Monoclonal Antibodies in Idiopathic Chronic Eosinophilic Pneumonia: A Scoping Review

doi:10.21203/rs.3.rs-2917753/v1

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Monoclonal Antibodies in Idiopathic Chronic Eosinophilic Pneumonia: A Scoping Review

https://doi.org/10.21203/rs.3.rs-2917753/v1

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published 08 Feb, 2024

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Background

Idiopathic chronic eosinophilic pneumonia (ICEP) is a rare disease characterized by pulmonary radiological alterations, peripheral eosinophilia, and demonstrated pulmonary eosinophilia. Oral steroids (OSs) are the standard management, but relapses occur in up to 50% of patients during the decrease or suspension of steroids, usually requiring reinitiation of treatment, exposing patients to secondary events derived from the management. Management with monoclonal antibodies has been proposed in these cases to control the disease and limit the secondary effects. The objective is to describe the extent and type of evidence regarding the use of monoclonal antibodies for ICEP.

Methods

A panoramic review of the literature was performed. Observational and experimental studies of pediatric and adult populations that managed recurrent ICEP with monoclonal antibodies were included. Data search, selection, and extraction were performed by two independent reviewers.

Results

937 studies were found. After applying the inclusion and exclusion criteria, 37 titles remained for the final analysis: a retrospective, observational, real-life study, two case series publications, and 34 case reports published in academic poster sessions and letters to the editor. In general, the use of monoclonal antibodies approved for severe asthma could be useful for the control of ICEP, since most of the results show a good response for clinical and radiological outcomes. Biological drugs seem to be a safer option for controlling relapses in ICEP, allowing lowering/suspension of OSs, and sometimes replacing them in patients intolerant to them, patients with significant comorbidities, and patients who have already developed adverse events.

Conclusion

The extent of the evidence supporting management of ICEP with monoclonal antibodies against IL-5 and IgE (omalizumab) is limited, but it could be promising in patients who present frequent relapses, in cortico-dependent individuals, or in patients in whom the use of steroids is contraindicated. The extent of the evidence for management with dupilumab is more limited. Studies with better design and structure are needed to evaluate quality of life and outcomes during a clear follow-up period. To our knowledge, this is the first scoping review of the literature showing the extent of the evidence for the management of ICEP with monoclonal antibodies.

Carrington syndrome

pulmonary eosinophilia

eosinophilic pneumonia

idiopathic chronic eosinophilic pneumonia

systemic corticosteroids

monoclonal antibodies

Eosinophilic pulmonary diseases comprise a rare and heterogeneous group characterized by eosinophilic infiltrate in the lung parenchyma as found in bronchoalveolar lavage (BAL) (generally at a proportion > 25%) or by biopsy. In most cases, there is peripheral eosinophilia (> 500 × 10 cells/L). [1, 2]. According to the existence of a specific cause, it is classified as primary or secondary. The etiology is broad and includes fungal and parasitic infections, drugs, toxins, autoimmune inflammatory diseases, and neoplasms, among others. When there is no evidence of underlying disease, it is classified as primary or idiopathic, so this is diagnosed by exclusion [1, 2, 3].

Eosinophilic pneumonia is a primary disorder that can be acute or chronic. Acute eosinophilic pneumonia has an acute, rapidly progressive presentation with fever, severe hypoxemia, and respiratory failure [2, 4]. It is more common in adults, affecting men most often. Generally, there is no history of asthma. It responds strongly to systemic steroids, without relapses and with resolution of the acute event [2, 4, 5].

Idiopathic chronic eosinophilic pneumonia (ICEP), or Carrington syndrome, is a rare disease with unknown prevalence. It has a subacute presentation, with chronic respiratory symptoms such as cough, fatigue, fever, diaphoresis, arthralgia, and weight loss [1, 2, 3, 4]. During the progression of the disease, there may be loss of lung function in 10% of those affected [6, 7, 8].

