clinical implications of asthma endotypes and phenotypes
TRANSCRIPT
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Clinical Implications of Asthma
Endotypes and Phenotypes
Dennis K. Ledford, MD, MPH
Ellsworth and Mabel Simmons Professor of Allergy/Immunology
Morsani COM and James A. Haley VA Hospital
University of South Florida
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Competing Interests
• Funded research: AstraZeneca, Genentech,Novartis
• Consultant: AstraZeneca, BioCrys, Genentech, GSK
• Speaker Bureau: AstraZeneca, Genentech, GSK, Novartis, Sanofi Regeneron
• Legal Opinions: Anaphylaxis, asthma death, indoor mold exposure
• Royalties: UpToDate, Taylor Francis (Allergens and Allergen Immunotherapy)
• Organization: AAAAI (Ask the Expert)
• Data Safety Committee: Galderma (- IL31, nemolizumab)
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• Define, compare and contrast the spectrum of phenotypes and endotypes in asthma
• Discuss treatment options based upon asthma phenotypes utilizing randomized trials and available biomarkers
• Review a potential algorithm to help select asthma therapy based upon phenotypes
Learning Objectives
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Outline
• Definitions
• Examples of phenotypes and endotypes
• Phenotype- and biomarker-based treatment algorithm
• General overview of treatment options
• Special thank you to Juan Carlos Cardet, MD, MPH
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Definitions
Phenotype
• An individual’s observed characteristics that result from
gene-environment interactions (e.g., atopy, obesity)
Wenzel SE. Nat Med. 2012;18(5):716-725. Lang DM. Allergy Asthma Proc. 2015;36:418-424.
Endotype
• A subtype of a condition defined by a distinct and
functional pathobiologic mechanism (e.g., AERD,
eosinophilic*, TH2-high*)
* Commonly used as example of endotype but pathophysiogic mechanism variable
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Phenotype versus Endotype
Asthma
Neutrophils Eosinophils
IL5IL8
Anemia
Hypochromic/microcytic
Hyperchromic/macrocytic
Beta-thalassemia
Iron deficiency
Vitamin B12deficiency
Folate deficiency
Disease
Phenotype
Endotype
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Definitions
PRACTALL Consensus report, EAACI and AAAAI
Requirement for defining an ‘endotype’:
--must fulfill at least 5 of 7 parameters:
1. Clinical characteristics
2. Biomarkers
3. Pulmonary physiology
4. Genetics
5. Histopathology
6. Epidemiology
7. Response to treatment
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The Relationship Between Phenotype and Endotype
Late-onset asthma
Severe eosinophilic
late-onset asthma**
Relationship Example
Asthma
Adapted from Lotvall J et al. J Allergy Clin Immunol. 2011;127:355-60
The asthma syndromeAsthma symptoms, variable airway obstruction
Phenotypic characteristics in asthmaObserved, directly related to the disease process. Includes physiology,
triggers, and inflammatory parameters.
Asthma endotypesDistinct disease entities; can be characterized by a phenotypic group
but are defined by a specific biologic mechanism
Endotype 1 Endotype 2 Endotype 3 Endotype 4 Endotype 5
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Eosinophil Levels Correlate With Asthma Exacerbations And Asthma Control
aData from medical records of asthmatics aged 12–80 years with 2 years of continuous records, including 1 year before (baseline) and 1 year after (outcome) their most recent eosinophil count. Patients assigned to 9 eosinophil count categories compared with a reference category of 200 cells per μL or less (n=68 407). Adjusted for age, sex, body-mass index, smoking status, and Charlson comorbidity index score.
RR=rate ratio; OR=odds ratio.
1. Price DB et al. Lancet Respir Med. 2015;3(11):849-58. 2. Wenzel SE et al. Am J Respir Crit Care Med. 1999;160:1001-1008. 3. Price DB et al. J Asthma Allergy. 2016;9:1-12.
