Prospective direct comparison of biological treatments on severe eosinophilic asthma: Findings from the PRISM study

Background: Although various monoclonal antibodies have been used as add-on therapy for eosinophilic severe asthma (ESA), no direct head-to-head comparative study has evaluated their efficacies. Objective: To compare the efficacy of reslizumab, mepolizumab, and dupilumab in patients with ESA through a multicenter, prospective, observational study. Methods: A total of 96 patients with ESA who had received one of these biological agents for at least 6 months were included in the study. Cox proportional hazard models were used to compare the risk of the first exacerbation event. The annual exacerbation rate was analyzed using a negative binomial model, and a mixed-effect model was used to analyze changes in forced expiratory volume in 1 second and asthma control test score over time. Results: In comparison to reslizumab adjusted for sputum eosinophils and common asthma-related covariates, the hazard ratios and 95% confidence intervals of the first exacerbation incidence were 2.90 (0.92-9.16) and 2.69 (0.87-8.29) for dupilumab and mepolizumab, respectively. During the follow-up period, the dupilumab group was more likely to experience exacerbation compared with the reslizumab group (rate ratio and 95% confidence interval, 3.97 [1.17-14.74]). No differences were observed when the models were adjusted for blood eosinophil counts. Both the forced expiratory volume in 1 second and asthma control test improved after treatment, but no group differences were found. Conclusion: Three biologics were equally effective as add-on therapy for ESA. Reslizumab may have an advantage in preventing future exacerbation compared with dupilumab. Sputum eosinophils may be a useful consideration when choosing a biological treatment.