Which asthma biologic do docs prefer? It's not that simple: analyst

From Roche and Novartis’ aging Xolair to Sanofi and Regeneron’s newcomer Dupixent, along with meds from respiratory nemeses AstraZeneca and GlaxoSmithKline, several biologics are vying for a bigger share of the asthma market. Which one of them do doctors prefer?

Surprisingly, there is no clear winner, SVB Leerink analyst Geoffrey Porges said in a note on Nov. 15 after talking to six U.S. general pulmonologists.

“[T]he discussion was not clearly positive for any one particular biologic,” he said, as Xolair, Dupixent, AstraZeneca’s Fasenra and GSK’s Nucala all got some love.

If one must pick a winner, the strongest preference seems to go to Fasenra “due to dosing convenience,” and then to Dupixent “due to its broader and less restrictive label,” specifically in atopic patients, Porges noted.

In a short survey Porges did with four of the pulmonologists, who currently collectively treat 1,550 asthma patients, three chose Fasenra as the biologic that they will be switching the most asthma patients to, and one picked Nucala.

RELATED: AstraZeneca's Fasenra offers severe asthma patients 2 years of benefits: analysis

Fasenra is given once every eight weeks after the initial loading-dose period, while its IL-5 rival Nucala comes as a monthly injection throughout. Both drugs recently picked up FDA approvals for self-administered, auto-injector versions, with Nucala's coming in June and Fasenra's in October. And despite Nucala's years-long head start on the market, the two are currently neck and neck in the sales race. The GSK drug has the slight lead with £203 million ($263 million) in third-quarter sales, versus Fasenra’s $202 million during the same period.

Last October, Dupixent won an FDA nod as an add-on treatment for certain asthma. Back then, it was the only biologic that patients could administer at home. That, plus its label’s superior efficacy, led Porges at the time to peg $2.5 billion in peak asthma sales alone for the drug.

On Sanofi’s third-quarter earnings call in late October, Genzyme unit chief Bill Sibold pointed out that Dupixent is the best launch of the biologics in terms of new-to-brand scripts in asthma.

RELATED: Dupixent's already a blockbuster, but there's much more to come: Sanofi exec

In that short survey SVB Leerink did with four doctors, responses clearly indicated an intention to increase Dupixent prescriptions. Right now, the group has a median 10% of patients on the drug, but based on their predictions, that number will rise to 27% in three years. 

However, three doctors ranked Dupixent their least favorite of all five existing biologics, a group that also includes Teva’s Cinqair. And the one doctor that put it in the middle only treats 100 patients.

Dupixent is also driving the growth for all biologics in asthma, with about 75% of Dupixent asthma patients new to large-molecule drugs, Regeneron commercial head Marion McCourt said on a recent conference call.

For now, biologics have penetrated 15% of the moderate-to-severe asthma market. While execs from both Regeneron and Sanofi touted the significant opportunity lying ahead, Porges noted that the rate is already over halfway to the physicians’ expected peak, and that “it appears unlikely to more than double.” But there is one physician who suggested that a lot more could come for biologics as pulmonologists’ prescription habits “become more like rheumatologists’,” he added.

RELATED: GlaxoSmithKline's Nucala cuts severe asthma attacks in 'reassuring' interim real-world data

“Patients are stepping up to biologics after maximum three-class, bronchodilator therapy, and although insurance requires patients remain on background therapy, these physicians had success removing/stepping down from oral corticosteroids and were generally positive on the benefit of injectables in their patients,” Porges said.

As the oldest asthma biologic on the market, Xolair still has a solid base despite the assault from newer meds, Porges noted, as some doctors still prefer “the tried and true efficacy” of a drug that they’ve used for over a decade.

Of the four physicians surveyed, three picked the anti-IgE drug as their favorite med and one put it in the middle. However, when asked which drug they'd be switching most of their asthma patients away from, three of the doctors ranked it as the top choice. Its prescription share will drop from above 40% now to right below 30% in three years, yielding most of the patients to Dupixent while the IL-5 class holds relatively steady, according to the physician responses.