Switching from mepolizumab to benralizumab helped many EGPA patients in a retrospective series

Design

Retrospective European multicentre cohort

Population

68 adults with EGPA given benralizumab after mepolizumab failure, median follow-up 28 months

Primary outcome

Complete and partial response (BVAS 0 with prednisone 4 mg a day or less, or higher)

Effect

Complete response 32%, partial 25%; primary mepolizumab failure OR 0.19 (95% CI 0.06 to 0.60) for complete response

This retrospective European multicentre study included 68 adults with eosinophilic granulomatosis with polyangiitis who received benralizumab after mepolizumab failure. Complete response was defined as a Birmingham Vasculitis Activity Score of 0 with prednisone at 4 mg a day or less, and partial response as the same score with a higher dose. Median follow-up on benralizumab was 28 months.

Complete and partial response were achieved in 32% and 25% of patients, and were maintained at last follow-up in 19% and 16%. Median time to complete response was 6 months. Forced expiratory volume in one second rose from 73% to 79% of predicted and 38% stopped glucocorticoids. Primary failure of mepolizumab was associated with a lower chance of complete response (OR 0.19, 95% CI 0.06 to 0.60). Benralizumab was stopped in 18% for persistent respiratory symptoms. Adverse events occurred in five patients, including two with severe SARS-CoV-2 infection.

There was no control group, so some patients might have improved without switching, and durable response was seen in fewer than one in five. It supports trying the switch in patients with persistent respiratory disease, in specialist care, but does not establish the sequence of biologics.

• Complete response occurred in 32% and partial response in 25% after switching.
• Responses were maintained at last follow-up in 19% and 16% respectively.
• FEV1 improved from 73% to 79% and 38% of patients stopped glucocorticoids.
• Primary mepolizumab failure predicted a lower chance of complete response (OR 0.19).
• Consider the switch for persistent respiratory disease in specialist care, but the series was retrospective and uncontrolled.

Why it matters

It gives a sizeable series on what happens when a second anti-eosinophil biologic is tried after the first fails in this rare disease.

Don't overread it

A retrospective series of 68 patients without a control group cannot show that switching is better than continuing or trying other treatments.

The statistics, in plain English

An odds ratio of 0.19 means that patients whose disease never responded to mepolizumab had about a fifth of the odds of complete response compared with those who initially responded. Without a comparison group, the response rates cannot be attributed to the switch.

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