Skip to main content
PMC home page
PLOS ONE logoLink to PLOS ONE
. 2021 Mar 11;16(3):e0248305. doi: 10.1371/journal.pone.0248305

Identification of distinct phenotypes related to benralizumab responsiveness in patients with severe eosinophilic asthma

Hideyasu Yamada 1,2,*, Masayuki Nakajima 1, Masashi Matsuyama 1, Yuko Morishima 1, Naoki Arai 3, Norihito Hida 2, Taisuke Nakaizumi 2, Hironori Masuko 1, Yohei Yatagai 4, Takefumi Saito 3, Nobuyuki Hizawa 1
Editor: Stelios Loukides5
PMCID: PMC7951858  PMID: 33705484

Abstract

Purpose

To characterize the clinical phenotypes of severe eosinophilic asthma based on early responsiveness to benralizumab in terms of forced expiratory volume in 1 second (FEV1) improvement.

Patients and methods

Sixty-four participants diagnosed with severe eosinophilic asthma and who had completed 4 months of benralizumab treatment were included in this analysis. Pre-treatment clinical factors were compared between responders and non-responders according to improvements in ACT or FEV1. Correlations between the sums of increased Type 2-related inflammatory parameters and changes of ACT or FEV1 were also evaluated before and after the 4-month treatment. A two-step cluster analysis was performed to identify distinct phenotypes related to benralizumab responsiveness in terms of FEV1.

Results

At the 4-month timepoint, all parameters, except for FeNO, were significantly improved after benralizumab treatment. FEV1 responders were associated with higher levels of Type 2-related inflammatory parameters. An improvement in FEV1 but not in ACT was clearly associated with increases in the sums of increased type 2-related inflammation parameters (p = 0.0001). The cluster analysis identified 5 distinct phenotypes of severe eosinophilic asthma according to the variable FEV1 responsiveness to benralizumab. The greatest response was found in the distinct phenotype of severe eosinophilic asthma, which was characterized by modest increase in total IgE and FeNO relative to blood eosinophils with least exposure to smoking.

Conclusion

This study, to the best of our knowledge, is the first cluster analysis to report distinct phenotypes related to clinical benralizumab response in a real-world population with severe eosinophilic asthma. These results may help to predict responsiveness to benralizumab in patients with severe eosinophilic asthma.

Introduction

In recent years, several new biologics, such as benralizumab, have been developed to treat patients suffering from asthma poorly controlled by high-dose ICS and long-acting bronchodilators. Benralizumab is a humanized, interleukin (IL)-5Rα-specific, monoclonal antibody that effectively ameliorates asthmatic episodes by inducing rapid and nearly complete depletion of eosinophils [1,2]. Although it has been reported to significantly improve clinical symptoms in patients with eosinophil counts above 150-300/μl in several international phase III trials, the optimal biologic for treatment of severe asthma varies based on each patient’s individual pathophysiology and a key unmet clinical need is a lack of clinically available biomarkers to guide treatment [3]. Traditional double-blind randomized controlled trials often result in a more homogenous patient population regarding demographics and disease characteristics than patients treated in everyday practice and it is necessary to obtain data on real-world outcomes to complement clinical trials and guide treatment-related decisions.

Based on the hypothesis that even severe eosinophilic asthma does not represent a single phenotype of asthma, this multi-center, non-interventional, retrospective observational study in a real-world setting sought to characterize the clinical phenotypes of severe eosinophilic asthma based on early responsiveness to benralizumab in terms of forced expiratory volume in 1 second (FEV1) improvement.

Material and methods

Ethical statement

All participants provided written, informed consent and the Ethics Review Committees of the Tsukuba University School of Medicine, the Hitachi Ltd, Hitachinaka General Hospital, and the Ibarakihigashi National Hospital approved the study protocols (IRB number: R01-350).

Study population

The participants were 64 patients who had been diagnosed with severe eosinophilic asthma and then treated with benralizumab for at least 4 months, the first time-point when therapeutic efficacy is conventionally assessed. All participating patients required treatment with high-dose ICS plus long-acting beta agonists while eighteen patients also required maintenance usage of systemic corticosteroids. All patients had blood eosinophil counts of at least 150 cells/μl for 2 years prior to initiation of benralizumab and started benralizumab therapy between June 2018 and March 2020 at University of Tsukuba University Hospital, National Hospital Organization National Ibarakihigashi Hospital, or Hitachinaka Hospital. We included only patients with data on all of the nine factors (sex, age, FEV1, blood eosinophil counts, total IgE, FeNO, ACT, age of onset and smoking index) used in the cluster analysis.

