Severe Uncontrolled Asthma Research Articles

Randomised controlled trial for the titration of oral corticosteroids using markers of inflammation in severe asthma

IntroductionBiomarkers are used to select biologic therapies for patients with severe asthma, but not to regularly adjust therapy, especially oral corticosteroids (OCS).ObjectiveOur goal was to test the efficacy of an...

Redefining the Role of Bronchoscopy in the Workup of Severe Uncontrolled Asthma in the Era of Biologics: A Prospective Study

Severe uncontrolled asthma (SUA) is frequently treated with biologic therapy if a T2 phenotype is found. Bronchoscopy is not routinely recommended in these patients unless a specific indication to rule out comorbidities is present. Is routine bronchoscopy safe and useful in phenotyping and endotyping SUA patients prior to the indication of a biologic therapy?. Prospective study of consecutive SUA patients who were referred to a specialized asthma clinic to assess the indication of a biologic therapy. Patients were clinically phenotyped as T2-allergic, T2-eosinophilic and non-T2. All patients underwent bronchoscopy and systematic data collection of endoscopic findings, microbiology of bronchial aspirate (BAS) and presence of eosinophils in bronchial biopsy were recorded and compared between asthma phenotypes. Cluster analysis was performed accordingly. One-hundred patients were recruited and classified as T2-allergic (28%), T2-eosinophilic (64%) and non-T2 (8%). On bronchoscopy, signs of gastroesophageal reflux disease were detected in 21%, vocal cord dysfunction in 5% and tracheal abnormalities in 3%. BAS culture isolated bacteria in 27% of patients, and fungi in 14%. Three clusters were identified: non-specific, upper airway, and infection being the latter less frequently associated to submucosal eosinophilia. Eosinophils were detected in 91% of bronchial biopsies. Despite a correlation to blood eosinophils, five patients with T2-phenotypes showed no eosinophils in bronchial biopsy, and 3 patients with non-T2 showed eosinophils in bronchial biopsy. Only one patient had a moderate bleeding. Routine bronchoscopy in SUA eligible for biologic therapy is a safe procedure that can help to better phenotype and personalize asthma management.

Delayed‐type hypersensitivity gastrointestinal symptoms induced by food oral immunotherapy and efficiently treated by dupilumab: A case report

Delayed‐type hypersensitivity gastrointestinal symptoms induced by food oral immunotherapy and efficiently treated by dupilumab: A case report

Consenso multidisciplinar español sobre las características de los pacientes con asma grave en tratamiento con biológicos susceptibles de pasar a tratamiento domiciliario

Background and objectiveBiologic therapies are known to reduce exacerbations and improve severe uncontrolled asthma management. The at-home administration of biologics has increased during the COVID-19 pandemic, but the characteristics of severe uncontrolled asthma patients who may benefit from at-home administration of biologic therapy have yet to be identified. Materials and methodsThis project is based on the Delphi method, designed to reach an expert consensus through a multidisciplinary scientific committee addressing the following questions: clinical characteristics, treatment adherence, patient or caregiver administration ability, patient self-care, relationship with the healthcare professional, patient preference, and access to the hospital. ResultsOne hundred and thirty-one healthcare professionals (pulmonologists, allergists, nurses, and hospital pharmacists) completed two Delphi consensus questionnaires. Fourteen items were identified as priority characteristics, the first five being: 1. The patient follows the healthcare team's indications/recommendations to control their disease, 2. The patient is capable of detecting any deterioration in their disease and of identifying exacerbation triggers, 3. The patient receives biologic therapy and has stable disease with no vital risk, 4. The patient takes responsibility for their self-care, 5. The patient has occupational/educational obligations that prevent them from going to the hospital regularly. ConclusionsDisease stability and control plus the ability to identify exacerbation triggers are the most important characteristics when opting for at-home administration for a patient with severe uncontrolled asthma on biologic therapy. These recommendations could be applicable in clinical practice.

