In last year’s update, the Global Initiative for Asthma (GINA) had established two pathways (tracks) that can be followed to treat bronchial asthma. The 2022 GINA update has remained faithful to this scheme – the most important change is an addition of treatment options for the severe form of the disease at level 5.
The rationale for the two treatment pathways (Fig. 1) was supported in the 2022 Update: Pathway 1, with ICS formoterol as an on-demand medication across treatment levels, is preferred over SABA based on study evidence for lower exacerbation risk and similar or better symptom control as a reliever. Anti-thymic stromal lymphopoietin (anti-TSLP) was included as a new biologic therapy option for severe asthma at the 5 level.
The antibody, which targets the epithelial cytokine TSLP, received approval in Switzerland this year for adults and children 12 years and older with uncontrolled severe asthma. TSLP is released when triggers such as allergens or viruses are released and cause exacerbations. Blockade of TSLP is thought to prevent the release of proinflammatory cytokines, thus providing a preventive effect leading to a decreased rate of exacerbations.
Eosinophils and FeNO as predictors of anti-TSLP response.
In studies of patients with severe asthma and exacerbations during the past 12 months, anti-TSLP resulted in a 30-70% reduction in exacerbation rate, associated with an increase in quality of life, lung function, and symptom control, regardless of allergy status. There was a correlation between higher baseline blood eosinophils or FeNO and better clinical outcome. In patients taking OCS as maintenance therapy, anti-TSLP did not result in a reduction in OCS dose compared with placebo. GINA therefore considers higher eosinophils and FeNO levels as strong potential predictors of good asthma response to anti-TSLP.
Eligibility criteria (in addition to those for severe asthma) vary by payer, but generally include severe exacerbations in the past 12 months. Anti-TSLP may also be considered in patients without elevated T2 markers, the guideline authors write.
Literature:
- Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention (2022 update); https://ginasthma.org/wp-content/uploads/2022/07/GINA-Main-Report-2022-FINAL-22-07-01-WMS.pdf.
InFo PNEUMOLOGY & ALLERGOLOGY 2022; 4(3): 30
