IF AT FIRST YOU DON'T SUCCEED, TRY TRY AGAIN!

Abstract

<h3>Introduction</h3> Current asthma guidelines recommend trying a biologic in severe persistent asthmatic patients for six months before switching to a different one. We report a patient who was trialed on no less than three biologics without success until finally improving after treatment with a fourth. <h3>Case Description</h3> 63 year-old male with severe persistent asthma presented using his Albuterol MDI ten times a day with nightly awakenings, despite treatment with high dose Budesonide/Formoterol and Montelukast. He required Prednisone bursts four times a year for asthma exacerbations. His total IgE was 539 with positive serum tests to aeroallergens. Omalizumab was initiated with mild improvement for a few months, but his asthma symptoms returned to baseline after one year of treatment. His absolute eosinophil count was 1,100. He was started on Mepolizumab but developed a rash after the first dose and dyspnea and rash after the second, prompting discontinuation. Patient then tried Benralizumab for a year without improvement. Lastly, Dupilumab was started and his asthma markedly improved, i.e. he was able to sleep through the night, his rescue MDI decreased to two times a week, and he has not required Prednisone in several months. <h3>Discussion</h3> It took trialing four different biologics before finding a therapeutic intervention that worked. It is important to be persistent and flexible when finding treatment options for difficult-to-treat severe asthmatic patients.