Impact of Omalizumab in Patients with Severe Uncontrolled Asthma and Possible Predictive Biomarkers of Response: A Real-Life Study

Most patients with asthma can control their symptoms with a basic standard of medical care and with maintenance and rescue medication. However, between 5% and 10% of asthmatics worldwide do not achieve control of their symptoms and have recurrent exacerbations and respiratory difficulties. The objective of the study was the real-life evaluation of the clinical improvement of patients with severe eosinophilic asthma treated with omalizumab, together with the search for biomarkers associated with the response. An observational retrospective cohort study was conducted that included patients with severe uncontrolled allergic asthma being treated with omalizumab. Three types of response were evaluated: lower use of oral corticosteroids, improvement in lung function, and reduction in exacerbations. A total of 110 patients under treatment with omalizumab were included, with a mean age of 48 ± 16 years. After 12 months had elapsed, significant reductions were found in the number of exacerbations, use of oral cortico-steroids and doses of inhaled corticosteroids (p < 0.001). Lung function and asthma control improved significantly (p < 0.001; p = 0.004) and eosinophil levels were significantly reduced (p = 0.004). Low scores in the Asthma Control Test were associated with the oral corticosteroid-saving effect; lower previous FEV1 levels and absence of chronic obstructive pulmonary disease (COPD) were related to improvement in lung function, and prior FEV1 values higher than 80% and absence of gastroesophageal reflux disease (GERD) with a reduction in exacerbations. The results of this study confirm the clinical benefit obtained after the introduction of omalizumab and the possible predictive biomarkers of response to the treatment.

Elevated PAI-1 Levels Are Associated With Severe COVID-19

A growing body of evidence points to endothelial dysfunction in severe COVID-19 cases. Plasminogen activator inhibitor-1 (PAI-1) is a marker of endothelial injury and correlates with severe uncontrolled asthma. PAI-1 could be a candidate as a prognostic marker of COVID-19-related hospitalization and clinical outcomes. Therefore, the association between PAI-1 and the severity of COVID-19 was investigated.

Effect of Baseline Blood Eosinophil Level on Asthma Exacerbations Among Patients Treated with Benralizumab During the Oral Corticosteroid Reduction Phase of the PONENTE Trial

The PONENTE trial evaluated the effectiveness and safety of a rapid, individualized algorithm for reducing oral corticosteroid (OCS) use after initiation of benralizumab in patients with uncontrolled severe eosinophilic asthma (SEA). Overall, 81.9% of patients eliminated OCS or reduced their daily dose to ≤5 mg prednisone/prednisolone. For this analysis, we examined the effect of baseline blood eosinophil (bEOS) level on asthma exacerbations during the OCS reduction phase of PONENTE.

Impact of Anti-IL5 Therapies on Patients with Severe Uncontrolled Asthma and Possible Predictive Biomarkers of Response: A Real-Life Study.

Severe Uncontrolled Asthma (SUA) counts for more than 25% of cases of severe asthma. The main factors that impair the quality of life of these patients are high doses of oral corticosteroids, the presence of exacerbations, and reduced lung function. The objective of this study was to evaluate, in real life, the clinical improvement of patients with SUA treated with anti-interleukin 5 (IL5) therapies: mepolizumab and benralizumab, together with the search for biomarkers associated with the response. We conducted a retrospective observational cohort study that included patients with severe uncontrolled eosinophilic asthma in a tertiary hospital receiving biological therapies. Three types of response were evaluated: improvement in lung function, reduction in exacerbations, and decrease in the use of oral corticosteroids. After 12 months of treatment, significant reductions were found in the number of exacerbations, the use of oral corticosteroids, and blood eosinophil levels for both biological therapies (p < 0.001). Lung function improved, achieving a significant improvement in %FEV1 (p < 0.001), as well as asthma control, with a significant increase in asthma control test (ACT) scores in both therapies. The markers associated with the corticosteroid-saving effect were the low doses of oral corticosteroids and absence of exacerbations for mepolizumab, and higher blood eosinophilia, absence of chronic obstructive pulmonary disease (COPD), and reduction in oral corticosteroid cycles for benralizumab. The greatest improvement in lung function in both therapies was linked to lower previous FEV1 levels and absence of other respiratory diseases. The reduction in exacerbations was associated with absence of exacerbations the previous year for mepolizumab and never smokers for benralizumab. The results of this real-life study confirm the clinical benefit obtained after the introduction of an anti-IL5 biological therapy and the possible predictive biomarkers of response to treatment.

