LA TERAPIA PERSONALIZZATA DELLASMA Girolamo Pelaia Cattedra UOC

LA TERAPIA PERSONALIZZATA DELL’ASMA Girolamo Pelaia Cattedra, UOC e Scuola di Specializzazione Malattie dell’Apparato Respiratorio Università Magna Graecia di Catanzaro

DISCLOSURE OF INTERESTS Girolamo Pelaia: I declare that I have received lecture fees and advisory board fees from: Alfasigma, Astra. Zeneca, Boehringer Ingelheim, Chiesi, GSK, Guidotti/Malesci, Menarini, Mundipharma, Novartis, Sanofi, TEVA, Zambon.

Controller Therapy for Asthma No night symptoms 100% No SABA use PEF FEV 1 % improvement Airway hyperresponsiveness ……. Exacerbations…… Days Weeks Months Years

Stepwise management - pharmacotherapy Diagnosis Symptom control & risk factors (including lung function) Inhaler technique & adherence Patient preference Symptoms Exacerbations Side-effects Asthma medications Patient satisfaction Non-pharmacological strategies Treat modifiable risk factors Lung function STEP 5 STEP 4 PREFERRED CONTROLLER CHOICE STEP 1 STEP 2 Low dose ICS Other controller options RELIEVER Consider low dose ICS Leukotriene receptor antagonists (LTRA) Low dose theophylline* As-needed short-acting beta 2 -agonist (SABA) GINA 2018, Box 3 -5 (2/8) (upper part) STEP 3 Low dose ICS/LABA** Med/high dose ICS Low dose ICS + LTRA (or + theoph*) Med/high ICS/LABA Refer for add-on treatment *Not for children <12 years e. g. tiotropium, *� anti-Ig. E, anti-IL 5* **For children 6 -11 years, the preferred Step 3 treatment is medium dose ICS #For Add tiotropium*� Add low Med/high dose OCS ICS + LTRA (or + theoph*) As-needed SABA or low dose ICS/formoterol# © Global Initiative for Asthma patients prescribed BDP/formoterol or BUD/ formoterol maintenance and reliever therapy �Tiotropium by mist inhaler is an add-on treatment for patients ≥ 12 years with a history of exacerbations www. ginasthma. org

PATHOBIOLOGY OF ASTHMA Pelaia G, Vatrella A, Maselli R. Nature Rev Drug Discov 11: 958 -972, 2012

Barnes PJ, Adcock IM. Ann Intern Med 139: 359 -370, 2003

MECHANISMS OF CORTICOSTEROID ACTION IN EOSINOPHILIC AIRWAY INFLAMMATION Pavord ID. Curr Opin Pulm Med 25: 51 -58, 2019

600 PD 20 methacholine (mg) % eosinophils 15 p < 0. 0001 400 p < 0. 0001 10 p < 0. 0001 p < 0. 001 200 5 p < 0. 0001 0 Basal 20 1 week 1 month 2 months 3 months % CD 4 DR+ 0 Basal p < 0. 0001 1 week 1 month 2 months 3 months % CD 4 CD 25+ 20 15 15 10 10 p < 0. 0001 5 0 Basal 5 p < 0. 001 1 week 1 month Budesonide p < 0. 0001 2 months 3 months Terbutaline 0 Basal 1 week p < 0. 0001 1 month 2 months 3 months Vatrella A, Perna F, Pelaia G, Parrella R, Maselli R, Marsico SA, Calabrese C. Int J Immunopathol Pharmacol 23: 745 -753, 2010

EFFECTS OF BUDESONIDE ON IMMUNE/INFLAMMATORY CELLS Inactivation of Th 2 cells T LYMPHOCYTES MAST CELLS EOSINOPHILS BUDESONIDE Inhibition of cytokine release Apoptosis DENDRITIC CELLS Reduction of cell density Pelaia G et al. Pulm Pharmacol Ther 40: 15 -21, 2016

O’Byrne et al, NEJM 2018

Bateman et al, NEJM 2018

Risk-benefit ratio of inhaled corticosteroids Response (Units) 40 30 20 10 0 0 Clinical effects (CE) 2 4 6 Systemic effects (SE) 8 10 Drug dose 12 CE-SE Ratio 14 16 18

Quadrupling ICS dose to abort asthma exacerbations Mc. Keever T et al. N Engl J Med 378: 902 -910, 2018

Quintupling ICS dose at the early signs of loss of asthma control Jackson DJ et al. N Engl J Med 378: 891 -901, 2018

STEPWISE TREATMENT OF ASTHMA Barnes PJ. Trends Pharmacol Sci 31: 335 -343, 2010

Diffusion Microkinetic Model Salbutamol Hydrophilic Salmeterol Lipophilic Formoterol Intermediate Rapid acting Short acting Slow onset Long acting Rapid acting Long acting From Anderson GP, Life Sci, 1993

