Dupilumab outperforms other biologics in reducing asthma exacerbation rate

Key takeaways:

• Patients with difficult-to-control asthma had reduced asthma exacerbation rates with dupilumab vs. benralizumab and mepolizumab.
• Use of dupilumab also prolonged the time to first exacerbation.

Between dupilumab, benralizumab and mepolizumab, patients with difficult-to-control asthma had the lowest rate of exacerbations in the first year of dupilumab, according to results published in Annals of the American Thoracic Society.

“In patients with difficult-to-control asthma who are started on biologic therapy, dupilumab is associated with lower rates of asthma exacerbations, longer time to first exacerbation and improved measures of asthma control in the first year of biologic therapy compared to treatment with benralizumab or mepolizumab,” Christopher M. Kearney, MD, MPH, assistant professor of pulmonary, allergy, sleep and critical care medicine at Boston University Chobanian & Avedisian School of Medicine, and colleagues wrote.

In a retrospective multicenter cohort study using data taken between October 2018 and September 2022, Kearney and colleagues assessed 3,943 patients with difficult-to-control asthma started on dupilumab, 1,902 patients started on benralizumab and 2,012 patients started on mepolizumab, all aged 12 years or older, to see which biologic therapy is linked to the lowest rate of asthma exacerbations at 1 year.

Researchers matched users of one biologic to users of a different biologic using propensity scores and compared the various pairings to see which was linked to a more favorable outcome.

Notably, matching made covariates “well balanced” across all pairwise comparisons, according to researchers.

When comparing dupilumab with benralizumab, each group had 1,805 patients, whereas between dupilumab and mepolizumab, each group had 1,865 patients. In the last pairing between mepolizumab and benralizumab, each group had 1,721 patients.

Patients within all groups received an inhaled corticosteroid, and fluticasone was the most frequently reported prescription (66%-70%).

Between dupilumab and benralizumab, researchers found a significantly reduced rate of asthma exacerbations in the dupilumab group (1.07 per year vs. 1.47 per year; rate ratio, 0.73; 95% CI, 0.63-0.85).

A similar result was observed when comparing patients who started on dupilumab with patients who started on mepolizumab, with the dupilumab group again having a lower rate of exacerbations at 1 year (1.04 per year vs. 1.45 per year; rate ratio, 0.72; 95% CI, 0.62-0.84).

In the last pairing of mepolizumab and benralizumab, researchers found comparable rates of exacerbations (1.4 per year vs. 1.41 per year; rate ratio, 1; 95% CI, 0.85-1.17).

Dupilumab further outperformed benralizumab and mepolizumab when assessing asthma exacerbation rates among those with a prior diagnosis of severe persistent asthma, as well as those with an absolute eosinophil count over 300 cells/µL.

As an additional measure, researchers evaluated the time to first exacerbation between the biologic groups and found a significantly longer time to this event in the dupilumab group compared with the benralizumab group (P = .002) and the mepolizumab group (P = .05). This time did not differ between the mepolizumab group and the benralizumab group.

Notably, the likelihood for several outcomes declined with use of dupilumab vs. benralizumab or mepolizumab, including:

• having one or more asthma exacerbations (RR = 0.87; 95% CI, 0.79-0.95; RR = 0.91; 95% CI, 0.83-0.99);
• receiving a prescription for a systemic corticosteroid at least once (both, RR = 0.94; 95% CI, 0.89-0.99); and
• receiving a diagnosis of severe asthma in the year after starting biologic therapy (RR = 0.88; 95% CI, 0.83-0.93; RR = 0.89; 95% CI, 0.84-0.94).

Between dupilumab and mepolizumab, researchers also observed that patients on dupilumab had a lower likelihood of adjunctive therapy use (RR = 0.9; 95% CI, 0.85-0.96) and having to switch to an alternative biologic agent (RR = 0.76; 95% CI, 0.64-0.91).

“Head-to-head prospective comparisons would be helpful to further inform biologic therapy selection,” Kearney and colleagues wrote.