Bronchial Asthma Exacerbation in the Emergency Department in a Saudi Pediatric Population: An Insight From a Tertiary Hospital in Riyadh, Saudi Arabia.

Background Severe uncontrolled asthma in the pediatric population is a complicated disease and is considered a major challenge for pediatricians. Severe bronchial asthma in the pediatric population is related to significant morbidity and mortality. Children with complicated asthma are at a higher risk for unfavorable outcomes, including medication-associated adverse effects, severe life-threatening exacerbations, and poor quality of life. Methodology A cohort study was conducted at National Guard Health Affairs Hospital in Riyadh, Saudi Arabia. Data were collected using the chart review method utilizing a data collection sheet. A total of 363 charts of children aged one month to 14 years who visited the emergency room (ER) due to asthma exacerbation at NGHA were reviewed, from January 2016 to May 2022, to extract the variables. Variables included demographic data, comorbidities, and asthma-related variables which included the number of asthma exacerbations, hospital admission, ER visit, medication use (non-steroidal anti-inflammatory drugs and steroids), and the presence of allergic rhinitis and eczema. Results A total of 363 patients were analyzed, with 229 (63.1%) males and 134 (36.9%) females. The mean age was 4.9 years (SD = 3.5 years). Overall, 8.5% of patients had congenital heart disease, 4.1% had gastroesophageal reflux disease, 2.2% had diabetes mellitus, 1.9% had obstructive sleep apnea, and 0.6% had hypertension. Most patients presented with a cough at 88.2% (n = 320), followed by shortness of breath at 59% (n = 214) and fever at 46% (n = 167). Male asthmatics visited ER more than females. Forty-four patients were admitted to the hospital. Inhaled steroids were associated with fewer emergency department visits and night symptoms. Most asthmatic patients presented in the winter and fall seasons. Conclusions Asthma is a common pediatric respiratory disease that could be a burden if not controlled well. Unfortunately, the frequency of hospital admissions and pediatric ER visits due to asthma exacerbation is increasing. Comorbidities such as obesity and gastroesophageal reflux disease play a significant role in asthma control.

Spanish multidisciplinary consensus on the characteristics of severe asthma patients on biologic treatment who are candidates for at-home administration

Background and objectiveBiologic therapies are known to reduce exacerbations and improve severe uncontrolled asthma management. The at-home administration of biologics has increased during the COVID-19 pandemic, but the characteristics of severe uncontrolled asthma patients who may benefit from at-home administration of biologic therapy have yet to be identified. Materials and methodsThis project is based on the Delphi method, designed to reach an expert consensus through a multidisciplinary scientific committee addressing the following questions: clinical characteristics, treatment adherence, patient or caregiver administration ability, patient self-care, relationship with the healthcare professional, patient preference, and access to the hospital. ResultsOne hundred and thirty-one healthcare professionals (pulmonologists, allergists, nurses, and hospital pharmacists) completed two Delphi consensus questionnaires. Fourteen items were identified as priority characteristics, the first five being: 1. The patient follows the healthcare team’s indications/recommendations to control their disease, 2. The patient is capable of detecting any deterioration in their disease and of identifying exacerbation triggers, 3. The patient receives biologic therapy and has stable disease with no vital risk, 4. The patient takes responsibility for their self-care, 5. The patient has occupational/educational obligations that prevent them from going to the hospital regularly. ConclusionDisease stability and control plus the ability to identify exacerbation triggers are the most important characteristics when opting for at-home administration for a patient with severe uncontrolled asthma on biologic therapy. These recommendations could be applicable in clinical practice.

