Which Asthma Biologic will it be?

Will it be, Door #1, Door #2, or Door #3 ?

Now that we’ve established that I indeed have an eosinophilic component to my asthma, the next logical step is to try me on a biologic medication that targets eosinophils and see it helps. But which one?

Currently there are 5 injectable biologic medications on the market; Nucala (mepolizumab), Fasenra (benralizumab), Dupixent (dupilumab), Cinqair (reslizumab) and Xolair (omalizumab), with a 6th one, Tezspire (tezepelumab) coming out in the next few months. With the exception of Xolair, which blocks the antibody that causes allergy and asthma responses (IgE), most of these biologic medications target the various pathways that affect eosinophils, which are involved in allergic type airway inflammation. The logic being that if you can reduce the amount of eosinophils that cause inflammation, you might be able to reduce your dependency on oral steroids. We all know how serious the side effects of oral steroids can be.

So which one will I be getting? My top pick is actually Tezspire, as it seems the most promising for my type of asthma. But because its not clear when the drug will become available, Ill have to put that one on the back burner for now. Likewise, it wont be Dupixent. Its a great drug, but I had some unpleasant side effects when they tried me on it a couple years ago and had to stop taking it. We can also eliminate Xolair. This is a solid and well established drug and has been around since the mid 2000s, but after being on it for a full year I wasn’t seeing a whole lot of improvement.

So that pretty much whittles it down to either Nucala, Fasenra or Cinqair. All 3 are anti IL-5 drugs, all target eosinophils and all have good reported outcomes. Nucala and Fasenra are given via injection and both are available in pen or auto-injectors, so that you can self-administer at home. Cinqair on the other hand, is administered via IV infusion and is given in a medical office, infusion center or by healthcare professional at your home. Of those 3 my I would probably choose Fasenra , as it only requires dosing every 8 weeks (after the initial loading doses), instead of every 4 weeks for Nucala. For extra convenience, both Fasenra and Nucala are now available in pen form for self-injection.

Ah, but not so fast. There’s a little matter of cost and who’s gonna pay. Biologics are extremely expensive, and unless you’re filthy rich it’s going to take some really good insurance to cover it. Most employer provided insurance plans will cover these types of drugs, and the manufacturers all have discount programs to reduce the co-pays. Being on Medicare I don’t quality for any of the manufacturer discount programs, Medicare part B however, will pay 80% of the cost for certain injectable drugs as long as they are administered in a hospital or doctors office setting. I’m responsible for the other 20%, but thankfully I have a Medigap insurance plan that will cover that 20%.

Finally, while Im super excited to have a new treatment option available to me, I also know that there’s no guarantee that my asthma will improve. It’s also important to note that all of these new biologic medications are considered “add-on” therapies, meaning that you have to continue taking your other asthma meds, especially your rescue meds, until you’re able to come off them… if ever. Some people seem to do really well and have good results on these drugs, some are able to come off steroids completely. Still, there are some that don’t see much improvement at all. Even if my PFTs or symptoms don’t turn around dramatically, if I can just reduce the number of severe exacerbations, hospitalizations and intubations, that would actually be an incredible improvement and more than enough to justify the expense of these kinds of drugs.

*******UPDATE as of 09/30/2021****** AND THE WINNER IS………… FASENRA!