Dupilumab outperforms other biologics in asthma outcomes
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Key takeaways:
- Dupilumab had lower hazard ratios for asthma-related exacerbations than omalizumab or mepolizumab.
- Patients had greater improvements in measurements of FEV1.
Patients with asthma and specific eosinophil and IgE levels experienced greater improvements in exacerbations and FEV1 with dupilumab compared with other biologics, according to a study.
These results indicate that dupilumab (Dupixent, Sanofi Genzyme/Regeneron) may be a better choice for patients who are eligible for multiple biologics, Ayobami T. Akenroye, MBChB, MPH, PhD, associate physician in the division of allergy and clinical immunology at Brigham and Women’s Hospital in Boston, and colleagues wrote in The Journal of Allergy and Clinical Immunology.
The retrospective cohort study analyzed 201 patients aged 18 years and older diagnosed with moderate to severe asthma who received biologics between March 1, 2016, and Aug. 31, 2021, in the Mass General Brigham Research Patient Data Registry.
Subgroups included 68 patients (mean age, 51.7 years; 61.8% women; 79.4% white) taking dupilumab, 68 patients (mean age, 47.7 years; 79.4% women; 76.5% white) taking omalizumab (Xolair; Genentech, Novartis) and 65 patients (mean age, 54.5 years; 66.2% women; 75.4% white) taking mepolizumab (Nucala, GSK).
Participants all had baseline IgE levels between 30 kU/L and 700 kU/L and eosinophil counts of at least 150 cells/µL. The researchers followed patients from their index date to 12 months later or Aug. 31, 2021, whichever came first.
During the 12-month follow-up period, the dupilumab group reported 31 exacerbations over 68 person years, or 0.46 exacerbations per person year. The omalizumab group reported 63 exacerbations over 68 person years, or 0.93 exacerbations per person year. The mepolizumab group reported 86 exacerbations over 65 person years, or 1.32 exacerbations per person year.
Adjusted incidence rate ratios (IRRs) included 0.28 (95% CI, 0.09-0.84) for dupilumab vs. mepolizumab, 0.36 (95% CI, 0.12-1.08) for dupilumab vs. omalizumab and 0.78 (95% CI, 0.32-1.91) for omalizumab vs. mepolizumab.
Similarly, among patients with eosinophil counts of 300 cells/µL and higher, IRRs included 0.26 (95% CI, 0.08-0.82) for dupilumab vs. mepolizumab and 0.33 (95% CI, 0.09-1.24) for dupilumab vs. omalizumab.
Also, during the follow-up, 17 patients (25%) in the dupilumab group, 28 (43.1%) in the mepolizumab group and 27 (39.7%) in the omalizumab group experienced asthma-related exacerbations.
Adjusted hazard ratios included 0.35 (95% CI, 0.18-0.71) for dupilumab vs. mepolizumab, 0.42 (95% CI, 0.2-0.87) for dupilumab vs. omalizumab and 0.84 (95% CI, 0.47-1.5) for omalizumab vs. mepolizumab.
Hazard ratios for patients with eosinophil counts of 300 cells/µL and higher included 0.26 (95% CI, 0.1-0.67) for dupilumab vs. mepolizumab and 0.24 (95% CI, 0.09-0.63) for dupilumab vs. omalizumab.
The researchers also found that 11 patients (18.6%) on omalizumab, one (1.4%) patient on dupilumab and 16 (25%) on mepolizumab switched therapy during the follow-up period, which the researchers considered failure events.
Hazard ratios for failure events with these switches included 0.44 (95% CI, 0.28-0.71) for dupilumab vs. mepolizumab, 0.72 (95% CI, 0.43-1.21) for dupilumab and omalizumab and 0.62 (95% CI, 0.38-1) for omalizumab vs. mepolizumab.
Patients on dupilumab experienced greater changes from baseline in FEV1 through the follow-up period compared with those on mepolizumab (mean difference, 0.11 L; 95% CI, –0.003 L to 0.222 L) and those on omalizumab (mean difference, 0.082 L; 95% CI, –0.04 L to 0.204 L).
The researchers noted, however, that these differences were not statistically significant. Also, they continued, results among patients with eosinophil counts of 300 cells/µL and higher were consistent.
Further, the researchers said, 51 (75%) of the patients on dupilumab, 62 (95.4%) of those on mepolizumab and 61 (89.7%) of those on omalizumab began therapy on or before Oct. 1, 2019.
The hazard ratios for exacerbations among these patients included 0.25 (95% CI, 0.11-0.59) for dupilumab vs. mepolizumab, 0.22 (95% CI, 0.09-0.54) for dupilumab vs. omalizumab and 1.12 (95% CI, 0.63-2.01) for omalizumab vs. mepolizumab.
There were no significant differences in the hazard ratios for ED visits for nonasthma conditions during the 12-month follow-up between the three groups.
Overall, the researchers concluded that patients on dupilumab had less risk for asthma-related exacerbations than those on omalizumab or mepolizumab, with greater but not statistically significant improvements in FEV1, with similar results among patients with higher eosinophil counts and across multiple sensitivity analyses.
However, the researchers said, additional research should investigate individuals who are eligible for multiple treatments and those who have both eosinophilic and allergic asthma to determine if there is a hierarchy of phenotypes among these patients.