A Case Study Showing Benralizumab’s Effectiveness in Treating Uncontrolled Severe Eosinophilic Asthma that is Resistant to Omalizumab

Asthma is a diverse illness that can range in severity. Because it has a significant impact on patients' quality of life and because people with severe asthma have symptoms, exacerbations, and drug side effects. Although first disregarded, eosinophils have since been directly linked to characteristics of the continuous inflammatory process in asthma, especially in the severe form. We present of the case of a 50year old female patient who presented with complaints of cough, breathing difficult on exertion and history of fever, chest pain and tiredness. The chest x ray showed left lower zone haziness. Patient was successfully treated with IV antibiotics, IV Proton pump inhibitor, Nebulised bronchodilators, IV Steroids, Anti-Hypertensive therapy and all other supportive medications along with pulmonary rehabilitations. In view of uncontrolled Eosinophilic asthma patient was treated with monoclonal antibody. Patient improved symptomatically better. This case study describes how benralizumab treatment for a patient with uncontrolled severe eosinophilic asthma resulted in significant improvements in lung function, asthma control, steroid use, and quality of life. Keywords: Benralizumab, Severe eosinophilic asthma, Omalizumab, Monoclonal antibodies

The Impact of Tezepelumab in Uncontrolled Severe Asthma: A Systematic Review of Randomized Controlled Trials.

Asthma, a chronic illness, is characterized by inflammation and airway constriction. Uncontrolled severe asthma is related to poor quality of life and increased utilization of health resources. Conventional treatments are associated with a significant amount of adverse effects. Recent years have seen the identification of various molecular effectors and signaling pathways as interesting targets for the biological therapy of severe asthma that is resistant to current therapies. Because they only target some downstream components of the inflammatory response in asthma, leaving other components unaffected, current biologic treatments only lower the exacerbation rate by 50%. If we focus on the upstream mediators of the inflammatory response in asthma, it might have a greater effect and be more efficient. Tezepelumab is a human monoclonal IgG2 antibody that specifically binds to thymic stromal lymphopoietin (TSLP) at the level of its TSLPR (thymic stromal lymphopoietin receptor) binding site, inhibiting the interaction between human TSLP and TSLPR. It is being used to treat the cytokines on the respiratory epithelial layer known as "alarmins." It is the only biologic drug available for treating severe uncontrolled asthma, despite limitations in biomarker and phenotype. In light of recent developments, the lack of knowledge on tezepelumab prompts us to publish a comprehensive systematic review. We discovered that regardless of blood eosinophil level and fractional exhaled nitric oxide levels, tezepelumab dramatically lowers asthma exacerbation in patients with severe uncontrolled asthma when compared to placebo. Tezepelumab also lessens patients' demand for healthcare resources while improving clinical indicators of lung function, health-related quality of life, and asthma management in patients. Tezepelumab plays a role in enhancing pre-bronchodilator FEV1 and lowering blood eosinophil count and fractional exhaled nitric oxide in patients with or without chronic allergies (FeNO). There have been no reports of fatalities or severe adverse events connected to tezepelumab.

Safety and efficacy of tezepelumab vs. placebo in adult patients with severe uncontrolled asthma: a systematic review and meta-analysis

