Asthma and Allergy Flashcards
You see a patient in the asthma clinic who has had 2 ED attendances in the last month. They take a beclomethasone inhaler 100mcg T BD and montelukast. Lung function laboratory spirometry confirms mild reversible airflow obstruction. Allergy skin testing to common aeroallergens confirms grass pollen allergy. Exhaled nitric oxide (FeNO) in clinic is measured at 68ppb. Their inhaler is increased to 200mcg BD and their inhaler technique is checked and found to be therapeutic. They return to clinic three months later and exhaled FeNO is measured at 74ppb .
Which ONE of the following is the single most likely explanation for the persistently raised FeNO?
A. Cocomitant allergy
B. incorrect diagnosis
C. Poor adherence to inhaled therapy
D. Smoking
E. Vape use
C. Poor adherence to inhaled therapy
The most likely cause of a persistently raised FeNO in this person with asthma, despite an increase in ICS dose, is that they are not taking their inhaled therepy consistently. There are many possible reasons for this, and it is the job of the clinician to create a trusting relationship in which this can be tackled with the patient.
What is the mechanism of action of Omaluzimab?
Omaluzimab (Xolair) was the first licenced biologic for asthma, in 2005. It is a mAb which binds to free circulating IgE, inhibiting attachment to its receptor, reducing downstream inflammatory responses.
What are the NICE criteria for the use of Omaluzimab in asthma?
Omaluzimab is a mAb available in the UK to people with severe allergic asthma, which means a positive skin prick test or in vitro reactivity to a perennial aeroallergen (spIgE), & ≥4 severe exacerbations in the last year (or the need for continuous oral corticosteroids) despite optimised treatment.
What is the mechanism of action of Mepoluzimab?
Mepoluzimab was licenced for severe eosinophilic asthma in 2015. It’s an anti IL-5 MAb (monoclonal antibody). IL-5 is crucial for development, migration & survival of eosinophils. Mepo reduces blood & sputum eos numbers.
What are the NICE criteria for the use of Mepoluzimab in asthma/allergic conditions?
Mepoluzimab is a mAb available in the UK to people with severe eosinophilic asthma, as well as those with EGPA or Chronic Rhinosinusitis with Nasal Polyps. In asthma, patients need eos ≥300 & 4 severe exacerbations, or eos ≥400 & 3 severe exacerbations in 12 months despite optimised treatment (the latter criteria is the same as for benralizumab or reslizumab).
What is the mechanism of action of Reslizumab?
Reslizumab is a recombinant humanised IgG4 mAb that, like mepolizumab, binds IL-5. IL-5 promotes the growth, differentiation, and activation of eosinophils. Resli is intravenous, not subcut like the other biologics for asthma, & was licenced in 2017.
What are the NICE criteria for Reslizumab?
Reslizumab is available to people with severe eosinophilic asthma ie eos ≥400 & 3 or more severe exacerbations in 12 months despite optimised treatment
What is the mechanism of action of Benralizumab
Benraluzimab is a mAb which ligates the α subunit of the IL-5 receptor, expressed on eosinophils & basophils, inducing antibody-dependent cell mediated cytotoxicity & apoptosis. Blood eos fall to 0 very rapidly (within 4hr) following administration of Benralizumab.
What are the NICE criteria for the use of Benralizumab?
Benraluzimab is available to people with severe eosinophilic asthma ie eos ≥400 & 3 or more severe exacerbations in 12 months despite optimised treatment
What is the mechanism of action of Dupilumab?
Dupilumab is a mAb targeted against the α subunit of the IL-4 receptor, a ligand for both IL-4 and IL-13.
What are the NICE criteria for the use of Dupilumab?
Dupilumab is available in the UK for severe asthma with eos ≥400 & FeNO ≥25ppb & 4 exacerbations in 12 months. Importantly patients have to have failed or not be eligible for mepo/resli/benra to get Dupi according to NICE guidance
What is the mechanism of action of Tezepelumab?
Tezepelumab is a mAb targeting the alarmin TSLP, which is released by epithelial cells in response to pro-inflammatory stimuli. It sits higher up the inflammatory cascade than IL-5, IL-4 & IL-13 so blocking it may have broader effects.
What is the NICE criteria for the use of Tezepelumab?
Dupilumab is now available in the UK (since Apr 2023) for severe asthma inadequately controlled despite high dose ICS plus one other drug with ≥3 exacerbations in past year requiring OCS or continuous OCS.