NH 2 VI VII V HO S HO I OH NH 2 II S IV III S S COOH

Grembiale RD, Pelaia G, Naty S, Vatrella A, Tranfa CME, Marsico SA. Pulm Pharmacol Ther 15: 463 -466, 2002 Formoterol Salmeterol Salbutamol

Effect of Inhaled Formoterol and Budesonide on respiratory function - The FACET Study FEV 1 (% of predicted value) 90 85 80 75 -1 0 BUD 100 mg bid + FORM 12 mg bid BUD 400 mg bid + FORM 12 mg bid 1 2 3 6 9 Month Pauwels RA et al, N Engl J Med 1997 12

CAN GUIDELINE-DEFINED ASTHMA CONTROL BE ACHIEVED? THE GAINING OPTIMAL ASTHMA CONTROL STUDY Bateman ED et al, Am J Respir Crit Care Med 170: 836 -844, 2004

Time to First Exacerbation Patients with severe exacerbations (%) Days since randomization O’Byrne P, et al. Am J Resp Crit Care Med 2005; 171: 129 -136

Kaplan-Meier curves of time to first severe asthma exacerbation Rabe KF, Atienza T, Magyar P, Larsson P, Jorup C, Lalloo UG. Lancet 368: 744 -753, 2006

Beclometasone-Formoterol as maintenance and reliever treatment in patients with asthma Papi A, Corradi A, Pigeon-Francisco C, Baronio R, Siergiejka Z, Petruzzelli S, Fabbri LM, Rabe KF. Lancet Respir Med 1: 23 -31, 2013

EFFICACY OF FLUTICASONE/FORMOTEROL COMBINATION THERAPY IN PATIENTS WITH MODERATE-TO-SEVERE ASTHMA Corren J, Mansfield LE, Pertseva T, Blazhko V, Kaiser K. Respir Med 107: 180 -195, 2013

Once-daily fluticasone furoate alone or combined with vilanterol in persistent asthma: FEV 1 changes O’ Byrne PM, Bleecker ER, Bateman ED, Busse WW, Woodcock A, Forth R, Toler WT, Jacques L, Lotvall J. Eur Respir J 43: 773 -782, 2014

Once-daily fluticasone furoate/vilanterol reduces risk of severe exacerbations in asthma versus fluticasone furoate alone Bateman ED, O’ Byrne PM, Busse WW, Lotvall J, Bleecker ER, Andersen L, Jacques L, Frith L, Lim J, Woodcock A. Thorax 69: 312 -319, 2014 Copyright © BMJ Publishing Group Ltd & British Thoracic Society. All rights reserved.

Comparison of early effects of budesonide/formoterol maintenance and reliever therapy with fluticasone furoate/vilanterol for asthma patients requiring step-up from inhaled corticosteroid monotherapy Hozawa S, Terada M, Haruta Y, Hozawa M. Pulm Pharmacol Ther 37: 15 -23, 2016

Comparison of early effects of budesonide/formoterol maintenance and reliever therapy with fluticasone furoate/vilanterol for asthma patients requiring step-up from inhaled corticosteroid monotherapy Hozawa S, Terada M, Haruta Y, Hozawa M. Pulm Pharmacol Ther 37: 15 -23, 2016

Comparison of early effects of budesonide/formoterol maintenance and reliever therapy with fluticasone furoate/vilanterol for asthma patients requiring step-up from inhaled corticosteroid monotherapy Hozawa S, Terada M, Haruta Y, Hozawa M. Pulm Pharmacol Ther 37: 15 -23, 2016

Comparison of early effects of budesonide/formoterol maintenance and reliever therapy with fluticasone furoate/vilanterol for asthma patients requiring step-up from inhaled corticosteroid monotherapy Hozawa S, Terada M, Haruta Y, Hozawa M. Pulm Pharmacol Ther 37: 15 -23, 2016

Interactions between glucocorticosteroids and long-acting b 2 agonists (LABA) Barnes PJ. Handb Exp Pharmacol 237: 93 -115, 2017

Glucocorticoid b 2 -agonist b 2 -AR Gs AC Cytoplasm c. AMP + PKA GR m. RNA Nuclear membrane Nucleus b 2 -AR gene GRE GRE Pelaia G, Muzzio CC, Vatrella A, Maselli R, Magnoni MS, Rizzi A. Expert Opin Pharmacother 16: 2009 -2021, 2015

Black JL, Oliver BGG, Roth M. Chest 136: 1095 -1100, 2009 © 2009 by American College of Chest Physicians

Priftis KN, Papadimitriou A, Nicolaidou P, Chrousos GP. Allergy 64: 18 -31, 2009

Pelaia G, Vatrella A, Busceti MT, Gallelli L, Calabrese C, Terracciano R, Lombardo N, Maselli R. Ther Clin Risk Manag 11: 1563 -1572, 2015 TIOTROPIUM M 3 PLC Gq IP 3 2+ Ca Ca 2+ BRONCHOCONSTRICTION