Patients with severe uncontrolled asthma still experience acute asthma symptoms and exacerbations, particularly those with non-eosinophilic inflammation who take the maximum amount of standard drug therapy. Tezepelumab, a human monoclonal antibody, can improve lung function and enhance control of asthma symptoms in those patients, regardless of the disease’s baseline characteristics. This study aims to investigate the safety and efficacy of using tezepelumab in controlling severe symptoms of uncontrolled asthma. We performed a comprehensive literature search in several databases, including PubMed, Scopus, Web of Science, Cochrane Library, and clinicaltrial.gov, using a well-established search strategy to include all relevant publications. According to our inclusion criteria, we searched for randomized controlled trials comparing tezepelumab versus placebo in patients with severe, uncontrolled asthma. We analyzed the data using The Revman 5.4 program software. The search identified 589 potential articles. After excluding studies inconsistent with selection criteria, four studies were included and analyzed qualitatively and quantitatively. The pooled effect demonstrated the better performance of tezepelumab over the placebo regarding the decrease in annualized asthma exacerbation rate (MD = − 0.74, (95% CI [− 1.04, − 0.44], p < 0.00001)), asthma control questionnaire-6 (ACQ-6) Score MD = − 0.32, (95% CI [− 0.43, − 0.21], p < 0.00001)), blood eosinophil count (MD = − 139.38 cells/mcL, (95% CI [− 150.37, − 128.39], p < 0.00001)), feNO (MD = − 10 ppb, (95% CI [− 15.81, − 4.18], p = 0.0008)) and serum total IgE (MD = − 123.51 UI/ml, (95% CI [− 206.52, − 40.50], p = 0.004)). All tezepelumab groups had higher pre-bronchodilator forced expiratory volume in 1 s than the placebo group (MD = 0.16, (95% CI [0.10, 0.21], p < 0.00001)). Higher efficacy and safety profile was detected for tezepelumab to control the exacerbations of severe uncontrolled adult asthmatics.

EE565 Cost-Utility Analysis of Dupilumab in Adults and Adolescents With Uncontrolled Persistent Severe Asthma in Portugal

EE565 Cost-Utility Analysis of Dupilumab in Adults and Adolescents With Uncontrolled Persistent Severe Asthma in Portugal

Efficacy and safety of dupilumab as add-on therapy for patients with severe asthma: A real-world Dutch cohort study

BackgroundDupilumab as add-on treatment for severe uncontrolled asthma (SA) has shown to be effective and safe by phase-III-trials. Real-world data on clinical efficacy and safety is limited. ObjectiveWe aim to investigate the efficacy and safety of dupilumab as add-on therapy for SA in a real-world cohort. Material and methodsThe primary endpoint was annually exacerbation-rate (AER). Secondary outcomes were maintenance oral corticosteroid (mOCS) dependency, asthma control (ACQ-5), pulmonary function (FEV1), quality of life (AQLQ) and frequency of reported adverse events (AEs). ResultsOverall, 148 patients were included. Median AER [IQR] reduced from 4.00 [2.00–5.00] at baseline to 1.00 [0.00–2.00] at 12 months (p < 0.001). mOCS-dependency reduced from 39.9% of the patients at baseline, to 20.3% at 6 months and to 14.9% at 12 months (p < 0.001). Median ACQ improved from 3.00 [2.00–3.80] at baseline to 1.80 [0.60–2.95] after 6 months and to 1.40 [0.20–2.60] after 12 months (p < 0.001). Median FEV1 (L) improved from 2.21 [1.58–2.85] to 2.50 [2.00–3.06] at 6 months and to 2.51 [1.88–3.04] after 12 months (p < 0.001). The outcomes improved most in subgroups with high eosinophils (≥300/μL) or FeNO (≥50 ppb) at baseline. AEs were reported by 45.3% (67/148), of which headache was most frequent. ConclusionsThis study indicates that dupilumab as add-on therapy for SA is associated with significant improvements in exacerbation-rate, mOCS-dependency, asthma control, pulmonary function, and quality of life. These results are in line with those of previous phase-III-trials.

Eosinophil depletion with benralizumab is associated with attenuated mannitol airway hyperresponsiveness in severe uncontrolled eosinophilic asthma