ICEP has a very low incidence in the pediatric population [9, 10], affects women: men at a 2:1 ratio, is found in patients with a history of asthma in up to 75% of cases, and can accompany severe asthma [2, 3, 4]. On chest X-ray and computed tomography (CT), alveolar and interstitial infiltrates are observed with a predominance of the bilateral, subpleural alveolar pattern in the upper lobes, which may be migratory. The infiltrates are distributed in the periphery, yielding an image that has been called the photographic negative of pulmonary edema; they can appear in superposition with an organized pneumonia or predominate with a ground-glass appearance [2, 11, 12].

Oral steroids (OSs) for 3 to 6 months are the standard management of ICEP [5, 13]. There is generally a favorable response with remission of symptoms and resolution of radiographic findings. Some patients may require longer management, of 1 to 3 years, at which time side effects of the OS can arise [5, 6, 13]. In addition, relapses of the disease occur in up to 50% of cases during the decrease or suspension of steroids, requiring restart of the drug to control the disease [6, 13].

The potential deleterious side effects of OS have made it necessary to evaluate additional treatments that allow us to control the disease and avoid complications [6, 14, 15]. With the current knowledge of the biology of eosinophils and T2 inflammation, management with approved monoclonal antibodies has been proposed for severe asthma [6, 15, 16]. The first of them, omalizumab, binds immunoglobulin E (IgE). The more recently approved mepolizumab binds interleukin 5 (IL-5). Reslizumab has the same mechanism of action as mepolizumab, but for intravenous application. Benralizumab acts on the IL-5 receptor. Dupilumab binds the IL-4 receptor, blocking the action of IL-4 and IL-13 [6, 16]. All of them are useful and safe for the management of severe asthma, but their usefulness in the management of ICEP is unknown (Table 1).

Table 1

Monoclonal antibodies for the management of severe asthma
Monoclonal Antibody	Mechanism of action and route of administration
Omalizumab	Human monoclonal antibody IgG1κ, subcutaneous. It binds to free IgE by inhibiting its binding to high- and low-affinity IgE receptors (FcεRI and CD23). This reduces the expression of the aforementioned receptors in mast cells, basophils, and dendritic cells, limiting the type 2 immune response mediated by IgE. It also modulates the production of interferon-alpha (IFN-α) dendritic cells, reducing virus-induced exacerbations.
Mepolizumab	Humanized monoclonal antibody IgG1κ, subcutaneous. It inhibits the maturation, activation, proliferation, and recruitment of eosinophils. It binds to a specific epitope of IL-5, preventing its interaction with the IL-5 receptor (IL-5Rα).
Reslizumab	Humanized monoclonal antibody IgG4κ, intravenous. It inhibits the maturation, activation, proliferation, and recruitment of eosinophils. It binds to IL-5, preventing its binding to IL-5Rα. It’s in vitro affinity for IL-5 and its ability to suppress proliferation is greater than that of mepolizumab.
Benralizumab	Humanized monoclonal antibody IgG1κ, subcutaneous. It binds to the alpha subunit of the receptor (IL-5Rα) avoiding the transduction of eosinophil survival signals. In addition, there is an amplified apoptosis mechanism induced by the activation of the FcyRIIIa (CD16a) receptor, mediated by natural killer cells and macrophages through a process called antibody-dependent cellular cytotoxicity. It reduces eosinophils and basophils.
Dupilumab	Human monoclonal antibody IgG4, subcutaneous. It binds to the alpha subunit of the IL-4 receptor (IL-4Rα) shared by IL-4 and IL-13, thereby inhibiting the type 2 immune response. Simultaneous receptor blockade occurs in hematopoietic and nonhematopoietic cells.
Modified from Agache et al.

In this scoping review, the extent of the evidence for the use of monoclonal antibodies in patients with ICEP is evaluated, the types of studies on this subject are defined, and their main findings are summarized.

Search strategy

The electronic search was carried out without time limits for English-language articles in the EMBASE, OVID, PubMed, Scopus, and LILACS databases. The terms used for the search were (("Pulmonary Eosinophilia") OR ("Carrington syndrome")) AND ("Antibodies, Monoclonal, Humanized" OR "Antibodies, Monoclonal, Murine-Derived" OR "Antibodies, Monoclonal"). In conducting this scoping review, the parameters proposed by Arksey and O'Malley, 2005 [17] were considered.

