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Severe asthma treated with tezepelumab — SCE Respiratory MCQ

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HardAsthmaSevere asthma treated with tezepelumabSCE Respiratory

A 48-year-old man is reviewed in a specialist severe asthma service. Before biological treatment, multidisciplinary assessment confirmed asthma, good adherence and correct inhaler technique. Despite high-dose inhaled corticosteroid/formoterol maintenance and reliever therapy plus tiotropium, he had four severe exacerbations requiring systemic corticosteroids in 12 months. He was not taking maintenance oral corticosteroids. Blood eosinophils were repeatedly 0.08–0.11 x 10^9/L, FeNO was 14 ppb, total IgE was 32 IU/mL and perennial aeroallergen testing was negative. Tezepelumab was commenced. At the protocolised 12-month review, he has had two severe exacerbations requiring systemic corticosteroids. His ACQ-6 score has improved by 0.3 points and FEV1 is unchanged. He has experienced no significant adverse effects. What is the most appropriate management?

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Correct answer: B — Continue tezepelumab because the severe exacerbation rate has fallen by 50%

Tezepelumab should be continued. This patient was eligible because severe asthma remained uncontrolled despite high-dose inhaled corticosteroid plus another maintenance treatment and he had at least three severe exacerbations in the preceding year. NICE does not require an eosinophil, FeNO, IgE or allergic-sensitisation threshold for tezepelumab. At 12 months, his severe exacerbations have fallen from four to two, an exact 50% reduction; this meets the NICE continuation criterion for a patient who was not receiving maintenance oral corticosteroids. A clinically important ACQ-6 or FEV1 improvement is not an additional mandatory NICE stopping criterion. Adding maintenance prednisolone would unnecessarily increase cumulative corticosteroid toxicity when the commissioned biologic has met its response threshold. Switching to an anti-IL-5 pathway biologic is poorly supported by his repeatedly suppressed eosinophil count and is not indicated merely because two breakthrough exacerbations occurred. Low type 2 biomarkers do not themselves justify bronchial thermoplasty or negate a qualifying tezepelumab response. Stopping because the ACQ-6 change is below its conventional minimal clinically important difference, or because FEV1 is unchanged, incorrectly substitutes secondary clinical measures for the specified NICE stopping rule.

Reference: Tezepelumab for treating severe asthma: Recommendations (20 April 2023) — https://www.nice.org.uk/guidance/ta880/chapter/1-Recommendations Tezepelumab for treating severe asthma: Recommendations (20 April 2023) — https://www.nice.org.uk/guidance/ta880/chapter/1-Recommendations