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Dupilumab is associated with greater improvement in asthma exacerbations than omalizumab and mepolizumab.

Multiple monoclonal antibodies (mAbs) are currently approved for asthma treatment. All of these improve outcomes in asthma patients who cannot be controlled with conventional therapy. However, only limited data is available regarding their comparative effectiveness, thus restricting opportunities to optimize patient selection for these costly medications. 

A target trial emulation study published in The Journal of Allergy and Clinical Immunology compared the effectiveness of omalizumab, mepolizumab, and dupilumab in reducing asthma exacerbations and improving pulmonary function in these patients.

Study Design and Population

The retrospective cohort study emulated a target trial. A total of 201 adult asthma patients were included in the study; 68 individuals were started on dupilumab, 68 on omalizumab, and 65 on mepolizumab.

Comparison of Incidence Rates of Asthma-Related Exacerbations

This study demonstrated that dupilumab is more effective for reducing exacerbations than omalizumab and mepolizumab in patients with eosinophil counts of at least 150 cells/mL and IgE levels of 30–700 kU/L.

Over a 12-month follow-up period, 31 exacerbations over 68 person-years were documented in the dupilumab group, 63 over 68 person-years in the omalizumab group, and 86 over 65 person-years in the mepolizumab group. The incidence rate ratio (IRR) for dupilumab vs. mepolizumab was 0.26 and for dupilumab vs. omalizumab it was 0.33 in individuals with an eosinophil count of at least 300 cells/mL.

Comparison of Cumulative Incidence of Asthma-Related Exacerbations

Over 12 months of follow-up, exacerbations were observed in 17 patients in the dupilumab group, 28 in the mepolizumab group, and 27 in the omalizumab group.

Switching Treatment to Another Biologic Medicine Was Considered a Failure Event

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During the follow-up period, 16 patients taking mepolizumab, 11 patients taking omalizumab, and 1 patient taking dupilumab switched treatment. In analyses including a switch to another biologic therapy as a failure event, the HRs were 0.44 for dupilumab vs. mepolizumab, 0.72 for dupilumab vs. omalizumab, and 0.62 for omalizumab vs. mepolizumab.

Comparative Improvement in Prebronchodilator FEV1 Value

Patients on dupilumab had a greater improvement in forced expiratory volume in one second (FEV1) value than patients on mepolizumab and omalizumab after 12 months of follow-up. The change from baseline in the prebronchodilator FEV1 value was greater with dupilumab than with mepolizumab (mean difference of 0.110 L) or omalizumab (mean difference of 0.082 L). However, the differences in FEV1 values were not statistically significant.

Sensitivity Analyses

The hazard ratios for exacerbations were 0.25 for dupilumab vs. mepolizumab, 0.22 for dupilumab vs. omalizumab, and 1.12 for omalizumab vs. mepolizumab.

Source:

Akenroye, A. T., Segal, J. B., Zhou, G., Foer, D., Li, L., Alexander, G., Keet, C. A., & Jackson, J. W. (2023). Comparative effectiveness of omalizumab, mepolizumab, and dupilumab in asthma: A target trial emulation. The Journal of Allergy and Clinical Immunology. https://doi.org/10.1016/j.jaci.2023.01.020