Background Patients with severe asthma may present with characteristics representing overlapping phenotypes, making them eligible for more than one class of biologic. Our aim was to describe the profile of severe adult asthma patients eligible for both anti-IgE and anti-IL5/5R and to compare the effectiveness of both classes of treatment in real life. Methods This was a prospective cohort study that included adult severe asthma patients from 22 countries enrolled into the International Severe Asthma registry (ISAR) who were eligible for both anti-IgE and anti-IL5/5R. The effectiveness of anti-IgE and anti-IL5/5R was compared in a 1:1 matched cohort. Exacerbation rate was the primary effectiveness endpoint. Secondary endpoints included long-term-oral corticosteroid (LTOCS) use, asthma-related emergency room (ER) attendance and hospital admissions. Results In the matched analysis (n=350/group), the mean annualized exacerbation rate decreased by 47.1% in the anti-IL5/5R group and 38.7% in the anti-IgE group. Patients treated with anti-IL5/5R were less likely to experience a future exacerbation (adjusted IRR 0.76; 95% CI 0.64, 0.89; p<0.001) and experienced a greater reduction in mean LTOCS dose than those treated with anti-IgE (37.44% vs 20.55% reduction; p=0.023).) There was some evidence to suggest that patients treated with anti-IL5/5R experienced fewer asthma-related hospitalizations (IRR 0.64; 95% CI 0.38, 1.08), but not ER visits (IRR 0.94, 95% CI 0.61, 1.43). Conclusions In real life, both anti-IgE and anti-IL5/5R improve asthma outcomes in patients eligible for both biologic classes, however anti-IL5/5R was superior in terms of reducing asthma exacerbations and LTOCS use.

Background: Allergic rhinitis (AR) is the most common allergic disease in children and is closely associated with asthma in the context of atopic march. The development process of AR in early childhood, however, is not well understood due to the absence of definitive diagnostic criteria. We prospectively investigated the process in regard to not only the nasal symptoms and sensitization, but also the nasal cytology, in relation to asthma in a high-risk cohort. Methods: Infants under 2 years of age with atopic dermatitis (AD) and/or food allergy (FA) without a diagnosis of asthma were recruited and followed prospectively for 2 years. The phenotype of perennial AR was classified based on the presence/absence of 1) persistent nasal symptoms, 2) nasal eosinophils and 3) HDM sensitization, the most common allergen for perennial AR in Japan. AR-like phenotypes were defined as positive for at least 2 of those 3 categories. Results: A total of 304 children were enrolled, and 242 subjects (80%) completed the 2-year observation. The prevalence of eosinophilia in nasal secretions increased from 18.5% to 69.9%, while HDM-specific IgE >0.35 kUA/L increased from 30.6% to 74.8%. AR-like phenotypes increased from 18.4% to 65.0%. The cumulative incidence of physician-diagnosed asthma during the 2-year follow-up was significantly higher in the subjects with an AR-like phenotype at 1 year than in those with a non-AR phenotypes. Conclusions: The prevalence of an HDM-related AR-like phenotype was markedly increased during infancy in high-risk infants with AD/FA and was associated with asthma.