Spirometry was performed at each hospital in accordance with criteria established by the Japanese Respiratory Society (JRS) [4].

Statistical analysis

Changes in asthma control test (ACT) scores, FEV1, %FEV1, fractional exhaled nitric oxide (FeNO), blood eosinophil counts (log transformed), total serum IgE (log transformed), and doses of systemic corticosteroid after 4 months of benralizumab were evaluated by the t-test.

Patients who achieved an ACT score of 25 or a 3 or greater increase in the ACT score at 4 months after starting benralizumab were considered ACT responders (n = 47) while improvement of FEV1 ≥ 100 mL at 4 months after treatment was considered as FEV1 responsive (n = 35). Pre-treatment clinical factors were compared by t-test between responders and non-responders in each criterion of 4-month responsiveness to benralizumab. We also used the Jonckheere-Terpstra trend test to evaluate correlations between the sums of increased type 2-related inflammatory parameters (eosinophils, IgE, and FeNO) and any changes of ACT or FEV1 before and after treatment. Cut-off values for these type 2 parameters were as follows: 300 eosinophils/μl, 25 ppb FeNO, and total IgE of 100 IU/ml.

The hypothesis-driven, Two-Step cluster analysis was performed using a set of variables that can be easily collected and used in routine practice; they included changes in FEV1 after 4-month treatment of benralizumab, age, percent-predicted FEV1, pack-years of cigarette smoking, ACT, FeNO, log-transformed peripheral blood eosinophil counts, log-transformed total IgE levels, and age of disease onset. For the cluster analysis, all factors were standardized and the number of clusters that gave the maximum difference in the FEV1 change were defined. The Two-Step Cluster Analysis procedure was conducted with IBM SPSS Statistics, version 24, which uses a likelihood distance measure that assumes independent variables in the cluster model (https://www.spss.ch/upload/1122644952_The%20SPSS%20TwoStep%20Cluster%20Component.pdf).

Results

Patient characteristics at baseline before initiating benralizumab are shown in Table 1 while Table 2 shows changes in the clinical parameters of 64 patients after 4 months of benralizumab treatment. Overall, all parameters, except for FeNO, were significantly improved after benralizumab treatment; however, we also observed a large variation in the magnitude of treatment response in patients with severe eosinophilic asthma in terms of FEV1 or ACT (Fig 1). In addition, we found no significant correlation between improvements in ACT and changes in FEV1 at the 4-month treatment timepoint (r = 0.2, p = 0.11, Fig 1).

Table 1. Baseline characteristics of the participants.

Mean or number SD or %
Female 24 37.5%
Age 69.42 12.50
Age at onset 57.75 18.56
BMI 23.72 4.12
Pack year 20.90 32.79
Smoking history (yes) 32 50%
Pack-years 0:0–10: >10 32: 7: 25
Allergic rhinitis 16 25%
Systemic steroid 18 28%
Prednisolone equivalent dose (mg) 0: 0–10: >10 46: 14: 4
ACT 16.91 3.97
FEV1 (ml) 1.47 0.55
%FEV1 (%) 64.89 22.53
FEV1/FVC 64.25 15.20
EOS(/μl) 428 555
Log EOS 2.40 0.51
IgE (IU/ml) 515 726
Log IgE 2.24 0.77
FeNO (ppb) 55.42 56.81
Asthma-COPD overlap† 17 26.6%
Previous history of Omalizumab 22 34.4%
Previous history of Mepolizumab 3 4.7%
Previous history of Dupilumab 4 6.3%
Open in a new tab

Numerical data are presented as means, SDs.

Categorical data are presented as N, %.

ACT, Asthma Control Test.

EOS, blood eosinophil counts.

†Asthma-COPD overlap was defined by the presence of more than 10 pack-years of smoking and FEV1/FVC less than 70% at baseline.

Table 2. Changes in clinical parameters in response to 4 months of benralizumab treatment.

