Benralizumab as a glucocorticoid-sparing treatment option for severe asthma in eosinophilic granulomatosis with polyangiitis

[...]most patients may need long-term glucocorticoid maintenance treatment to control asthma and chronic rhinosinusitis with nasal polyposis, with a significant drug-related morbidity.3 IL-5 is a critical cytokine for priming, proliferation, and migration of eosinophils,4 and its inhibition with neutralizing mAbs, such as mepolizumab, proved effective in prolonging EGPA remission and reducing the requirement for glucocorticoids.5 Unfortunately, up to 47% of patients with EGPA treated with high-dose mepolizumab did not achieve protocol-defined remission and on treatment cessation, disease manifestations recurred.5 Benralizumab is an mAb that binds IL-5 receptor, thus neutralizing eosinophils via antibody-dependent cellular cytotoxicity, and currently has been approved for the treatment of severe eosinophilic asthma.6 To date, only 2 case reports describing the efficacy of benralizumab in EGPA have been published: one demonstrated a decrease in myeloperoxidase-ANCA,7 and the other proved the efficacy of benralizumab in the treatment of eosinophilic myocarditis.8 Here, we describe clinical features and patient-reported outcomes in a series of refractory and glucocorticoid-dependent patients with asthma with EGPA, treated with benralizumab. Deep suppression of eosinophils via antibody-dependent cellular cytotoxicity might be crucial for an improved control of EGPA symptoms and could justify the efficacy of benzalizumab in patients who failed mepolizumab therapy.9 However, the lack of improvement in c-reactive protein or ANCA status and the inclusion of a cohort with a persistent asthma EGPA phenotype does not allow us to investigate the treatment efficacy on extrapulmonary, vasculitic disease phenotype. [...]our follow-up might be short, but it is in keeping with the 24-week primary end point of the mepolizumab trial.5 In conclusion, benralizumab has proven to be a promising treatment option in severe/refractory EGPA asthma.