TIOTROPIUM FOR ASTHMA TREATMENT: lung function and severe exacerbations. Kerstjens HAM et al. N Engl J Med 367: 1198 -1207, 2012

Casale et al, JACIP 2018

Add-on montelukast in inadequately controlled asthma patients Virchow JC, Mehta A, Ljungblad L, Mitfessel H. Respir Med 104: 644 -651, 2010

Vatrella A, Ponticiello A, Pelaia G, Parrella R, Cazzola M. Pulm Pharmacol Ther 18: 89 -92, 2005 Salmeterol plus SR-Theophylline Salmeterol SR-Theophylline Placebo

Residual disease burden in optimally treated asthma Anderson GP. Lancet 372: 1107 -1119, 2008

Pelaia G, Vatrella A. , Maselli R. In: Asthma: Targeted Biological Therapies. Springer International Publishing, 2017

Stepwise management Diagnosis Symptom control & risk factors (including lung function) Inhaler technique & adherence Patient preference Symptoms Exacerbations Side-effects Asthma medications Patient satisfaction Non-pharmacological strategies Lung function Treat modifiable risk factors STEP 5 STEP 4 PREFERRED CONTROLLER CHOICE STEP 1 STEP 2 Low dose ICS Other controller options RELIEVER Consider low dose ICS Leukotriene receptor antagonists (LTRA) Low dose theophylline* As-needed short-acting beta 2 -agonist (SABA) STEP 3 Low dose ICS/LABA** Med/high dose ICS Low dose ICS + LTRA (or + theoph*) Med/high ICS/LABA Refer for add -on treatment e. g. tiotropium, *� anti-Ig. E, anti-IL 5* *Not for children <12 years **For children 6 -11 years, the preferred Step 3 treatment is medium dose ICS #For Add tiotropium*� Add low Med/high dose OCS ICS + LTRA (or + theoph*) As-needed SABA or low dose ICS/formoterol# patients prescribed BDP/formoterol or BUD/ formoterol maintenance and reliever therapy �Tiotropium by mist inhaler is an add-on treatment for patients ≥ 12 years with a history of exacerbations

BIOLOGICAL THERAPIES FOR ASTHMA Pelaia G, Vatrella A, Maselli R. Nature Rev Drug Discov 11: 958 -972, 2012

OLD AND NEW DRUGS FOR ASTHMA Bel EH, ten Brinke A. Chest 152: 1276 -1282, 2017

OMALIZUMAB: mechanism of action and therapeutic effects Pelaia C, Calabrese C, Terracciano R, de Blasio F, Vatrella A, Pelaia G. Ther Adv Respir Dis 12: 1 -16, 2018

IL-5/IL-5 RECEPTOR-TARGETED ANTIBODIES Reslizumab Mepolizumab IL-5 Eosinophil Benralizumab IL-5 Ra/bc Pelaia G, Vatrella A et al, Ther Clin Risk Manag 12: 1075 -1082, 2016

BENRALIZUMAB: MECHANISMS OF ACTION Pelaia C, Calabrese C, Vatrella A, Busceti MT, Garofalo E, Lombardo N, Terracciano R, Pelaia G. Bio. Med Res Int 4839230, 2018

DUPILUMAB: mechanism of action Pelaia C, Vatrella A, Gallelli L, Navalesi P, Maselli R, Pelaia G. Expert Opin Biol Ther 17; 1565 -1572, 2017

Agusti A et al. Lancet 390: 980 -987, 2017

Biomarkers for the assessment of T 2 -type asthma Holgate ST, Wenzel S, Postma DS, Weiss ST, Renz H, Sly PD. Nature Rev Dis Primers 1: 15025, 2015

SEVERE ASTHMA oral corticosteroid sparing effects of biologics

Pavord ID. Curr Opin Pulm Med 25: 51 -58, 2019

Steroid Side Effects

N° Severe asthma patients 437 Gender (female) 58. 3% Mean Age (yrs) 57. 1 BMI 25. 7 Oral Corticosteroid Users 64. 6% Years since asthma diagnosis 20. 03 Basal ACT 14. 4 Severe exacerbations 5. 2 (average of annual number) Heffler E, Blasi A, Latorre M, Menzella F, Paggiaro P, Pelaia G, Senna G, Canonica GW. J Allergy Clin Immunol Pract 2019, in press

TSLP and other alarmins activate dendritic cells and ILC 2 s Gon Y, Hashimoto S. Allergol Int 67: 12 -17, 2018

CRTh 2 -MEDIATED INFLAMMATION IN ASTHMA Howell MD, Fitzsimons C, Smith PA. Ann Allergy Asthma Immunol 120: 367 -275, 2018

Existing and emerging therapeutic approaches to target T 2 -HIGH SEVERE ASTHMA Siddiqui S et al. Am J Respir Crit Care Med 2019, in press

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