Is Tezepelumab safe for severe asthma with low eosinophils?

Question

Hello doctor,

I am a 31-year-old female with severe eosinophilic asthma (4 exacerbations requiring systemic steroids in the past year). Failed Mepolizumab after 6 months.

Current medications: Fluticasone/Salmeterol 500/50 BID, Montelukast 10mg, Tiotropium.

Lab test: Blood eosinophils 450 cells/µL (down from 750 baseline), IgE 180 IU/mL, normal CMP (comprehensive metabolic panel). Spirometry: FEV1 (forced expiratory volume) 65% predicted with 18% reversibility. ACQ-6 (asthma control questionnaire) score 2.8.

Would Tezspire be appropriate despite lower eosinophil counts?
What is the expected timeline for the response?
Should we continue montelukast during Tezspire therapy?

Please help.

Thank you.

Answer 1

Hi,

Welcome to icliniq.com.

I have gone through your query and understand your concern.

Given your severe eosinophilic asthma with recurrent exacerbations, failure of Mepolizumab, and current medication regimen, Tezspire (Tezepelumab) could be a suitable next step. Tezspire targets TSLP (thymic stromal lymphopoietin), a cytokine involved in asthma inflammation, and does not rely on eosinophil counts, making it beneficial even with lower eosinophil levels (450 cells/µL).

Appropriateness of Tezspire: Yes, Tezspire is appropriate despite the reduced eosinophil count. Unlike IL-5 (interleukin-5) inhibitors (like Mepolizumab), which target eosinophils directly, Tezspire works through a different mechanism that modulates multiple inflammatory pathways (including T2 inflammation), which may still provide benefit even with lower eosinophil levels. The expected timeline for response is generally within 12 weeks, with the most significant improvements typically seen by 6 months of therapy.
Continued use of Montelukast: Montelukast is generally used for additional symptom control, but since Tezspire is a robust treatment targeting multiple inflammatory pathways, you may consider tapering off Montelukast after observing the initial response, unless your physician feels it is still beneficial. The ACQ-6 (asthma control questionnaire) score of 2.8 suggests some symptoms remain, so a trial of continuing Montelukast alongside Tezspire may still be reasonable, but ongoing symptom monitoring will be crucial.

Monitoring for response to Tezspire should include reduced exacerbation frequency, improved FEV1 (forced expiratory volume, a measurement of how much air a person can exhale in the first second after inhaling fully), and a decrease in ACQ-6 score. Regular follow-ups are essential to assess the effectiveness and adjust the treatment plan as needed.

I hope I have answered your question.

Let me know if I can assist you further.

Thank you.