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Exacerbations of Severe Asthma While on Anti-IL-5 Biologics

Bhalla A1*, Zhao N1*, Rivas DD2, Ho T1, Perez de Llano L2, Mukherjee M1, Nair P1

1Firestone Institute for Respiratory Health, St Joseph’s Healthcare & Department of Medicine, McMaster University, Hamilton, Ontario, Canada
2Department of Respiratory Medicine, Lucus Augusti University Hospital, EOXI, Lugo Cervo, Monforte, Spain
*Both authors contributed equally.

J Investig Allergol Clin Immunol 2020; Vol 30(5) : 307-316
doi: 10.18176/jiaci.0628

Anti-interleukin 5 (IL-5) and anti-IL-5 receptor α monoclonal antibodies markedly decrease airway and peripheral blood eosinophil numbers and are thus highly effective in reducing asthma exacerbations. Nonetheless, these biologics do not completely resolve exacerbations. There is very little information on the cellular nature of exacerbations during treatment with biologics. Using illustrative clinical case scenarios, we highlight the importance of carefully characterizing asthmatics at the time of exacerbation and recognizing neutrophilic causes of exacerbations to ensure optimal management. While an eosinophilic exacerbation may improve with more corticosteroids or by switching to another anti-IL-5 monoclonal antibody, a noneosinophilic exacerbation will likely not. An infective exacerbation needs to be recognized, and the pathogen must be identified and treated with the appropriate antimicrobial agent.

Key words: Severe asthma, Exacerbations, Anti-IL5 biologics, Sputum cell counts, Airway infections, Eosinophils