201–300 cells per µL (n=25,882)
301–400 cells per µL (n=15,030)
401–500 cells per µL (n=8659)
501–600 cells per µL (n=4928)
601–700 cells per µL (n=2726)
701–800 cells per µL (n=1631)
801–900 cells per µL (n=947)
901–1000 cells per µL (n=1019)
>1000 cells per µL (n=1019)
Severe
Exacerbations
0.5 0.7 1.0 1.5 2.0Adjusted RRa
2.5
Acute
Respiratory Events
0.5 0.7 1.0 1.5 2.0 2.5Adjusted RRa
Overall
Asthma Control
0.3 0.5 0.7 1.0 1.5 2.0Adjusted ORa
Pe
rip
he
ral
Blo
od
Eo
sin
op
hil
s
Elevated eosinophil counts are associated with asthma severity, severity of exacerbations, and level of asthma control1-3
Risk-domain
Asthma Control
0.7 1.0 1.5 2.0Adjusted ORa
0.3 0.5
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Asthma Phenotypes
Hekkin P et al. JACI Pract Nov-Dec 2014
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Phenotype versus Endotype: T2 High is Phenotype
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Problems with This Definition
“Severe eosinophilic late-onset asthma”
• Not really hypereosinophilic (normal blood count)
• Severity, age, disease duration, and the presence of
eosinophils are phenotypic descriptions
• Eosinophils: neither necessary nor sufficient to cause
severe asthma.
• Allergy: neither necessary nor sufficient to cause severe asthma.
• The presence of “hypereosinophilia” does not denote
the pathobiologic mechanism or pathway.
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Asthma: A Heterogeneous Disease
Agache et al Allergy 2012; 67: 835–846
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Types of Inflammation, 1 versus 2
Israel NEJM 2017
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Phenotypes: Unbiased Data-Driven Analysis
Moore AJRCCM 2010
1. Mild atopic asthma
2. Mild-moderate atopic asthma
3. Non-atopic late-onset asthma
4. Severe atopic asthma
5. Severe asthma with fixed airflow
obstruction
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Allergen
MucusAirway LumenEpithelial Injury
Subepithelial Mucosa
FeNOEosinophils
Periostin
EosinophilsPeriostin
Bloodstream
ILC2Mast Cell
B CellActivated
B cell
Eosinophil Maturation
Bone Marrow
Airway Epithelium
Anti IL-25
Anti IL-33
Anti-TSLP
Prostaglandin D2CRTH2 Antagonists
Fevipiprant
Setipiprant
OC000459
TH2
TH2
IL-25IL-33TSLP
IL-13IgE
IL-13
IL-5
Benralizumab
Mepolizumab
Resilizumab
Lebrikizumab
Tralokinumab
Dupilumab
Omalizumab
iNOS
Allergen
Novel Therapies Targeting T2 High Asthma
Parulekar A et al. Curr Opin Pulm Med 2017
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Hanania NA et al. Ann Int Med
2011;154:573-582
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Asthma Exacerbation Reductions in Omalizumab
Pivotal Clinical Trials by Eosinophil Strata
Casale et al, Allergy 2018
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Omalizumab Persistence After
Discontinuation of Long Term Rx:
Prediction of Relapse or Remission
(EXCEL extended or EXPORT)
Ledford, Dennis, et al. Journal of Allergy and Clinical Immunology 140.1 (2017): 162-169.
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The Targets: IL-5 or Eosinophils/Basophils (IL-5Rα)
Casale, JACI. 2017
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Exacerbation Rate Reduction Similar Among IL-5
Blockers
Carbon et al, Clin Expt Allergy, 2016
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Dupilumab: Fully Human mAb to IL-4Rα
Casale, JACI,2017
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Dupilumab Phase 2b FEV1 Results
All Patients
>300 Eos
<300 Eos
Wenzel, et al, Lancet, 2016
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Dupilumab Phase 2b Exacerbation
ResultsC
um
ula
tiv
e N
um
ber o
f E
ven
ts
0.0
0.1
0.2
0.3
0.4
0.5
0.6
Week
0 6 12 18 24
Placebo Dup 200 mg q4wDup 300 mg q4w Dup 200 mg q2wDup 300 mg q2w
EOS >300
Cu
mu
lati
ve
Nu
mb
er
of
Ev
en
ts
Week
Cu
mu
la
tiv
e N
um
ber o
f E
ven
ts
0.0
0.1
0.2
0.3
0.4
0.5
Week
0 6 12 18 24
Placebo Dup 200 mg q4wDup 300 mg q4w Dup 200 mg q2wDup 300 mg q2w
EOS <300
Cu
mu
lati
ve
Nu
mb
er
of
Ev
en
ts
Week
Placebo
200 mg q2w
300 mg q2w
200 mg q4w
300 mg q4w
Wenzel, et al, Lancet, 2016
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Molecular Changes in the Atopic Dermatitis Transcriptome in Studies M4A and M4B.