Mean (SD) T p
PSL (mg) -1.0 (3.2) 2.5 0.016
FEV1 (L) 0.1 (0.2) -4.5 <0.001
%FEV1 (%) 6.1 (11) -4.4 <0.001
ACT 4.5 (4.3) -8.5 <0.001
EOS (/μl) -428.2 (555) 6.2 <0.001
IgE (IU/ml) -101.2 (244) 3.3 0.002
FeNO (ppb) -2.9 (42) 0.6 0.58
Open in a new tab

PSL, prednisolone.

ACT, Asthma Control Test.

EOS, blood eosinophil counts.

Fig 1. Relationship between ACT improvement and FEV1 improvement.

Fig 1

Open in a new tab

Pre-treatment phenotypic differences between responders and non-responders were examined for each responsiveness criterion (FEV1 and ACT responders) (Table 3). FEV1-responders were associated with higher levels of type 2 inflammation-related parameters; however, no clinical factors, except for baseline ACT, were associated with ACT responders. The number of patients on maintenance oral corticosteroid tended to be higher in FEV1 responders (p<0.1). Correlations of baseline type 2 parameters, including blood eosinophil counts, FeNO, and total IgE levels, with changes in FEV1 or ACT are also shown in Table 4. Baseline levels of FeNO and total IgE were significantly correlated with 4-month changes in FEV1 while no baseline type 2 parameters were correlated with 4-month changes in ACT. When we also associated the sums of increased type 2 inflammation-related parameters with changes in ACT or FEV1 (Figs 2 and 3, Tables 5 and 6), improvement in FEV1, but not in ACT, was strongly associated (p<0.001).

Table 3. Comparisons of baseline factors between responders and non-responders.

FEV1 (35 responders, 29 non-responders) Mean (SD) or N(%) p
Age Responder 68.3 (11.9) 0.45
Non-Responder 70.7 (13.2)
Age at disease onset Responder 56.3 (18.4) 0.49
Non-Responder 59.5 (18.9)
BMI Responder 23.6 (3.7) 0.77
Non-Responder 23.9 (4.6)
Smoking (pack-years) Responder 20.0 (37.4) 0.81
Non-Responder 22.0 (26.8)
ACT Responder 17.1 (4.0) 0.74
Non-Responder 16.7 (4.0)
%FEV1 Responder 60.6 (21.6) 0.096
Non-Responder 70.1 (22.9)
EOS Responder 554.6 (681.1) 0.045
Non-Responder 275.9 (294.5)
IgE Responder 659.6 (885.6) 0.065
Non-Responder 341.1 (418.1)
FeNO Responder 74.7 (69.4) 0.001
Non-Responder 32.1 (19.5)
mOCS use Responder 13 (37.1) 0.099
Non-Responder 5 (17.2)
ACT (47 responders, 17 non-responders Mean (SD) or N(%) p
Age Responder 68.7 (13.0) 0.42
Non-Responder 71.5 (11.2)
Age at disease onset Responder 57.0 (18.7) 0.61
Non-Responder 59.8 (18.5)
BMI Responder 23.8 (4.3) 0.71
Non-Responder 23.4 (3.8)
Smoking (pack-years) Responder 15.0 (27.3) 0.054
Non-Responder 37.1 (41.3)
ACT Responder 16.2 (3.6) 0.019
Non-Responder 18.8 (4.4)
%FEV1 Responder 64.8 (21.6) 0.94
Non-Responder 65.2 (25.7)
EOS Responder 451.5 (621.9) 0.58
Non-Responder 364.3 (310.7)
IgE Responder 557.6 (783.1) 0.44
Non-Responder 398.3 (538.7)
FeNO Responder 55.0 (61.9) 0.93
Non-Responder 56.5 (41.2)
mOCS use Responder 12 (25.5) 0.53
Non-Responder 6 (35.3)
Open in a new tab

ACT, Asthma Control Test.

EOS, blood eosinophil counts.

mOCS, maintenance oral corticosteroid.

Table 4. Correlations between type 2-related inflammation parameters at baseline and changes in ACT or FEV1 after 4 months of treatment.

Correlation Coefficient(P) Changes in ACT Changes in FEV1
FeNO 0.1(0.42) 0.36(0.004)
Log EOS 0.045(0.73) 0.17(0.19)
Log IgE 0.079(0.54) 0.26(0.037)
Open in a new tab

ACT, Asthma Control Test.

