Monoclonal antibody therapy for severe asthma: updated guidance for primary care

By Dr Emily Lathlean MB BS, FRACPGP

The National Asthma Council (NAC) has released an updated monoclonal antibody therapy for severe asthma information paper and accompanying wall­ chart to assist primary health­care professionals when treating patients with severe asthma.

‘Monoclonal antibodies are very well tolerated, and highly effective in managing patients with refractory severe asthma and type 2 airway inflammation,’ said  Dr Tom Skinner, a Respiratory and Sleep Physician at Inspira­tion Respiratory and Sleep, Brisbane, and a collaborator with NAC in the creation of these resources. ‘These treatments do change patients’ lives. Monoclonal antibodies markedly reduce the rate of severe asthma exacerbations, improve symptom control and can reduce the use of systemic corticosteroids.’

The information paper explains that the monoclonal antibody therapies available in Australia (benralizumab, dupilumab, mepolizumab and omalizumab) are subsidised by the PBS for patients in specialist care who meet specified criteria. Although the therapies are prescribed by specialists, they can be administered in primary care or by the patient or carer.

The information paper provides key points, practice points and other guidance for primary healthcare providers on monoclonal antibody therapy for asthma, including how primary care clinicians can fast­-track patients’ access to these therapies.

‘When asthma symptoms are poorly controlled, firstly it is important to get the basics correct,’ Dr Skinner said. ‘This includes confirming the diagnosis, and assessing for and managing common causes of symptoms, such as incorrect inhaler technique, suboptimal adherence and comorbidities.’

‘When symptoms remain poorly controlled, primary care physicians are encouraged to refer patients promptly, and can fast track their progress by assessing for type 2 airway inflammation,’ said Dr Skinner.

The information paper discusses type 2 airway inflammation and the available clinical tests to detect it, such as a blood eosinophil count, and notes that although most people with asthma have type 2 inflammation, a small proportion of patients have type 2 inflammation that does not respond as well to inhaled and oral corticosteroids.

The information paper also highlights the potential harms of oral corticosteroids and advocates for early specialist referral when asthma symptoms are poorly controlled, rather than waiting until the patient requires maintenance treat­ment with, or frequent short courses of, oral corticosteroids.

‘We are particularly keen to review patients who have required systemic corticosteroids to manage their condition,’ Dr Skinner said. ‘Even relatively modest cumula­tive doses of prednisolone, such as two five-­day courses of 50 mg over a patient’s lifespan, have been linked with long-­term complications.’

The information paper and wallchart are available on the NAC website (https://www.nationalasthma.org.au/living­with­asthma/resources/health-professionals/information­paper/monoclonal­antibody­therapy­for­severe­asthma).