Selection of studies and data collection

The search was carried out by two independent observers (IC and AM). The selected articles were reviewed by both of them, who screened each article for the inclusion criteria. A third independent reviewer (AG) resolved any eligibility disagreements.

Eligibility criteria

Analytical and observational studies were included. These could be cohort studies and case reports published in journals, academic sessions of poster presentations, and letters to the editor. They had to address pediatric and adult patients with the diagnosis of ICEP who required management with monoclonal antibodies. Annexes and supplementary materials were also included. Articles that did not fall under this topic, literature reviews, duplicate publications, and articles without full text available were excluded.

Study selection and data abstraction

For the case reports, the observers recorded details about the publication (title, first author, date of publication), details about the participants (number of patients included, demographic characteristics), the biological studied, the duration of follow-up, outcomes, and any adverse events reported. Of the identified studies and case series, the study design, follow-up, number of participants, variables analyzed, intervention, outcomes and results were recorded. Tables 2 and 3 summarize the studies and case reports recorded.

Table 2

Studies and case series of monoclonal antibodies for the management of ICEP
Study	Design	Follow-up	Participants	Intervention	Outcomes	Excluded	Variables	Results
Brenard et al., 2020 [21].	Multicenter, open-label, retrospective study (real-life study)	Median follow-up 9 months from diagnosis to start of mepolizumab. Median follow-up after initiation of mepolizumab 9 months (6–12 m)	12 patients, 2 excluded. Total 10 (5 men, 5 women)	Mepolizumab 100 mg every 4 weeks (6 patients: approved dose for severe asthma; 4 patients: 300 mg every 4 weeks/EGPA and hypereosinophilic syndrome)	- Annual relapse rate - Use of systemic corticosteroids before and after the start of mepolizumab - Lung lesions, evaluated by CT before starting the biological and at the last follow-up while on the biological	-Patients with eosinophilia related to JAK1 inhibitors and PDGFRα- FIP1L1. -Multiorgan involvement (heart, skin) -Infections -Findings secondary to other medications	Peripheral eosinophilia, BAL, lung function, CT, Comorbidities, and exposures Relapse: symptoms (cough, dyspnea) with increased pulmonary eosinophils, radiographic or CT changes in the absence of infection. -All had at least 1 relapse before mepolizumab.	No significant differences between doses of mepolizumab. Annual relapse rate reduction. Decrease in eosinophils at 3 months. 7 of 8 evaluated by CT had complete resolution, after the 6th month of mepolizumab. Two patients were evaluated with radiography at 6 months and no alterations were found. OS dose reduction in 9 patients at the 3rd month. At the 6th month only one patient still took OS, but in low doses due to tolerance of the decline. No patient had secondary events in the study.
Askin & Morris, 2021 [22].	Retrospective Case Series	Not described	53 patients, 12 received biological. .	Mepolizumab Benralizumab They do not describe doses, nor do they describe treatment allocation	Improvement in radiological, clinical, psychological changes; relapses; decrease or suspension of corticosteroid	Hypereosinophilic syndrome, patients who did not have a BAL study, or a report of eosinophils in BAL < 20%	Not described	All had sustained improvement in radiological and clinical changes, including lung function and psychological field. There were no relapses. OS decreased in all patients. No patient had serious secondary events.
Tashiro et al., 2022 [23].	Retrospective Case Series	Patient 1:8 months Patient 2:4 months Patient 3:19 months Patient 4:17 months	30 patients with the diagnosis, 12 relapses (6 had > 2 relapses), 4 received anti-IL5 biologic	2 men aged 68 and 74: Mepolizumab 100 mg every 4 weeks. 2 women aged 67 and 37: Benralizumab 30 mg every 4 weeks × 3 doses, then 30 mg every 8 weeks	Relapses, decrease in eosinophils, withdrawal, or reduction of corticosteroid dose	Findings due to drugs, mycoses, parasitic diseases, EGPA, ABPA, and other systemic diseases.	Patients with T₀ > 37.5°C, cough > 2 weeks, pulmonary infiltrates on CT, eosinophilia > 1000, BAL eosinophils > 25%, improvement of changes after initiation of steroids	1. Patient with type 2 diabetes, without relapses after starting benralizumab. Improvement at 4 weeks in FEV1 and absence of eosinophils. Systemic corticosteroid was withdrawn. 2. Patient without comorbidities, without relapses after starting benralizumab. Absence of eosinophils, there is no complete withdrawal of systemic corticosteroid, but dose reduction continues. 3. Patient with hypertension, hyperlipidemia, and heart failure, without relapses after the start of mepolizumab, at 4 weeks eosinophil reduction. Systemic corticosteroid was withdrawn. 4. Patient with type 2 diabetes mellitus, without relapses after the start of mepolizumab, at 4 weeks eosinophil reduction. Systemic corticosteroid was withdrawn.