EOS, blood eosinophil counts.

Fig 2. Correlation between ACT improvement and the number of increased type 2-related inflammation parameters.

Fig 2

Open in a new tab

An increased level of each type 2-related marker was counted as 1, resulting in a sum ranging from 0 (none of parameters were elevated) to 3 (all 3 type 2 markers were elevated) for each patient. Error bars: +/- 2SE.

Fig 3. Correlation between FEV1 improvement and the number of increased type 2-related inflammation parameters.

Fig 3

Open in a new tab

An increased level of each type 2-related markers was counted as 1, resulting in a sum ranging from 0 (none of type-2 parameters were elevated) to 3 (all 3 type 2 markers were elevated) for each patient. Error bars: +/- 2SE.

Table 5. Association between total number of Th2-related inflammatory parameter positives and FEV1 improvement 4 months after benralizumab treatment.

Th2 positive Mean Std. Deviation N
0 0.08 0.17 7
1 0.07 0.25 20
2 0.13 0.21 19
3 0.26 0.17 18
Total 0.13 0.23 64
Open in a new tab

Table 6. Association between total number of Th2-related inflammatory parameter positives and ACT improvement 4 months after benralizumab treatment.

Th2 positive Mean Std. Deviation N
0 3.86 5.146 7
1 4.90 3.493 20
2 3.53 4.982 19
3 5.39 4.017 18
Total 4.52 4.272 64
Open in a new tab

We identified 5 distinct phenotypes of severe eosinophilic asthma in terms of FEV1 response to benralizumab. In addition to the FEV1 changes at 4 months, type 2 inflammation-related parameters differed significantly among these 5 clusters (Fig 4, Table 7).

Fig 4. Early responsiveness to benralizumab in FEV1 by cluster.

Fig 4

Open in a new tab

The observed absolute changes from baseline FEV1 (L) in response to benralizumab over 4 months. The error bar represents standard error.

Table 7. Baseline clinical characteristics of the clusters.

Cluster A (n = 20) B (n = 13) C (n = 9) D (n = 14) E (n = 8) P value║
FEV1 Responder† 5 (25%) 11 (85%) 4 (44%) 14 (100%) 1 (13%) <0.001
ACT Responder‡ 15 (75%) 9 (69%) 6 (67%) 13 (93%) 4 (50%) 0.26
Changes in FEV1 (ml) -20 (140) 200 (130) 150 (220) 400 (150) -110 (150) <0.001
Changes in ACT 4.45 (5.19) 4.46 (3.10) 3.00 (2.50) 6.57 (3.76) 2.88 (5.19) 0.24
Female 7 (35%) 3 (23%) 5 (56%) 8 (57%) 1 (13%) 0.14
Age 77.1 (5.7) 74.5 (12.2) 73.3 (6.4) 62.4 (9.6) 50.0 (9.0) <0.001
Age at onset 73.0 (6.8) 63.1 (18.8) 56.0 (13.5) 43.9 (14.6) 37.3 (13.2) <0.001
BMI 23.4 (4.3) 22.2 (3.6) 23.9 (3.2) 23.9 (3.7) 26.4 (5.6) 0.24
Pack year 47.0 (42.1) 3.4 (5.8) 29.4 (30.8) 3.3 (8.3) 5.6 (9.6) <0.001
Smoking history (yes) 15 (75%) 5 (38%) 7 (78%) 2 (14%) 3 (38%) 0.003
Smoking index 0:0–200: >200 5: 0: 15 8: 4: 1 2: 2: 5 12: 0: 2 5: 1: 2 <0.001
Allergic rhinitis 0 (0%) 3 (23%) 4 (44%) 6 (43%) 3 (38%) 0.021
Systemic steroid (SS) 2 (10%) 6 (46%) 4 (44%) 4 (29%) 2 (25%) 0.16
Prednisolone equivalent dose (mg) 0:0–10: >10 18: 2: 0 7: 4: 2 5: 4: 0 10: 3: 1 6: 1: 1 0.26
ACT 15.9 (4.0) 18.0 (4.3) 20.3 (2.4) 16.7 (3.1) 14.3 (3.9) 0.009
FEV1 (ml) 1260 (440) 1210 (580) 1990 (480) 1490 (450) 1770 (550) 0.001
%FEV1 (%) 61.5 (23.0) 56.2 (21.3) 91.4 (21.1) 62.9 (18.1) 61.0 (12.2) 0.002
FEV1/FVC 61.6 (18.0) 61.8 (13.9) 67.3 (7.7) 62.7 (14.8) 74.3 (15.4) 0.30
EOS(/μl) 249.9 (262) 928.0 (951) 213.9 (179) 455.4 (415) 256.3 (185) 0.003
Log EOS 2.26(0.34) 2.85 (0.30) 2.00 (0.83) 2.50(0.42) 2.31 (0.32) 0.001
IgE (IU/ml) 125.8 (163) 1123.6 (1113) 720.1 (408) 503.6 (675) 290.5 (521) 0.001
Log IgE 1.68 (0.68) 2.87 (0.43) 2.78 (0.29) 2.22 (0.79) 2.00 (0.65) <0.001
FeNO (ppb) 31.4 (21.7) 112.8 (96.7) 47.3 (30.9) 58.3 (28.8) 26.5 (17.1) <0.001
Asthma-COPD overlap§ 11 (55%) 0 (0%) 2 (22%) 2 (14%) 2 (25%) 0.007
Open in a new tab