Airway hyperresponsiveness (AHR) and eosinophilia are hallmarks of persistent asthma. We investigated whether eosinophil depletion with benralizumab might attenuate indirect mannitol AHR in severe uncontrolled asthma using a pragmatic open-label design. After a 4-week run-in period with provision of usual inhaled corticosteroids and/or long-acting β-agonist (baseline), adults with mannitol-responsive uncontrolled severe eosinophilic asthma received 3 doses of open-label benralizumab 30 mg every 4 weeks, followed by 16 weeks' washout after the last dose. The primary outcome was doubling difference (DD) in provocative dose of mannitol required to decrease FEV1 by 10% (PD10) at the end point after 12 weeks, powered at 90% with 18 patients required to detect 1 DD. Secondary outcomes included measures assessed by the asthma control questionnaire and mini-asthma quality of life questionnaire. Twenty-one patients completed 12 weeks' benralizumab therapy at the end point at week 12. Mean (SEM) age was 53 (4) years, and FEV1 80.2% (4.1%) inhaled corticosteroid dose was 1895 (59) μg, with 12 receiving long-acting muscarinic antagonist and 13 leukotriene receptor antagonists. Improvement in AHR was significant by 8 weeks, with a mean 2.1 DD (95% confidence interval 1.0, 3.3; P< .01) change in PD10 at week 12, while mean changes in asthma control questionnaire and mini-asthma quality of life questionnaire were significant by week 2 and sustained over 12 weeks, both exceeding the minimal important difference. Peripheral blood eosinophils were depleted by 2 weeks (439 to 6 cells/μL). No significant improvement occurred in lung function after 12 weeks. Domiciliary peak flow and symptoms also improved with benralizumab. Eosinophil depletion results in clinically meaningful attenuated AHR in severe uncontrolled asthma patients.

Uncontrolled severe T2 asthma: Which biological to choose? A biomarker-based approach.

In recent years, advances in knowledge of molecular mechanisms involved in asthma have changed uncontrolled severe asthma (USA) treatment, with the appearance of biological treatment. USA is a heterogeneous entity with different endotypes and phenotypes. Nowadays, the biological drugs approved with asthma indication are omalizumab, mepolizumab, reslizumab, benralizumab and dupilumab. Tezepelumab is approved by the Food and Drug Administration (FDA) in the United States and, recently, by the European Medicines Agency (EMA). All these biological drugs have shown their efficacy in clinical trials, especially in reducing exacerbations, improving asthma control, quality of life, pulmonary function, and withdrawing systemic corticosteroids or at least reducing their daily dose, with some differences between them. Except for mepolizumab and reslizumab, biological drugs have different targets and thus different therapeutic indications should be expected; however, in some patients, more than one drug could be indicated, making the election more difficult. Because there are no direct comparisons between biological drugs, some biomarkers are used to choose between them, but they are not unbeatable. In this article, an algorithm to choose the first biological drug in a specific patient is proposed based on different study results and patient' characteristics.

Tezepelumab for Patients with Severe Uncontrolled Asthma: A Systematic Review and Meta-Analysis.

Tezepelumab is a human monoclonal antibody that blocks thymic stromal lymphopoietin, an epithelial-cell-derived cytokine implicated in the pathogenesis of asthma. It was approved by the United States Federal Drug Administration (US FDA) as an add-on maintenance treatment for patients with severe uncontrolled asthma in December 2021. We conducted a systematic review and meta-analysis to investigate the safety and efficacy of tezepelumab on forced expiratory volume (FEV1) (L), the rate of asthma exacerbations, health-related quality of life, fractional exhaled nitric oxide (FeNO) (ppb), and blood eosinophil count (cells/mL) in patients with severe, uncontrolled asthma. Mean changes for efficacy and proportions (safety) with their corresponding 95% confidence intervals (CIs) were used to provide pooled estimates. A total of six randomized controlled trials comprising 2667 patients were included, of whom 1610 were treated with tezepelumab and 1057 received placebo. The pooled analysis showed that tezepelumab treatment resulted in an improvement in FEV1 of 0.15 L (95% CI: 0.12 to 0.17), a reduction in the asthma exacerbation rate per year of 0.60 (95% CI: 0.51 to 0.70), and a reduction in FeNO of -12.41 ppb (95% CI: -14.28 to -10.53) when compared to placebo. Improvements in FEV1 and FeNO levels were maintained at 24 and 52 weeks. As for safety, patients did not experience a higher incidence of adverse drug reactions with tezepelumab (0.79 (95% CI: 0.55 to 1.12)) as compared to placebo. As for quality of life, different doses of the tezepelumab intervention group depicted non-significant improvement in the QoL, from 0.15 (95% CI: -0.09 to 0.38) for 70 mg, 0.18 (95% CI: -0.10 to 0.46) for 210 mg, 0.08 (95% CI: -0.16 to 0.32) for 280 mg as compared to the placebo. Tezepelumab significantly reduced exacerbation rates and improved FEV1 with an acceptable safety profile.

