New Asthma Treatments on the Horizon

{Note: in October we heard Dr. Arnold Levinson challenge an audience of allergists to name a breakthrough in asthma treatment since inhaled corticosteroids. To find out what is going on, we asked our favorite pulmonologist to look into the crystal ball and tell us about upcoming developments.}

By Dr. Francis V. Adams

Asthma is a chronic inflammatory disease of the airways that affects 300 million individuals worldwide. Current therapies that combine inhaled corticosteroids (ICS) with bronchodilators called beta-agonists (short or long-acting) are generally effective for the control of mild to moderate bronchial asthma. Omalizumab, a monoclonal antibody that binds an allergy protein (IgE), and bronchial thermoplasty, in which radio frequency waves target excess smooth muscle in the airways, are useful in the treatment of severe asthma. Both treatments, however, are highly expensive and may not be covered by insurance carriers.

New treatments for asthma, especially severe asthma, are necessary. These treatments must pass through the required phases or trials that prove safety and effectiveness. They must also be affordable and covered by insurers.

A number of new therapies are under development and many have reached phase 3 or human trials. In addition, the approach to treating the individual patient is also changing. In the next few years I expect to see the following advances in the treatment of asthma:
1. Ultra long-acting beta agonists (ultra-LABAs). One agent, indacaterol, is already licensed for COPD and several others are in development. These medications will likely be combined with once a day inhaled corticosteroids for patients with moderate to severe asthma.
2. Long acting anti-muscarinic bronchodilators (LAMAs). Two agents, tiotropium bromide and aclidinium, are already licensed for COPD. These medications are more effective in COPD but will be useful “add-ons” in patients with uncontrolled asthma. I expect these agents to be combined with ultra-LABAs and once a day inhaled corticosteroids.
3. Biological agents that block cytokines called interleukins which promote inflammation. Two agents, mepolizumab, which is anti-interleukin-5, and lebrikumab, anti-interleukin-13, are in phase 3 trials. These agents are given by injection and should target patients with severe asthma.
4. Inhibitors of the pro-inflammatory prostaglandins, hormone-like substances that are found in inflamed airways. One of these agents is in phase 3 trials and is given by mouth. These agents will likely be used in combination with other asthma controllers, like inhaled corticosteroids.
5. Routine use of genetic testing in the treatment of the individual patient. Current research has already identified a genetic mutation that reduces the response of patients to beta-agonists. Additional body markers may also predict responsiveness to corticosteroids. Routine use of these technologies will speed effective control of this disease as treatment is “personalized” for the individual patient.

Francis V. Adams, M.D. is a pulmonologist in private practice in Manhattan and an Assistant Professor of Clinical Medicine at NYU Langone Medical Center He is the author of “The Asthma Sourcebook” and “Healing Through Empathy-An Expanded Edition”. Dr. Adams maintains a web site, www.adamsmd.com, where you can find ordering information about his books, and publishes an electronic newsletter weekly. He is also a Police Surgeon with the NYPD, a frequent contributor to the LA Times and hosts Doctor Radio on SiriusXM satellite radio every Tuesday morning from 6 to 8AM (Eastern time) where Dr. Ehrlich is an occasional guest.