Numerical data are presented as means, SDs.

Categorical data are presented as N, %.

ACT, Asthma Control Test.

EOS, blood eosinophil count.

†FEV1 responder was defined as FEV1 improvement by 100 ml or more in 4 months.

‡ACT responder was defined as ACT improvement by 3 points or more in 4 months.

§Asthma-COPD overlap was defined by the presence of more than 10 pack-years of smoking and FEV1/FVC less than 70% at baseline.

║The chi-square test was used to compare categorical variables while one-way ANOVA was used to compare the numerical variables among the clusters.

Cluster D (n = 14), with the greatest improvement in FEV1, was characterized by middle age disease onset, lower smoking exposure, moderate airflow obstruction, and moderately increased levels of type 2 parameters. Two clusters, B (n = 13) and C (n = 9), showed moderate FEV1 improvements. Cluster B was characterized by the prominent intensity of type 2 inflammation with the lowest lung function and lower smoking exposure while Cluster C was characterized by the mildest symptoms, milder airflow obstruction, high intensity of smoking exposure, and the presence of allergic rhinitis with heightened type 2 parameters. Two clusters, A (n = 20) and E (n = 8), showed no FEV1 improvements over 4 months. Cluster A was characterized by the oldest age at onset, the highest exposures to smoking with impaired lung function and mildly elevated type 2 parameters, corresponding to asthma-COPD overlap. Cluster E was characterized by male dominance, the youngest onset, lower smoking exposure, the mildest impairment of lung function and the highest BMI. It was evident that responsive clusters D, B and C were characterized by enhanced type 2 immunity, as assessed by blood eosinophil counts, FeNO, or total IgE, in comparison to non-responsive clusters A and E (Fig 5, Table 7).

Fig 5. Type 2 inflammation-related parameters at baseline by cluster.

Fig 5

Open in a new tab

Responsive clusters, D, B and C, were characterized by enhanced type 2 immunity as assessed by total IgE, FeNO or blood eosinophils (EOS) in comparison to non-responsive clusters A and E. Most importantly, however, the cluster analysis indicated the presence of several distinct phenotypes with various early responsiveness to benralizumab. Among these clusters, EOS (p = 0.001), total IgE (p = 6.0×10−6) and FeNO (2.30×10−4) differed significantly (One-way ANOVA). Right axis: IgE (IU/ml), Left axis: EOS (/microl), FeNO (ppb).