Statistical analysis

Normally distributed dichotomous variables are reported as n (%) and continuous ones as median (IQR) or mean (SD). Statistical analyses were performed with Stata® 14.0 (Stata Corp., 2014, College Station, TX, USA).

The search strategy yielded 937 results. After applying the exclusion criteria, 39 manuscripts were obtained, to which six articles were added that were found in the bibliographic references. More detailed analysis excluded eight articles, leaving 37 titles for the final analysis: a retrospective observational study done in real time, two case series, and 34 case reports. One patient was described by two articles, a first report and a follow-up report. The flow chart in Fig. 1 shows the selection process in detail. Studies published up to December 2022 were included.

A total of 63 patients received monoclonal antibody management, but one publication did not describe how the allocation was done for the 12 patients who received a biological. The median age was 49 years (57.5–31), and 70.5% were women. Regarding the assigned treatment, 31 patients received mepolizumab, 14 received benralizumab, five received omalizumab and only one received dupilumab. There were three case reports in which patients received more than one monoclonal antibody. In the case report by Lin et al., the patient began management with omalizumab, but due to a partial response, a change to mepolizumab was indicated [18]. In the case report by Shimizu et al., the initial treatment was mepolizumab, with a change to benralizumab. In their report, the patient relapsed after the monoclonal antibody was changed [19]. In the case report of Sarkis et al., management with mepolizumab was administered for 6 months, followed by management with reslizumab [20].

In the open, retrospective, real-life study conducted by Brenard et al., 10 patients were included; six patients received mepolizumab at a dose of 100 mg every 4 weeks, and four received 300 mg every 4 weeks. The median follow-up was 9 months after the start of mepolizumab [21]. There were no significant differences in disease response by dosage. With both doses, a significant reduction in the annual relapse rate was observed with mepolizumab, both falling to a value of 0 [21]. In seven of eight patients evaluated by CT, complete resolution was found after the 6th month on mepolizumab. Two patients were evaluated with a chest radiograph at 6 months, and no alterations were found. The decrease in OS dose began after the 3rd month of management, and only one patient did not tolerate the decrease [21]. At the 6th month of management, only one patient still needed the OS, but at low doses due to adequate tolerance of the low-dose OS. No patient had secondary events in the study [21].

In the retrospective case series by Askin & Morris, with 53 patients, 12 received mepolizumab or benralizumab. All patients achieved sustained clinical improvement, including lung function and psychological status, as well as in radiological findings. There were no relapses, all patients lowered their OS dosage, and no serious secondary events were reported. The shortcoming of this case series was that it did not describe the treatment allocation, the duration of follow-up, or the dose used [22].

In the retrospective case series by Tashiro et al., 12 out of 30 patients had relapses in the OS decline phase, of whom six had more than two relapses. Four patients were assigned to monoclonal antibody management, of whom only one had no comorbidities [23]. Two patients received mepolizumab at a dose of 100 mg every 4 weeks, and two patients received benralizumab at 30 mg every 4 weeks for three doses, followed by 30 mg every 8 weeks. The two patients who received benralizumab were observed 4 and 8 months after the initiation of the monoclonal antibody [23]. In both, the absence of symptoms was observed at 4 weeks; one tolerated the decrease in OS, while the other tolerated full withdrawal. The absence of eosinophils was also observed at 4 weeks, and no adverse events were reported. The patients who received mepolizumab both stopped the OS, with a reduction in peripheral eosinophilia and clinical improvement at 4 weeks. The follow-up time after the monoclonal antibody was 19 and 17 months [23] (Table 2).

