Dr. Puja Rajani smiles for a photo.
Dr. Puja Rajani

Severe asthma in children is one of the leading causes of emergency department visits, hospitalizations and missed school days and affects up to 10% of kids with the condition, said Dr. Puja Rajani, a pediatric allergist at Novant Health Pediatric Allergy & Immunology.

Asthma, a lung disease that makes it harder to move air in and out of the lungs, is the most common chronic condition in children – affecting more than 6 million people under 18. While it’s often controlled by identifying and avoiding triggers, as well as using an inhaler or corticosteroids, these treatments don’t work for everyone. Instead, allergists like Rajani are using a new group of medications, known as biologics, to better treat severe asthma in kids.

“By targeting the molecules, cells or antibodies that cause asthma, biologics disrupt the pathways that lead to inflammation and asthma symptoms,” Rajani said.

Biologics help manage severe asthma

Biologics are an option for people who use standard daily controller medications but continue to have symptoms like wheezing, shortness of breath or frequent coughing. There are five approved biologics for asthma including:

  • Omalizumab.
  • Mepolizumab.
  • Reslizumab.
  • Benralizumab.
  • Dupilumab.
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    “These medications are very well studied and have very few side effects, though we don’t know what the long-term effects are. However, they’re keeping kids out of hospitals and preventing deaths,” Rajani said. “This can be a deadly disease and unfortunately, I’ve seen kids pass away from asthma.”

    While biologics are expensive, Rajani connects parents with programs to cover the cost for kids who qualify. “Basic blood work” will show if a child is a good candidate, she said.

    Age 6 and above

    Omalizumab, an approved biologic for kids age 6 and above, targets allergy antibodies known as IgE and can decrease the hospitalization rate and severity of symptoms. Mepolizumab, also for those 6 and above, works a bit differently and targets pathways that affect eosinophils, a cell involved in allergic inflammation.

    “Asthma is basically a disease of inflammation in the airway, so basically, you’re targeting those cells of inflammation to say, ‘Hey, calm down,’ and stop them from surviving,” Rajani said.

    Omalizumab and mepolizumab are administered via injections that can be done in the doctor’s office or at home using a prefilled syringe. They are subcutaneous, meaning the needle goes just below the skin but not in a muscle. The frequency of biologic injections varies from every two weeks to eight weeks, depending on the medication.

    Age 12 and above

    Dupilumab is a biologic that Rajani said is “most exciting.” It targets a receptor for two molecules that cause allergic inflammation.

    “Dupilumab performed great in studies and was remarkable at improving asthma symptoms and reduced the number of exacerbations of asthma. It’s also good at preventing the need for systemic steroids,” Rajani said.

    Benralizumab is another biologic that targets pathways that affect eosinophils, a cell involved in allergic inflammation. Both mepolizumab and benralizumab, approved for kids 12 and above, are also administered via subcutaneous injection.

    Age 18 and above

    Reslizumab, which also targets eosinophils, treats adults age 18 and above and must be administered with an IV.

    “Reslizumab is also interesting because it’s weight based,” Rajani said. “So, I typically consider this for older patients who are a little bit heavier.”

    ‘We want to use steroid-sparing treatment wherever we can’

    Traditionally, asthma has been treated with nebulizers (a device that turns liquid medicine into a mist), inhalers, or oral medications. Systemic corticosteroids, such as prednisone, are also helpful in managing symptoms but “come with a lot of side effects over time,” Rajani said, as do inhaled corticosteroids, which decrease inflammation by getting the steroid directly to the lungs.

    “If we can treat severe, persistent asthma with biologics instead of corticosteroids, which are very strong anti-inflammatories, that’s the goal. We want to use steroid-sparing treatment wherever we can,” Rajani said.

    Long-term side effects of systemic steroids include bone loss, weakness, changes in eyesight, acne, and weight gain, as well as mood or behavior changes.

    Albuterol, a quick-relief medication that is in certain inhalers, can also prevent and treat more mild asthma symptoms by opening the airway so it’s easier to breath. Albuterol does not contain steroids.

    Don’t let asthma go untreated

    Asthma symptoms in kids can show up at any age during childhood. Major signs that parents should look for include:

  • Wheezing.
  • Recurrent respiratory illnesses that linger.
  • Persistent cough, especially at nighttime.
  • Shortness of breath.
  • Chest tightness.
  • If left untreated, asthma can have both short and long-term consequences, including damage to the airway that can be irreversible.

    “True asthma doesn’t go away. It can be a bit of a roller coaster, with the symptoms going up and down throughout someone’s lifetime, but it’s a chronic illness that should be treated because it can be fatal,” Rajani said.