Discussion

Benralizumab exerts a very rapid and effective therapeutic action in patients with severe eosinophilic asthma [5]. Overall, our study supports the contention that, following 4 months of treatment, type 2-related inflammatory parameters, including peripheral blood eosinophil counts, FeNO, and total serum IgE levels, were associated with FEV1-responsiveness to benralizumab. However, a large variation in the magnitude of the responsiveness to benralizumab was also observed. Most importantly, our cluster analysis of the FEV1 responders clearly indicated the presence of several distinct phenotypes with variable early responsiveness to benralizumab. The greatest response was found in the distinct phenotype of severe eosinophilic asthma (Cluster D), which was characterized by modest increases in total IgE and FeNO relative to blood eosinophils with less smoking exposure. Moderate responses were in Clusters B and C, and poor responses were in Clusters A and E. Interestingly, Cluster B, with the highest levels of type 2 parameters, did not demonstrate the strongest effect of benralizumab. It is likely that the intensity of type 2 inflammation in Cluster B may have overwhelmed the ability of benralizumab to fully suppress it over 4 months and thus Cluster D, with milder type 2 inflammation intensity, paradoxically showed the greatest responsiveness. In addition, since increased levels of IgE and/or FeNO reflect the activity of IL-4 and/or IL-13, but not that of IL-5, benralizumab may have failed to effectively suppress activities of these cytokines which led to the notably milder responsiveness observed in Clusters B and C. Indeed, benralizumab failed to lower the levels of FeNO in the overall patient population. This may also explain why Cluster D, which was characterized by lower levels of total IgE and FeNO in comparison to Cluster B, showed the greatest responsiveness to benralizumab. Elevated levels of total IgE and/or FeNO relative to blood eosinophils may therefore be predictive for reduced responsiveness to benralizumab.

Given that two responsive clusters (B and D) had a low smoking exposure, higher exposures to cigarette smoking, which characterized Clusters A and C, seem to reduce the effect of benralizumab. In fact, smoking exposure has been shown to adversely impact the effectiveness of ICS and accumulating evidence indicates that smoking exposure may induce significant pathobiological changes through predominance of activated macrophages and neutrophils [6]. Persistent exposure to cigarette smoke may therefore drive additive or synergistic inflammatory and remodeling responses in the asthmatic airways, leading to the development of ACO and explaining the impaired responsiveness to benralizumab. In contrast, the poor response seen in Cluster E may be explained by its highest observed BMI levels and possible systemic inflammation from increased levels of several obesity-associated cytokines (TNF-α, IL-6, and leptin). The presence of non-type 2 inflammation complicated by smoking or obesity might hinder the effect of benralizumab, which primarily targets enhanced type 2 immunity. In fact, we recently reported that, as a result of comprehensive whole blood gene expression analysis focusing on responsiveness to benralizumab, enhanced gene expression related to neutrophilic activity resulted in distinct patient clusters in cases of poor responders with severe eosinophilic asthma [7].

Because the importance of peripheral blood eosinophil count as a biomarker of benralizumab responsiveness has been consistently described [8], physicians in real-world settings may possibly decide to administer benralizumab solely based on peripheral blood eosinophil counts. In this sense, it is important to note that this study clearly indicates that defining detailed phenotypes of severe eosinophilic asthma by considering levels of total IgE and FeNO, as well as the presence of smoking or obesity, could help to guide more appropriate and individualized treatments.

Pooled data analysis from the Phase III studies (SIROCCO and CALIMA) identified oral corticosteroid (OCS) use, nasal polyposis, pre-bronchodilator forced vital capacity (FVC), prior year exacerbations, and age at diagnosis as baseline factors that influenced benralizumab efficacy [9]. In addition, the real-world effectiveness study of benralizumab also highlighted higher eosinophil counts, nasal polyposis, and adult-onset asthma as baseline characteristics associated with a superior response to benralizumab [10]. In the current study, in addition to elevated type-2 markers, lower FEV1 or OCS use appeared to be related to increased FEV1 response to benralizumab, which is in line with the previous studies. In contrast, age at disease onset was not related to the responsiveness in our study, which may be attributed to the rather older disease onset (57.8 years old) observed in our cohort.

In this study, there was no clear correlation between improvements in ACT and FEV1. Given that improvements in ACT were not associated with any of the baseline levels or changes in type 2-related markers, including eosinophils, FeNO, and total IgE, we assumed that ACT-responders were likely to have confounded our results by a placebo effect that relates to the complexity of psychological and biological mechanisms [11]. The disparity between patient perception and actual improvement of type 2 inflammation or airflow obstruction emphasizes the importance of referring to these objective parameters to evaluate clinical responses to benralizumab.

Our study population may not be typical of those often recruited to phase 3 studies of benralizumab. Our participants were older and had a higher proportion of smoking histories, especially in cluster A. Given that this cluster had a rather high number of ACT responders, the effectiveness of benralizumab based on the FEV1 improvement may be underestimated because of the possible coexistence of COPD. The main limitations of the study, therefore, include the small sample size, uncertainty on the generalizability of the findings and whether the assessment of response using changes in FEV1 at 4 months was predictive of the response to other clinical outcomes, such as exacerbation rate at one year.

