Severe Asthma Update: Clinical Management and Key Considerations to Target Optimal Patient Care – Tweetorial #5 Activity

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Greg is a 51-year-old male with a 7-year history of severe asthma, daily asthma symptoms requiring a rescue inhaler, and 4 exacerbations the past year, despite high-dose ICS/LABA. He also reports peripheral neuropathy & purpuric rash. Initial tests show the following:

Greg’s peripheral neuropathy and rash, not typical of atopic dermatitis, suggest other conditions that can significantly impact his asthma care and should prompt further investigation.

Repeat labs, plus a chest x-ray and skin biopsy, show WBC=6200; EOS=680/µL; ANCA=pANCA+, 1:160; pulmonary infiltrates; and cutaneous eosinophilic infiltrates. Based on these results, Greg’s diagnosis could include eosinophilic granulomatosis with polyangiitis (EGPA) or hypereosinophilic syndrome (HES).

EGPA, formerly Churg-Strauss, is a rare but important differential consideration of severe asthma. It has an unknown etiology and affects 1-3/100K US adults annually. The average onset of EGPA is 48 years old and it requires early recognition and treatment to improve prognosis and decrease mortality.

EGPA can impact any organ. It features alveolar hemorrhage from pulmonary capillaries and extravascular necrotizing granulomas. It also features blood and tissue eosinophilia, and vasculitis of small and medium-sized arteries.

EGPA is typically described in three stages:

HES is also a rare blood condition that may be confused with severe asthma. It is a chronic, progressive blood disorder associated with inflammation, diverse symptoms, and organ dysfunction. HES should be considered if AEC>500/µL 2x ≥1 month apart and other causes of elevated eosinophils are excluded.

Greg’s evaluation supports a diagnosis of severe asthma and EGPA. He is initiated on 40 mg daily prednisone. After initial improvement, he’s unable to taper below 15 mg/day.

Mepolizumab is currently the only biologic approved for EGPA and HES. Recent clinical trials have shown its addition (300 mg q4w) to decrease absolute risk reduction, decrease time to first relapse, and be associated with a favorable safety profile.

In summary, EGPA and HES are rare but important considerations in evaluation of severe asthma, requiring early recognition and treatment to improve prognosis and mortality. Mepolizumab demonstrates good safety data, decreased relapse, and is the only treatment approved for EGPA, HES, and severe asthma.

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