Dupilumab seems to prevent exacerbations more effectively than do other agents.

About 70% of asthma patients have ‘type 2’ disease with eosinophilic or allergic inflammation. For such patients whose asthma is not controlled by inhaled corticosteroids and long-acting beta-agonists, several biologics are available that target mediators of type 2 inflammation: mepolizumab, benralizumab and reslizumab target interleukin (IL)-5; dupilumab targets IL-4/IL-13; omalizumab targets IgE; and tezepelumab targets thymic stromal lymphopoietin. Because we have no head-to-head data to compare these drugs, researchers analysed data from US patients (age, 12 years and older) who started dupilumab, benralizumab or mepolizumab (about 1800 patients in each group) within one year of asthma diagnoses.

Incidence of exacerbations within one year of starting treatment among patients who took dupilumab, benralizumab and mepolizumab were 1.04, 1.47 and 1.45, respectively. 

Comment: Patients who started dupilumab had fewer exacerbations than did those who started anti-IL-5 biologics. Tezepelumab was not yet available when this study was done, but a network meta-analysis has suggested that tezepelumab is comparable to dupilumab. Conversely, previous analyses suggest omalizumab is less effective in preventing exacerbations than are the other biologics. When clinicians are choosing a biologic, they should first think about comorbid conditions (e.g. dupilumab is effective for atopic dermatitis, eosinophilic esophagitis and chronic sinusitis with nasal polyps; the anti-IL-5 products are effective for hypereosinophilic syndromes; and omalizumab is used for chronic urticaria and food allergy). All else being equal, dupilumab (and probably tezepelumab) seem to be superior for limiting asthma exacerbations.

David J. Amrol, MD, Associate Professor of Clinical Internal Medicine, Director of the Division of Allergy and Immunology, University of South Carolina School of Medicine, Columbia, USA.

Kearney CM, et al. Comparative effectiveness of mepolizumab, benralizumab, and dupilumab among patients with difficult-to-control asthma: a multicenter retrospective propensity-matched analysis. Ann Am Thorac Soc 2024; 21: 866-874.

This summary is taken from the following Journal Watch titles: General Medicine, Ambulatory Medicine.