Conclusion

This study, to the best of our knowledge, is the first cluster analysis to report distinct clinical phenotypes related to benralizumab response in a real-world population with severe eosinophilic asthma.

Although the results of this study supported the contention that benralizumab was shown to be effective in patients with heightened type 2 inflammatory parameters such as eosinophils, IgE, and FeNO at baseline, our findings also indicated the importance of defining detailed phenotypes of severe eosinophilic asthma, including relative increase in total IgE and/or FeNO to blood eosinophils or the co-existence of smoking or obesity. Future studies will seek novel molecular pathways underlying these distinct clinical phenotypes. This study may also facilitate larger clustering analyses for the other biologics developed for severe asthma, which will clarify distinctive therapeutic roles by identifying individually responsive phenotypes.

Acknowledgments

We thank Dr. Bryan J. Mathis of the Medical English Communications Center, University of Tsukuba, for English revision of this manuscript.

Abbreviations

FEV1

forced expiratory volume in 1 second

ACT

Asthma Control Test

FeNO

fractional exhaled nitric oxide

ACO

Asthma-COPD overlap

Data Availability

All relevant data are within the manuscript.

Funding Statement

The funder “Hitachi Ltd” provided support in the form of salaries for authors [HY, N Hida and TN], but did not have any additional role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. The specific roles of these authors are articulated in the ‘author contributions’ section.

References

  • 1.FitzGerald J Mark, Eugene R Bleecker, Parameswaran N, Korn S, Ohta K, Lommatzsch M, et al. Benralizumab, an anti-interleukin-5 Receptor α Monoclonal Antibody, as Add-On Treatment for Patients With Severe, Uncontrolled, Eosinophilic Asthma (CALIMA): A Randomised, Double-Blind, Placebo-Controlled Phase 3 Trial: Lancet. 2016; 388: 2128–2141. 10.1016/S0140-6736(16)31322-8 [DOI] [PubMed] [Google Scholar]
  • 2.Eugene R Bleecker, FitzGerald J Mark, Pascal C, Papi A, Weinstein SF, Barker P, et al. Efficacy and Safety of Benralizumab for Patients with Severe Asthma Uncontrolled with High-Dosage Inhaled Corticosteroids and Long-Acting β 2-agonists (SIROCCO): A Randomised, Multicentre, Placebo-Controlled Phase 3 Trial: Lancet. 2016; 388: 2115–2127. 10.1016/S0140-6736(16)31324-1 [DOI] [PubMed] [Google Scholar]
  • 3.Bleecker Eugene R., Wechsler Michael E., FitzGerald J. Mark, Andrew Menzies-Gow, Yanping Wu, Ian Hirsch, et al. Baseline patient factors impact on the clinical efficacy of benralizumab for severe asthma. Eur Respir J. 2018t; 52(4): 1800936. Published online 2018. October 18. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 4.[Guideline of respiratory function tests—spirometry, flow-volume curve, diffusion capacity of the lung]. Nihon Kokyuki Gakkai Zasshi 2004; Suppl: 1–56. [PubMed] [Google Scholar]
  • 5.Moran AM, Ramakrishnan S, Borg CA, Connolly CM, Couillard S, Mwasukuet CM, et al. Blood Eosinophil Depletion with Mepolizumab, Benralizumab and Prednisolone in Eosinophilic Asthma. Am J Respir Crit Care Med. 2020. June 25. 10.1164/rccm.202003-0729LE Online ahead of print. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 6.Polosa R, Thomson NC. Smoking and asthma: dangerous liaisons. Eur Respir J. 2013; 41(3):716–26. 10.1183/09031936.00073312 [DOI] [PubMed] [Google Scholar]
  • 7.Nakajima M, Matsuyama M, Arai N, Yamada H, Hyodo K, Nonaka M, et al. Identification of whole blood gene expressions correlated with responsiveness to benralizumab. J Allergy Clin Immunol. 2020; Online ahead of print. 10.1016/j.jaci.2020.08.004 [DOI] [PubMed] [Google Scholar]
  • 8.Nair P, Wenzel S, Rabe KF, Bourdin A, Lugogo NL, Kuna P, et al. Oral Glucocorticoid-Sparing Effect of Benralizumab in Severe Asthma. N Engl J Med. 2017. June 22;376(25):2448–2458. 10.1056/NEJMoa1703501 [DOI] [PubMed] [Google Scholar]
  • 9.Bleecker ER, Wechsler ME, FitzGerald JM, Menzies-Gow A, Wu Y, Hirsch I, et al. Baseline patient factors impact on the clinical efficacy of benralizumab for severe asthma. Eur Respir J. 2018;18;52(4):1800936. 10.1183/13993003.00936-2018 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 10.Joanne EK, Andrew PH, Jaideep D, Gráinne d’ A, Abdel D, Cris R, et al. Real-World Effectiveness of Benralizumab in Severe Eosinophilic Asthma. Chest. Online ahead of print. 10.1016/j.chest.2020.08.2083. [DOI] [Google Scholar]
  • 11.Dutile S, Kaptchuk TJ, Wechsler ME. The placebo effect in asthma. Curr Allergy Asthma Rep. 2014;14(8):456. 10.1007/s11882-014-0456-2 [DOI] [PMC free article] [PubMed] [Google Scholar]