Of the case reports, 19 patients received management with mepolizumab, 12 with benralizumab, five with omalizumab and one with dupilumab. There were three patients under 18 years of age; one of them, an 11-year-old female, was the only one to receive dupilumab and had a clinical and radiological response at 2 weeks, tolerating withdrawal of OS and decreased cyclosporine. They reported no adverse effects of treatment at the 12-month follow-up [24]. Another of them was a 16-year-old male patient who received benralizumab with an 8-month follow-up from the start of the monoclonal antibody. He had immediate clinical improvement, allowing reduction and suspension of OS, evolving without relapses and with improvement in lung function [25]. The third, 17-year-old patient received omalizumab, with an observation period of 33 months from the start of the monoclonal antibody. After treatment for 9 months, there was an adequate response, with improvement of symptoms, no relapses during the follow-up period, and radiological improvement. No adverse events reported during handling [26].

The 34 remaining patients described in the case reports were adults, many of whom had comorbidities such as diabetes, hypertension, and anxiety disorders, and some reported cortico-dependent disease and secondary events derived from the management of OS. In general, an adequate response was observed, with improvement of respiratory symptoms, control of relapses, and achievement of reduction and later cessation of OS. All the reports mentioned the response of the respiratory symptoms, only two reports did not record relapses during treatment with the monoclonal antibody, and one did not mention whether the OS was decreased or suspended. Sixteen case reports evaluated lung function; reporting improvement compared to before the monoclonal antibody. The response time of the symptoms was variable but favorable. In general, the response began between the first week and 9 months after starting management. Regarding the OSs, the majority reported a decrease and suspension after the start of the biological test, but the vast majority of the reports do not indicate how long this outcome was achieved.

Eight reports did not mention the dose of the monoclonal antibody used in the management of patients. There were two reports of management with a single dose of benralizumab and one with a single dose of mepolizumab. In the last three cases mentioned, the symptoms improved, with resolution of relapses and suspension of OS, but only in one did they record the follow-up time after the start of treatment, which was 4 months. Twelve case reports did not report tomographic or radiological changes after treatment, and seven reports did not mention the follow-up time after the initiation of the monoclonal antibody. None of the case reports, case series, or real-life studies evaluated quality of life.

Regarding the secondary effects of the treatment, the majority reported that no events were seen during the treatment, but 17 reports did not mention whether any occurred during treatment. There were only two reports of adverse events during treatment. Sarkis et al. described a local reaction with mild anaphylaxis during management with mepolizumab, which led to a switch to reslizumab [20]. In the case report by McKillion et al., they indicated an unspecific reaction that forced the discontinuation of mepolizumab, but the reaction was not described [27].

Although ICEP is a rare disease, when it occurs it brings a 50% risk of relapses and a long-term need for steroids. Patients are at risk of developing complications derived from prolonged management with OS. From this scoping review, it can be inferred that monoclonal antibodies approved for severe asthma could be useful for the control of the disease, but the extent of the evidence is limited and is composed mostly of case reports and case series, though most of the results show a good response. Biological drugs seem to be a safer option to control relapses of ICEP, allowing lowering/suspension of OS and sometimes replacing the OS in patients with OS intolerance, patients with significant comorbidities, and patients who have already developed adverse events.

For omalizumab, the little evidence available is provided by case reports that have had a longer follow-up and have indicated a profile of safety and effectiveness. Omalizumab was the first biological to be approved for severe asthma.