EGPA: A DIAGNOSTIC DILEMMA

<h3>Introduction</h3> Eosinophilic granulomatosis with polyangiitis (EGPA) is a diagnostically difficult disorder due to multisystem involvement, and dual categorization with hypereosinophilic syndromes and systemic vasculitides. The early allergic phase may present in isolation for years prior to eosinophilic organ infiltration and vasculitis, highlighting the importance of consistent screening and multidisciplinary treatment in preventing complications. <h3>Case Description</h3> A 40-year-old male with allergic rhinitis, chronic rhinosinusitis with nasal polyps, and severe persistent asthma presented with peripheral eosinophilia (maximum 2950/μL) and uncontrolled asthma. Workup of secondary causes of hypereosinophilia was unrevealing. Sinus CT revealed extensive mucosal thickening with near complete opacification and lung CT showed bilateral lung ground-glass opacities admixed with consolidative opacities. Patient underwent endoscopic sinus surgery and bronchoscopy with biopsies failing to show signs of granulomata/vasculitis or eosinophilic infiltration. Evaluation of pertinent biomarkers and echocardiogram were also unrevealing. Despite this, given the concerning constellation of symptoms and a positive rheumatoid factor, EGPA remained on the differential with possibility of biopsy sampling error and seronegative ANCA vasculitis. Patient was treated with prolonged steroid taper followed by benralizumab for uncontrolled severe eosinophilic asthma with only temporary relief followed by mepolizumab, the first FDA biologic agent approved for EGPA. <h3>Discussion</h3> This patient presents with multiple features concerning for EGPA. Even without a current pathologic diagnosis, EGPA presents in phases and remains high on our differential. It is crucial to continue monitoring for end organ involvement and new systemic symptoms. New biologic agents present a promising therapy resulting in increased remission and reduced glucocorticoid use.

GAPS IN CLINICAL CARE ESCALATION AMONG SEVERE, PERSISTENT ASTHMA PATIENTS FOLLOWING INDICATORS OF UNCONTROLLED ASTHMA

<h3>Introduction</h3> Approximately 5-10% of patients with asthma have severe asthma (SA). Standard of care recommends escalation of care with uncontrolled disease. To evaluate current gaps in care in the US, this analysis examined care received among SA patients following events indicating uncontrolled disease (EUD). <h3>Methods</h3> Administrative claims databases for SA patients with Medicare Fee-for-Service, Medicare Advantage, Managed Medicaid, or commercial insurance spanning 2015-2020 were utilized. Severe, persistent asthma patients were indexed hierarchically on asthma-related EUD: ≥1 hospitalization, ≥2 emergency department (ED) visits with systemic corticosteroid treatment (SCS), 1 ED + ≥1 outpatient (OP) visit with SCS, or ≥2 OP visits with SCS. SA patients without any events were matched as controls. All were required to be 12+ years old, have 12 months enrollment pre- and post-index, and have no other major respiratory disease or biologic treatment during the pre-period. Specialist visits and medication escalation were examined during the post-index period. <h3>Results</h3> 181,548 SA patients were identified (90,774 uncontrolled, 90,774 controlled). Across payer channels, 33-51% of uncontrolled SA patients presented no specialist nor medication escalation intervention (Figure). Patients with 2 ED visits were most likely to present an absence of any intervention. <h3>Conclusion</h3> Results demonstrate that a substantial portion of uncontrolled SA patients do not have evidence of care escalation following uncontrolled disease, highlighting substantial gaps in care. Guidelines in the US recommend referral to an asthma specialist for systematic assessment or co-management for all SA patients, particularly those with uncontrolled disease. Accelerating subspecialist referrals and/or medication escalation may improve asthma care.