthma by targeting IL-5 pathways (mepolizumab, reslizumab, and benralizumab), and one that treats both eosinophilic and allergic asthma by targeting IL-4/IL-13 pathways (dipilumab). Patients with eosinophilic asthma should have their blood eosinophils tested several times per year, as studies have shown that eosinophil count may shift over time into a range that may warrant immunotherapy [11; 35; 42]. Another novel monoclonal antibody (tezepelumab-ekko) binds to human thymic stromal lymphopoietin (TSLP) and blocks the interaction with the TSLP receptor. The interaction reduces the biomarkers and cytokines associated with inflammation, including blood eosinophils, airway submucosal eosinophils, IgE, IL-5, and IL-13. Tezepelumab-ekko is the first biologic approved for all types of severe asthma [35; 43] Mepolizumab was approved in 2015 for use in patients 12 years of age and older. Patients with uncontrolled asthma who are receiving NAEPP step 5 or 6 treatment, with an initial blood eosinophil count of ≥150 cells/mcL and at least two asthma exacerbations requiring systemic corticosteroids in the past year are good candidates for therapy ]. Mepolizumab is administered
as a subcutaneous injection every four weeks at a fixed dose of 100 mg [9; 35; 42]. Reslizumab is approved for patients 18 years of age and older. Patients with severe eosinophilic asthma (initial blood eosinophil count of ≥400 cells/mcL) that is not controlled with high-dose corticosteroids and inhalers and who have a history of exacerbations may be good candidates. Reslizumab is administered as an IV infusion every four weeks at a dose of 3 mg/kg [35; 42. Benralizumab is approved for patients 12 years of age and older as add-on maintenance treatment for uncontrolled severe eosinophilic asthma (recommended for blood eosinophil count of ≥300 cells/mcL). Benralizumab is administered at a dose of 30 mg subcutaneous every four weeks for the first three doses and then once every eight weeks [35; 42]. Dupilumab is also approved for patients 12 years of age and older as an add-on maintenance treatment for moderate-to- severe allergic and/or eosinophilic asthma. Indications for use include NAEPP steps 5–6, inflammation characterized by increased blood eosinophils and/or elevated FeNO. Dupil- umab is initially administered as two 200-mg (total: 400 mg) or two 300-mg (total: 600 mg) subcutaneous injections, followed by one 200-mg or 300-mg injection (depending on initial dose) every other week [35; 42]. Tezepelumab-ekko was approved in 2021 for patients 12 years of age and older as an add-on maintenance treatment for patients with severe asthma (with or without inflammatory markers) and a history of severe exacerbations. Tezepeluab-ekko may be used for any type of asthma and is administered subcu- taneously at a dose of 210 mg once every four weeks [35; 43] Complementary or Alternative Treatments There are many alternative or complementary therapies avail- able to patients with asthma. In general, these therapies should be regarded as adjuncts, not replacements, to conventional treatment. The most common complementary therapies used in the management of asthma include breathing exercises, acupuncture, yoga, postural drainage, massage therapy, home- opathy, and herbal medications. There has been relatively little research into the effectiveness of complementary treatments in the management of asthma. However, some inconclusive, small trials support the further investigation of these treatment modalities. For example, studies focusing on magnesium’s role in lung function have found that the element appears to block chemicals that inflame the lungs by stabilizing mast cells and T cells released during exposure to allergens. The results are relaxed airway muscles and open bronchioles, which contribute to improved lung function and a reduction in wheezing and other allergy-induced asthma symptoms. Magnesium is often used in the emergency department, but it is not recommended in the management of chronic asthma. Patients and/or their caregivers should be cautioned not to self-prescribe these and
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