Dear Editor
An even more transformative step change in the management of asthma is the documentation of a significantly beneficial outcome from coprescription of benralizumab(ABRA) and oral corticosteroid therapy in acute exacerbations of asthma characterised by a blood eosinophil count of 300 microlitres or more[1]. In the latter study the 28-day total visual analogue scale mean difference between the subgroup managed with BENRA and oral corticosteroids and the corticosteroid only subgroup amounted to 49 mm(95% Confidence Interval 14-84; p=0.0065) favouring the BENRA subgroup[1].
There is a potential for a step change also in the documentation of a beneficial effect from the use of metformin as add on medication in asthma[2]. In the latter cohort study of 12,0702 subjects with asthma, metformin was associated with a lowered risk of asthma attacks by approximately 30%. In that cohort 81.5% had a recorded body mass index(BMI). Of those who had a recorded BMI, 53.9% were overweight or obese. Type 2 diabetes was documented in 6.9%.. Furthermore, in that cohort, coprescription of Glucagon-like peptide receptor agonist therapy was associated with an additional lowered risk of asthma attacks amounting to approximately 40%[2].]
The rationale for the use of metformin is that it ameliorates inflammation and airway remodeling in the animal model of allergic asthma[3].The phenotype of asthma, diabetes, and obesity[2],[4], appears to be one which benefits from the coprescription of metformin and GLP receptor agonists. In that context an additional beneficial effect of ABRA might be predicted from the observation that ABRA also has a corticosteroid-sparing effect[5] which might mitigate the risk of incident diabetes associated with corticosteroid medication in asthma.
References
[1]Ramakrishnan S., Russell REK., Mahmood HR et al
Treating eosinophilic exacerbations of asthma and COPD with benralizumab(ABRA): a double-blind, double-dummy, active placebo-controlled randomised trial
Lancet Respir Med 2024;doi.org/10.1016/S2213-2600(24)00299-6
[2]Lee B., Man KKC., Wong E et al
Antidiabetic medication and asthma attacks
JAMA Internal Medicine 2024;doi.org:10.1001/jamainternmed.2024.5882
[3]Ma W., Jin Q., Guo H et al
Metformin ameliorates inflammation and airway remodeling of experimental allergic asthma in mice by resoring AMPKalpha activity
Frontiers in Phramacology2022;18:Article 780148
[4]Peters U., Dixon A., Forno E
Obesity and asthma
J Allergy Clin Immunol 2018;14:1169-1179
[5]Menzies-Gow A., Gurnell M., Heaney L et al
Oral corticosteroid elimination via a personalised reduction algorithm in adults with severe, eosinophilic asthma treated with benralizumab(PONENTE): a multicentre, open-label, single-arm study
Lancet Respir Med 2022;10:47-58
Re: Asthma: New UK guidelines signal “step change” in diagnosis and treatment and other recent step changes