Biologic therapy improves clinical outcomes in severe asthma with incomplete response to long term antibiotics

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Background: Long term antibiotics (LTA) are used in asthma that is uncontrolled despite standard therapies. The effectiveness of biologics in severe asthma that is uncontrolled despite LTA is not known. Objective: Compare the clinical response to biologics in patients who received vs. did not receive LTA. Methods: Retrospective analysis of real-world patients completing 12 months of a first-line biologic agent in a UK severe asthma service. Clinical response was defined by a 50% reduction in annualised asthma exacerbation rate (AAER) and/or oral corticosteroid (OCS) dose at 12 months. Prescription records were checked for LTA. Results: 36/427 (8.4%) were on LTA at baseline. Biologic agents were anti-IL5(R) (n=319), anti-IgE (n=98), anti-IL4Rα (n=6) and anti-TSLP (n=4). LTAs were macrolides (n=26) or tetracyclines (n=10). At baseline, patients on LTA had lower exhaled nitric oxide (22 [16-48] vs. 37 [20-60]; p=0.029) and FEV1% (63.0 [44.0-75.4] vs. 72.8 [57.4-87.8]; p=0.020 but similar blood eosinophils (0.40 [0.14-0.63] vs. 0.42 [0.25-0.68]; p=0.14) and AAER (5 [3-9] vs. 5 [2-7]; p=0.378). There was no difference in biologic response rate in those receiving vs. not receiving LTA (75% vs. 88%; p=0.070). Comparing those receiving vs. not receiving LTA there was no difference in ΔAAER (3 [2-5] vs. 3 [1-5]; p=0.821) or ΔOCS dose (5 [4-8] mg vs. 5 [3-8] mg, p=0.493) after biologic. Conclusion: The majority of patients receiving LTA at biologic initiation achieved a clinical response. This suggests that clinical outcomes can be improved by combining treatment. Prospective trials are required.

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