Anti-IL-5 therapy is more recent, and although the follow-up period in most case reports is shorter, there is more information available about mepolizumab, including an observational, retrospective, real-life study, which supports its use for ICEP. Benralizumab seems to be effective, and it seems that it generates a rapid decrease in eosinophils for up to 8 weeks, so authors have tried to space its doses or even give a single dose, but the case reports that tried this strategy were not clear in defining the follow-up. There were also no real-life studies of benralizumab for ICEP. Reslizumab seems to have a similar effect as mepolizumab, but reports on it are even rarer, and none have evaluated it as a first-line biologic.

Dupilumab has only been used in one pediatric patient, who had a good response [24]. However, as we were selecting manuscripts and carrying out the detailed analysis, we found some case reports that have linked it as a cause of ICEP [28, 29, 30, 31].

The findings of this review suggest that anti-IL-5 and omalizumab could be safe for the management of patients with ICEP. No adverse events of any severity were reported in the real-life study or in the case series. Only two case reports described adverse events with mepolizumab, which caused biological changes or the suspension of treatment, but no deaths or other complications were reported.

The findings of this review are not surprising, since management with biologics is recent and ICEP is a low-frequency entity. This study has limitations arising from the quality of the included studies, as they were all observational studies and case series, so its interpretation should be carried out taking into account these limitations. Given the characteristics of the included studies, it is not feasible to assess their quality. Furthermore, this makes it impossible to extrapolate the results to all patients with ICEP.

Research in this field needs to be expanded. There need to be more cohort studies or case-series studies in real-world settings, where the impact on the quality of life of the patients is considered and the follow-up time of the patients after the start of the evaluated drug is clearly described.

The extent of the evidence for management with monoclonal antibodies (omalizumab, mepolizumab, benralizumab, reslizumab) is limited but could be promising for cases of ICEP with frequent relapses and cases where the use of corticosteroids is contraindicated. The extent of the evidence for management with dupilumab is even more limited. Well-designed studies that evaluate quality of life and outcomes during a clear follow-up period are needed. To our knowledge, this is the first scoping review of the literature detailing the extent of the evidence for the management of ICEP with monoclonal antibodies.

ICEP Idiopathic chronic eosinophilic pneumonia

AEL Acute eosinophilic pneumonia

OS Oral steroid

BAL Bronchoalveolar lavage

CT Computed tomography

IgE Immunoglobulin E

IgG1 Immunoglobulin G subclass 1

IgG4 Immunoglobulin G subclass 4

IL-5 Interleukin-5

IL-5Rα Interleukin-5 receptor

IL-5Rα IL-5 receptor alpha subunit

FcyRIIIa/CD16a Low-affinity immunoglobulin gamma Fc receptor region III- A

FcεRI High affinity IgE receptor

CD23 low affinity IgE receptor

IL-4 Interleukin-4

IL-4Rα IL-4 receptor alpha subunit

ABPA Allergic bronchopulmonary aspergillosis

EGPA Eosinophilic granulomatosis with polyangiitis

HT Arterial hypertension

ACT Asthma control test

FENO Exhaled nitric oxide.

FEV1/FEV1 Forced expiratory volume in the first second.

JAK 1 Janus kinases type 1.

FIP1L1-PDGFRA Fip1-like 1-platelet-derived growth factor receptor alpha

Ethics approval and consent to participate.

Does not apply to this manuscript.

Consent for publication

Does not apply to this manuscript.

Availability of data and materials

Extracted information and synthesized data is available on reasonable request to the corresponding author. In addition, the protocol of this study is submitted to “JMIR Preprint” with the reference number 48394-758611-1-SM.docx 2023-04-21.

Competing interests

The authors declare no conflicts of interest.

Funding

No funding sources were used.

Authors' contributions

ADM: Conceptualization, methodology, data curation, formal analysis, writing-original draft preparation, writing-review & editing. AIC: Data curation, formal analysis, writing-original draft preparation, writing-review & editing. CDS: Conceptualization, writing-review & editing, supervision. LFT: Conceptualization, methodology, data curation, formal analysis, conceptualization, writing-review & editing, supervision.

Acknowledgment

Not applicable.

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Monoclonal Antibodies in Idiopathic Chronic Eosinophilic Pneumonia: A Scoping Review

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