Smaller Differences in the Comparative Effectiveness of Biologics in Reducing Asthma-Related Hospitalizations Compared With Overall Exacerbations

Abstract

Evidence on the comparative effectiveness of respiratory biologics remains sparse. We sought to evaluate the comparative effectiveness of omalizumab, mepolizumab, benralizumab, and dupilumab in a matched retrospective cohort of patients with asthma. We identified patients with asthma aged ≥18 years who were incident users of these biologics between November 1, 2018, and June 30, 2023, in administrative claims data from the FDA's Sentinel System and Merative™ MarketScan® Commercial Database. We compared asthma-related exacerbations and hospitalizations in the 12-months since biologic prescription in pairwise comparisons of propensity score-matched cohorts. Covariates used in matching included age, sex, allergic comorbidities, baseline asthma medications use, and the Charlson Comorbidity Index. Incidence rate ratios (IRR) and 95% CIs were estimated using negative binomial regression models. Eight hundred and ninety-three mepolizumab users, 1300 benralizumab, 1170 omalizumab, and 1863 dupilumab patients were identified. The average age was 55 years and two-thirds of the participants were female. At baseline, over 80% of these individuals had an active prescription for an inhaled corticosteroid. Almost half of patients on dupilumab had concomitant nasal polyposis compared to 6-13% of patients on the other biologics. Covariates were balanced after matching. In matched analyses, dupilumab was associated with the lowest incidence of exacerbations over the follow-up period (vs dupilumab): mepolizumab (IRR: 1.36; 95% CI: 1.12-1.64), omalizumab (IRR: 1.33; 95% CI: 1.13-1.58), benralizumab (IRR: 1.19; 95% CI: 1.00-1.41). For exacerbations leading to hospitalizations, benralizumab and mepolizumab were associated with the lowest incidence of hospitalizations and the greatest difference was between mepolizumab vs dupilumab (IRR 0.76; 0.56 - 1.03). Dupilumab was associated with the lowest incidence of overall exacerbations and mepolizumab with the lowest incidence of asthma hospitalizations in this administrative claims-based cohort of individuals with asthma. Despite matching propensity scores, residual confounding, such as baseline eosinophil count, may explain some of these findings.