Successful benralizumab therapy for severe asthma secondary to EGPA refractory to mepolizumab

Abstract

Background: Eosinophilic granulomatosis with polyangiitis (EGPA) is a multisystem inflammatory disease. It presents a type 2 inflammatory profile and IL-5 overexpression which stimulates eosinophil production and contributes to the development of severe and late-onset asthma.

Case report: We present the case of a female in her sixth decade of life, diagnosed with EGPA 37 years ago and currently with severe asthma. Despite being on triple inhaled therapy, she exhibited persistent severe airflow obstruction (ACT: 13; ACQ-5: 2; blood eosinophils: 545 cells/μL). Mepolizumab 100 mg monthly (institutionally approved dosage) was initiated for over a year, with poor clinical response and multiple exacerbations. A switch to benralizumab 30 mg every two months was made, achieving sustained clinical control within four months: normalized spirometry, ACT: 22, ACQ-5: 0.2, undetectable serum eosinophils, and no exacerbations. This allowed discontinuation of the second controller inhaler and reduction to a low dose of inhaled corticosteroid, without adverse events attributable to treatment.

Discussion: A significant challenge in institutional clinical practice is that both biologics are approved only at doses indicated for severe eosinophilic asthma, resulting in suboptimal dosing according to international guidelines for EGPA.

Conclusion: In institutional practice, benralizumab at 30 mg every two months may be a viable therapeutic option for patients with severe asthma secondary to EGPA, aiming to reduce corticosteroid dependence and improve respiratory function.