Asthma is perhaps the most common chronic disease in children, affecting 8%-10% of U.S. children. Asthma exacerbations and poor asthma control can lead to missed school days, missed parental workdays, decreased lung function, inability to participate in physical activity, and for some children, hospitalizations and mortality.
Biologic medications are a promising treatment modality to improve asthma control and decrease exacerbations in children with severe or difficult-to-treat asthma and atopy. Additionally, these atopic treatment pathways are an exciting target for the treatment of allergic skin disease, including chronic urticaria and atopic dermatitis.
A new AAP clinical report, Biologics for Asthma and Allergic Skin Diseases in Children, addresses how pediatricians and pediatric subspecialists can work together to use biologic medications. The report, from the Section on Allergy and Immunology and Section on Pediatric Pulmonology and Sleep Medicine, is available at https://doi.org/10.1542/peds.2021-054270 and will be published in the November issue of Pediatrics.
Candidates for biologics
For all children with chronic asthma or allergic skin disease, pediatricians’ first steps should always include verifying the diagnosis, excluding other potential diagnoses, mitigating triggers including allergens and tobacco smoke, and assessing and improving adherence to the medication regimen when possible.
For patients whose disease remains severe or difficult to control despite these steps, collaboration with a pediatric allergist, dermatologist or pulmonologist is recommended to develop a therapeutic plan that may include biologic treatments.
Available therapies
Multiple biologic therapies are available for these diseases, all targeting different parts of the atopic inflammatory pathway. Omalizumab, an IgE antagonist, is the oldest and most studied in children. There are two anti-interleukin (IL)-5 biologics for children, mepolizumab and benralizumab, and one anti-IL-4, dupilumab. The clinical report discusses the indications and appropriate age ranges for administration of these medications.
Although much of the data is from an adult population, the most important takeaway is that all have been shown to decrease asthma exacerbations in children.
Further studies should focus on the long-term efficacy and safety of these medications specifically in pediatrics.
Key recommendations for pediatricians
- Evaluate adherence to medications in patients with poorly controlled atopic diseases, such as asthma, urticaria and atopic dermatitis.
- Refer to a pediatric subspecialist (allergist, dermatologist or pulmonologist) to determine if a patient is an appropriate candidate for biological therapy and to determine which therapy best fits the patient’s phenotype.
- Be familiar with adverse effects including the risk of anaphylaxis.
- Be aware that some medications are administered in the clinic, and some are approved for administration at home.
Key recommendations for pediatric subspecialists
- Evaluate adherence to medications in patients with poorly controlled atopic diseases, such as asthma, urticaria and atopic dermatitis.
- Partner with general pediatricians to identify appropriate patients for biological therapy.
- Monitor for adverse effects that are specific to each therapy.
- Monitor for clinical response to therapy.
- Continue research to identify new biomarkers to help monitor response and personalize therapy.
Improving lives
The goal of asthma and allergic skin disease treatment is to allow children to enjoy their lives and be able to participate in school, sports and life activities just as their peers do. Pediatricians and pediatric subspecialists should partner to make this a reality even for patients with the most severe or difficult-to-treat disease. Biologics are an effective class of medications that can change the course of asthma therapy.
Dr. De Keyser is a lead author of the clinical report.
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