Low persistence in biologic therapy linked to asthma exacerbations, steroid use

Key takeaways:

• Persistence was defined as a lack of a treatment gap of more than two doses, with more than half of refills completed.
• Patients who were less persistent and not persistent had 18% more asthma exacerbations.

SAN FRANCISCO — Patients with asthma who did not persist with biologic treatment had more exacerbations and used more oral corticosteroids, according to an abstract presented at the American Thoracic Society International Conference.

Persistence rates varied depending on the biologic, Justin Kwiatek, PharmD, senior director and U.S. medical affairs lead, respiratory biologics, GSK, said during his presentation.

“We wanted to understand the clinical and real-world impact that biologics can have based on patterns of adherence and persistence,” Kwiatek told Healio.

Justin Kwiatek

Earlier this year, he said, the researchers presented data indicating strikingly different adherence patterns in biologics, leading them to ask how these patterns might affect patient outcomes.

“Here, we investigated levels of persistence with biologic therapies in patients with asthma, and the clinical impact on exacerbations and use of oral corticosteroids,” Kwiatek said.

The researchers defined adherence as how well a patient matches a prescribed treatment plan and persistence as how long a patient follows the treatment plan.

“For example, if we see a patient is still on a therapy at 12 months, have they adhered to the regimen the whole time, or are there big gaps where treatment was paused? How does that compare to those who discontinue treatment?” Kwiatek said.

“Those are the types of questions we want to answer through our adherence/persistence categories,” he said.

The retrospective cohort study included data from 16,336 patients aged 12 years and older with asthma in the Komodo Research Database who began biologic treatment between Jan. 1, 2016, and June 30, 2024.

The cohort included 10,266 patients (62.6%) classified as persistent, or treatment with no gap of more than two doses and more than 50% of refills completed.

Also, 1,972 patients (12.1%) were classified as non-persistent, defined as a treatment gap of more than two doses or 50% or fewer refills completed.

There were 499 patients (3.1%) classified as non-persistent, with treatment gaps of more than two doses with 50% or fewer refills completed.

Finally, treatment for 3,699 patients (22.3%) was classified as discontinued, with a treatment gap of more than three doses with resumption.

Patients who initiated IL-5/5R biologics had the highest rates of persistence, including 72.2% for benralizumab (Fasenra, AstraZeneca), 69% for reslizumab (Cinqair, Teva Pharmaceutical) and 68% for mepolizumab (Nucala, GSK).

Tezepelumab (Tezspire; Amgen, AstraZeneca) had the highest rate of discontinued treatment at 33.2%, followed by omalizumab (Xolair; Genentech, Novartis) at 29.6% and dupilumab (Dupixent; Sanofi, Regeneron) at 23.3%.

“Patients with less persistence to a biologic therapy had a significantly greater rate of asthma exacerbations and OCS use,” Kwiatek said.

Overall exacerbation rates were 18% higher (RR = 1.18; 95% CI, 1.12-1.24) and hospitalization-defined exacerbations per patient-year were 28% higher (RR = 1.28; 95% CI, 1.17-1.39) for partially non-persistent and non-persistent patients compared with persistent patients.

Oral corticosteroid dispensing rates per patient year were 39% higher for non-persistent patients (P < .05) and 33% higher for discontinuation patients (P < .05) compared with persistent patients.

Similarly, oral corticosteroid burst rates per patient year were 37% for non-persistent patients and 19% higher for discontinuation patients compared with persistent patients (P < .05 for both).

Mean daily oral corticosteroid doses were 0.4 mg higher for non-persistent patients and 0.71 mg higher for discontinuation patients for discontinuation patients compared with persistent patients as well (P < .05 for both).

Based on these findings, the researchers concluded that persistence to biologic therapies varied depending on the treatment and that less persistence led to more exacerbations and oral corticosteroid use.

“Overall, these results indicate that lack of persistence may lead to some patients not receiving the full potential clinical benefit of their biologic therapy,” Kwiatek said.

Although the researchers did not directly evaluate barriers to adherence and persistence in their study, Kwiatek did note that there are general factors that can impact such behavior.

“Research has shown us that patients may discontinue therapies due to factors such as difficulty of the injection or device, getting to the clinic, cost and fear of needles,” he said.

Dosing frequencies and types of administration vary by biologic agent as well, he continued, which also impacts patient preference and adherence.

“It’s important to note that regardless of the reason, we see increased exacerbations when persistence is lower,” Kwiatek added.

Shared decision-making is critical to adherence and persistence, he continued, as doctors emphasize treatment goals and the reasoning behind biologic choices to motivate patients to follow the plan.

“Biologics with longer dosing intervals should be considered, as these were generally associated with a greater proportion of patients remaining persistent with treatment,” he said. “Access to patient support programs is also helpful to ensure that patients are able to have their questions answered and continue on the medication, especially if taken at home.”

Further, Kwiatek said that he and his colleagues now have an understanding of adherence and persistence patterns as well as of the real-world impact on patients who may not be receiving the full benefits of their therapy and that they will continue their studies.

“From here, we want to understand more about who these patients are, looking at demographics and social determinants of health, to see which patients are likely to be in the persistent vs. less/non-persistent categories,” he said.

For more information:

Justin Kwiatek, PharmD, can be reached at allergy@healio.com.