First new treatment for asthma attacks in 50 years

A new study has found that an injection given to people who suffer from asthma and COPD - chronic obstructive pulmonary disease - attacks is much more effective than the current treatment with steroid tablets, which - alarmingly - fails three quarters of the time. The new therapy - an injected antibody that targets a population of white blood cells called eosinophils, which drive the inflammatory response that causes many asthma attacks and COPD exacerbations - is called benralizumab. And the authors say it could be “game-changing” for millions of people. Here’s Richard Russell at King’s College, London…

Richard - We know people have these attacks. These attacks occur and they affect individuals. They cause loss of lung function. They make them feel really sick. They lead to hospitalisation and indeed, in some cases, lead to death. The treatments we've had have not changed for over 50 years. We give these people oral corticosteroid treatments, anti-inflammatory therapies. We were then aware that these treatments themselves, 1) are not very effective. 2) have got side effects; osteoporosis, diabetes, obesity, skin thinning, bruising, cataracts. We needed to think can we find a better treatment? We identified, over 15 years ago now, that there are groups of patients who have attacks of a particular pattern of inflammation, we'll call it eosinophilic inflammation. Now what was really exciting is that, in the last few years, we've developed new treatments which are specific to reducing this pattern of inflammation.

Chris - But what are eosinophils and why are they uniquely bound up with these particular patterns of attacks?

Richard - Well, that's a really great point. Eosinophils are part of your immune system. They're white blood cells. They are relatively uncommon in our blood in comparison with other blood cells. Historically, we believe they've been associated with particular things like allergy and indeed asthma, but also worm infection. We've now recognised that these eosinophils are really important in our guts and in our lungs, particularly at monitoring what is going on in the immune environment. We recognise these cells are actually really important and what happens is, when you have an eosinophilic attack, you have an increase in breathlessness, increasing in cough and sputum, and in your blood we can measure an increased level of these eosinophils. That's what we're targeting with this new treatment.

Chris - The rationale being then that if there's a lot of these cells and they're linked to attacks, if you reduce the number of them, you should have fewer attacks.

Richard - Absolutely correct. That's exactly what we did. We designed a study using a treatment called benralizumab. Benralizumab is an antibody therapy given by injection which specifically targets eosinophil production and migration into the lungs. We compared this with standard therapy oral corticosteroids, and indeed we had a third arm, which was a combination of the two treatments together.

Chris - How many people did you look at and who? Who were the patients?

Richard - We looked at 158 patients. These patients were all comers, whether they had asthma or COPD, that had an attack. If you were a patient out there on the street and you had a worsening of your condition, you would come along to us. We would do a blood test at that moment. If your eosinophils were raised, we would then randomise you into the study. It was everyone with asthma and COPD who had this raised level of eosinophils and we followed them for three months, 90 days. Our primary outcome was what we call treatment failure, meaning: did your treatment work or not? If your treatment failed is defined by needing more treatment or having to go to hospital or even dying. We were comparing the failure rates of standard treatment with the failure rates of this new therapy.

Chris - And how did they compare?

Richard - What we demonstrated was a couple of things. One, if you have eosinophilic exacerbation attack (from asthma or COPD), you have got with standard therapy around a 74% chance of your treatment not working. Now, that should shock the audience today because I think that's where we are right now. That is standard therapy. Is that good enough? Absolutely not. But what we demonstrated was that, with the new therapy, we were able to reduce that rate to around 44%, which is a 74% reduction in treatment failure.

Chris - Is it practical and is it cost effective? Because that's the thing that NICE are very keen on. We have drugs that might work, but if they don't work well enough to return a good bang for their buck, they won't say we can use them. Where do we sit on that line?

Richard - There are two points there. Let me put the first one to bed: is it practical? Yes, absolutely it is. We have technology which can allow for point of care testing of your blood with an answer within seconds, if not a couple of minutes. That is available right now and indeed our standard therapies in hospital can give you a blood result within a few minutes. It is absolutely practical. The injections are given, can even be given by the patient themselves, but certainly are very easy to administer, and the side effect profile is extremely good. We've got experience with these over time. The practicality I think gets a big tick, absolutely. Cost effect is much more difficult. Steroids are very cheap but, hold on, steroids fail 75% of the time, so what the heck are we doing with this? We're exposing people to side effects and risk, so we need to do a bigger study, a phase three, larger scale multinational study, and then we can do some cost effective analysis which will make the argument, I would hope, to use these treatments. This is a one-off treatment, not recurrent treatment. If you end up being admitted to hospital, or even worse, you end up being admitted to intensive care, you are looking at a cost of 2, 3, 4, 5,000 pounds a day. This treatment costs around a thousand pounds. So, although it is expensive, if it's saves intensive care and even death, that will end up being cost effective.