Beck LA et al. N Engl J Med 2014;371:130-139
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Annualized Rate of Asthma Exacerbations at Week 52, According to Baseline Biomarker Status, and Change from Baseline in the Fraction of
Exhaled Nitric Oxide (Feno).
Corren J et al. N Engl J Med 2017;377:936-946
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Tezepelumab OCS Sparing?
• Embargoed until May 12, 2021
• Lead author Michael Wechsler
• Press release suggested did not reach
outcome…is it possible a therapeutic
effective in more diverse population
may not demonstrate CS sparing effect
expected with Type 2 selective
therapies such as CS?
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Radiologic Phenotype: Mucus impaction, Proposed
Endotype MUC5AC:MUC5B:high, EPO:high
Dunican et al JCI 2018
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Hudey, Cardet Ledford. Curr Opinion Immunol 2020;66:123-28
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Phenotype: Neutrophilic Asthma
Moore JACI 2014
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Gibson PG et al. Lancet 2017;390:12-18
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Neutrophilic Asthma: Proposed Endotype of Low-
LXA4 and SAA-high
Rickleffs I et al. JCI Insight 2018 Mar 22;3(6)
% inhibition of IL8 production
by epithelial cells exposed to
BALF from patients
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Endotype:
Aspirin Exacerbated Respiratory Disease
AERD or NERD
● Asthma
● Nasal polyposis (NP) with
chronic hyperplastic
eosinophilic rhinosinusitis
● Sensitivity to COX-1 inhibitors
What it is What it is not
● Not IgE-mediated allergy to
aspirin
● Not Mendelian inheritance
● Not childhood disease
● Not due to obvious
environmental trigger
● Not transient
A disease with many names
Ledford JACI IP 2016
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AERD: Eicosanoid Dysregulation Relates to the
Pathobiologic Mechanism of the Endotype
= implicated in AERD
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Late-onset Asthma Associated with Obesity: Proposed Endotype with
Reduced eNO Due to Increased Catabolism
Holguin AJRCCM 2013; Winnica CEA 2017
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Response to Weight Reduction in Obese Asthma
Hasegawa et al JACI 2015
N=2,261
OR = 0.42
(95% CI, 0.35-0.50;
P<0.001)
OR = 0.98
(95% CI, 0.85-1.13;
P=0.80)
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Phenotype- and Biomarker-Based Treatment Algorithm
Carr et al AAAI 2018
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Phase 2/3 Trial Asthma Cemetery
Lebrikizumab
TralokinumabFevipiprant
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Summary
1. Asthma is heterogeneous.
2. Knowledge is limited of endotypes defined by
molecular aberrations consistently demonstrated in
longitudinal analyses.
3. There are only a few existing treatments geared
towards particular asthma phenotypes.
4. Endotypes help select the ‘right patient for the right
drug’ but effective therapies for multiple phenotypes
are appealing as a worthy trial in challenging or
severe asthma
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References1. Wenzel SE. Nat Med. 2012;18(5):716-725
2. Lang DM. Allergy Asthma Proc. 2015;36:418-424.
3. Agache et al. Allergy 2012; 67: 835–846
4. Moore et al. Am J Respir Crit Care Med 2010; 181: 315–323
5. Lotvall et al. JACI 2011; 127: 355-60
6. Israel et al. N Engl J Med. 2017; 377: 965-976
7. Carr T AAAI 2018 in press
8. Choi S et al. JACI 2017;140:690-700
9. Dunican et al JCI 2018; vol 128 pp 997-1009
10. Denlinger et al. AJRCCM 2017 195(3):302-313
11. Ledford et al. JACI IP 2016 vol 4 pp 590-8
12. Muthus et al. Clin Exp Allergy. 2018 pp1–30
13. Holguin AJRCCM 2013 Vol 187, Iss. 2, pp 153–159
14. Winnica et al. Clin Exp Allergy. 2017; 47: 190–199
15. Hasegawa et al. J Allergy Clin Immunol 2015 vol 136 pp288-94
16. Moore et al J Allergy Clin Immunol 2014 vol 133 pp1557–1563
17. Green R, et al. Lancet. 2002; 360(9347):1715-21.
18. Price DB et al. Lancet Resp Med. 2015;3:849-58.
19. Patel et al. Expert Opin Biol Ther. 2018 July ; 18(7): 747–754.
20. Evans et al. JACI 2018 ;142:415-23
21. Ricklefs et al. JCI Insight. 2018 Mar 22;3(6)
22. Wechsler