Monica Kraft, MD: Biologics Potential in Asthma

Monica Kraft, MD

Biologics—the eosinophil-targeting drug class which has become a stable of care in severe asthma cases in a couple of iterations—have become a highly accepted and proven tool in the treatment of asthma. But there’s still questions surrounding the capability of the therapies, and not all have yet reached the market.

In an interview with MD Magazine® while at the CHEST 2019 Annual Meeting in New Orleans, Monica Kraft, MD, the Department of Medicine chair at the University of Arizona College of Medicine — Tucson, gave an overview on how biologics have affected patient care options, shared decision making, and what’s to expect in future clinical research.

MD Mag: Give you give us a quick overview of your session on biologics?

Kraft: One of the sessions that I participated in really was talking about where are we, in 2019, with treatment of severe asthma. When we think about making the diagnosis, we think of the comorbidities that are associated with asthma—like sleep apnea, reflux, sinus disease, atopic dermatitis— how to make sure those are managed. And then, when do we get to the place where we're thinking about biologics?

And now we have 5 of them at our disposal. So what's the decision making process for that? And really, there's biologics available for home use as well as at the office. And so, that really involves a partnership with patients, to really understand issues around adherence, issues around even medication use, and then comorbid condition management. And then, there's this issue of how they want to use their biologic to get to it.

MD Mag: Today's clinical discussion of biologics usually reserves them for severe cases—worst-case scenarios among eligible patients. Are we progressing at all to any point where biologics may become a frontline therapy?

Kraft: I don't think anytime soon first-line. But what is happening, especially with one of the biologics dupilumab, which is an IL-4 receptor antagonist—that one, we can actually think of in moderate to severe asthma, so that's important. So, patients don't have to be on necessarily the highest dose of inhaled steroids. That tends to be the way we do it. But actually, it's been approved from moderate to severe. So, that's moving down.

There's also another sort of a pre-biologic under investigation right now called feviviprant. It's prostaglandin antagonist—a CPG receptor antagonist. That's in phase 3 trials. That's an oral agent, and it's positioning itself almost as a pre-biologic—meaning that in those patients who are already on inhaled steroids and bronchodilator, still not doing well, you're sure of the diagnosis and you're addressing all the comorbid conditions, you can try that before you move to biologics.

And so that's something that could really enter into the primary care arena quite easily.

MD Mag: There's a lot of discussion right now and interest in various inflammation-based comorbid conditions. Are there other conditions outside of that inflammatory background that we see any of these biologics benefiting or targeting?

Kraft: At this point, we're really focusing more on the allergic comorbid conditions. That's what the biologics look at. And right now, we are really limited to biologics in that type 2 asthma space, which often is allergic.

Now, one of the other good news is there's a another phase 3 biologic under assessment right now: tezepelumab. That may have benefit across the spectrum of asthma—both the eosinophilic and non-eosinophilic respect. It looked that way in the phase 2 studies, so it received Breakthrough status from the FDA.

It's very exciting, because there are patients who don't have eosinophils, and they have a whole different pathobiology. And we don't have as many treatments for those patients. So it would be really great if we had another choice.

MD Mag: In navigating the care discussion with patients—what's their role now? And how exactly do you navigate that? How do we stay on top of the constantly new information?

Kraft: I think that the patient is very much involved in the decision-making, and it really is a partnership. Especially because some of these agents are moving to home-use. So absolutely, the patient has to be all-in and really be part of the process.

I feel like my role is to give the tools. I can provide the tools. But ultimately, they're going to be the ones really living it. I want to maximize their quality of life, and to do that, it is really a partnership and a shared decision-making model.

MD Mag: How will biologics begin to more aggressively affect the treatment guidelines and standards of care for asthma?

Kraft: They actually have. The GINA guidelines' newest iteration actually has a very large section devoted to biologics. So that's great—and it even entails what you do even before you get there. It's a much more comprehensive look at asthma evaluation and care. So I think they're quite up to date. And I'm glad. I'm glad to see it.

MD Mag: There's a lot of excitement behind these biologics. Is there any reason for concern or apprehension?

Kraft: I think it's a great time to be in the asthma care arena, because you have choices for patients we didn't have before. We still have work to do. You know, we're not done.

This whole non-type 2 asthma is a big unmet need. And I have patients on the biologics who still are not completely controlled. So I think we still have some work to do.

And I also think a lot about making sure that patients get to us from my primary care colleagues. So we're doing a lot of educating in that arena. I'm going to the American College of Physicians meeting in the spring to talk just about this, because I think it's really helpful for all of us to have an awareness of what's available.