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September 16, 2022
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Q&A: Severe asthma treatment with biologics remains safe during COVID-19 pandemic

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Patients who received biologic treatment for asthma did not experience higher SARS-CoV-2 infection rates than the general population, according to a study published in The Journal of Allergy and Clinical Immunology: In Practice.

Also, the use of biologics in treating severe asthma did not seem related to adverse outcomes from severe COVID-19, although infected patients with asthma appeared to be at higher risk for hospitalization, the researchers found.

Woman receiving a vaccine
Source: Adobe Stock

Healio spoke with Andriana I. Papaioannou, MD, PhD, consultant in respiratory medicine at Attikon University Hospital in Athens, Greece, to find out more about the study and its results.

Healio: What prompted this study?

Papaioannou: Because respiratory viral infections have been well recognized as risk factors for asthma exacerbations, it was initially hypothesized that SARS-CoV-2 infection would also act as an exacerbation trigger. However, at the time we were designing this study, relevant published reports studying patients with asthma had provided controversial results on whether severe asthmatic patients were at increased risk for experiencing more severe disease.

Andriana I. Papaioannou

Another important issue we were concerned with at the time was whether the use of biological agents for severe asthma might increase the risk for infection from SARS-CoV-2 and, if it does, if it negatively affects the outcome of the disease.

Therefore, we decided to prospectively observe a cohort of patients with severe asthma treated with biologics regarding their risk for SARS-CoV-2 infection and COVID-19 severity and outcomes and to assess any differences in all the above with respect to the different biological treatments administered.

Healio: Were there any particularly surprising or significant results?

Papaioannou: We showed that treatment with biologics was not associated with an increased risk for SARS-CoV-2 infection. In fact, only 4.4% of the patients in our cohort had a SARS-CoV-2 infection during the first 14 months of the pandemic, which is a lower prevalence than the estimated prevalence of COVID-19 in Greece at that time.

Potential reasons for this observation might include self-protection measures such as social distancing, lockdown restrictions and hygiene rules, mainly due to awareness of viruses acting as a trigger for exacerbations.

Another possible explanation is that the use of biological therapies results in better asthma control among patients with severe disease, preventing the chronic or recurrent use of systemic corticosteroids, which is a predisposal factor for SARS-CoV-2 infection, due to decreased innate and acquired immunity.

However, once infected, these patients seem to be at greater risk of hospital admission due to COVID-19 complications. Some also seem to lose asthma control and to experience symptoms of an asthma exacerbation. In our cohort of severe asthmatics treated with biologics, almost 35% required hospital admission, an incidence that is much greater than those reported from other severe asthma registries.

Because we have not evaluated significant differences in the baseline characteristics between patients who required hospital admission and those who did not, these results should be interpreted with caution. Further research is probably needed to recognize the patients who are at greater risk for more severe COVID-19.

Healio: Are there any other factors that could have affected these results?

Papaioannou: Interestingly, all patients admitted to the hospital were under anti-IL-5 treatment. At that time, very few patients were receiving anti-IL-5 receptor treatment for severe asthma, and the remaining patients in our study were receiving anti-IgE therapy. This association might be related to the eosinophil depletion caused by this biologic, which, according to the previous studies, might predispose patients to more severe disease.

Moreover, the presence of allergic disease in combination with anti-IgE therapy might have exhibited a somehow protective role against severe COVID-19. It has been shown in previous studies that allergies are associated with significant reduction in angiotensin-converting enzyme 2, or ACE2, expression, which is the cellular receptor for SARS-CoV-2.

Also, it is known that the blockage of the circulating IgE by anti-IgE therapy leads to a long-lasting reduction of its production and a decrease in the expression of IgE receptors on plasmacytoid dendritic cells, a phenomenon that might generally strengthen the antiviral immune responses of these cells of the immune system.

However, we have to admit that patients in the anti-IL-5 group were older, and the one patient who died was obese and had severe comorbidities (diabetes and cardiovascular disease) that are known predisposing factors for poor outcomes with COVID-19.

Finally, in our cohort, only two patients did not receive their scheduled dose of biologic during SARS-CoV-2 infection on time. They both received it 7 days later. In our study, the treating physician was free to decide whether to postpone biologic administration. In most cases, scheduled administration was decided, even in patients who were hospitalized for severe COVID-19. These decisions did not lead to adverse outcomes, and we believe that also contributed to the fact that in most patients, asthma remained controlled during SARS-CoV-2 infection.

Healio: How can doctors use these findings to improve care?

Papaioannou: Our study confirms that the use of biologics for the treatment of severe asthma is safe during the pandemic and, despite the initial concerns, COVID-19 is not more common among asthmatics treated with biologics compared with the general population.

Although there is no official guideline on whether biologic treatment should be postponed during SARS-CoV-2 infection, it has been suggested that treatments with biologics during the COVID-19 pandemic appear to be safe and can be administered normally but should be interrupted in cases of confirmed SARS-CoV-2 infection.

From the clinical experience in our country, we suggest that scheduled doses of biologic therapy could be administered on time, even regardless of SARS-CoV-2 infection, as such a practice does not seem to result in adverse outcomes.

Healio: What is the next step in this research?

Papaioannou: We believe that it would be interesting to study the outcomes of the same cohort of patients during the vaccination period, when a high coverage of this vulnerable population has been achieved.

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Caminati M, et al. J Allergy Clin Immunol. 2020;doi:1016/j.jaci.2020.05.049.

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For more information:

Andriana I. Papaioannou, MD, PhD, can be reached at papaioannouandriana@gmail.com.