Decision Letter 0

Stelios Loukides

3 Feb 2021

PONE-D-20-37996

Identification of distinct phenotypes related to benralizumab responsiveness in patients with severe eosinophilic asthma

PLOS ONE

Dear Dr. Yamada,

Thank you for submitting your manuscript to PLOS ONE. We apologise for the delay. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Both reviewers raised some concenrs. These concerns are mainly related to low number of patients, to the way that introduction and discussion are presented and fnally to some methodological issues which may affect the interpretation of the results. 

Please submit your revised manuscript by Mar 20 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

  • A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

  • A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

  • An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

We look forward to receiving your revised manuscript.

Kind regards,

Stelios Loukides

Academic Editor

PLOS ONE

Journal requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

2. Thank you for including your ethics statement:  "All participants provided written, informed consent and the local institutional review board approved the study protocols (IRB number: R01-350)."

Please amend your current ethics statement to include the full name of the ethics committee/institutional review board(s) that approved your specific study.

Once you have amended this/these statement(s) in the Methods section of the manuscript, please add the same text to the “Ethics Statement” field of the submission form (via “Edit Submission”).

For additional information about PLOS ONE ethical requirements for human subjects research, please refer to http://journals.plos.org/plosone/s/submission-guidelines#loc-human-subjects-research.

3. In your Methods section, please provide additional information about the participant recruitment method and the demographic details of your participants. Please ensure you have provided sufficient details to replicate the analyses such as:

a) the date(s) that you accessed patient data,

b) a description of any inclusion/exclusion criteria that were applied to participant recruitment,

c) a statement as to whether your sample can be considered representative of a larger population, and

d) a description of how participants were recruited.

4. Thank you for stating the following in the Competing Interests section:

"H.Y. has received lecture fees from AstraZeneca, Sanofi and Boehringer Ingelheim. N. Hizawa is on the GlaxoSmithKline advisory board; has received research support from Astellas, AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, Kyorin, MSD, Novartis, and Chugai Pharmaceutical; and has received lecture fees from Astellas, AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, Kyorin, MSD, and Novartis. The rest of the authors declare that they have no relevant conflicts of interest."

a) Please confirm that this does not alter your adherence to all PLOS ONE policies on sharing data and materials, by including the following statement: "This does not alter our adherence to  PLOS ONE policies on sharing data and materials.” (as detailed online in our guide for authors http://journals.plos.org/plosone/s/competing-interests).  If there are restrictions on sharing of data and/or materials, please state these. Please note that we cannot proceed with consideration of your article until this information has been declared.

b) We note that one or more of the authors are employed by a commercial company: Hitachi Ltd

(1) Please provide an amended Funding Statement declaring this commercial affiliation, as well as a statement regarding the Role of Funders in your study. If the funding organization did not play a role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript and only provided financial support in the form of authors' salaries and/or research materials, please review your statements relating to the author contributions, and ensure you have specifically and accurately indicated the role(s) that these authors had in your study. You can update author roles in the Author Contributions section of the online submission form.

Please also include the following statement within your amended Funding Statement.

“The funder provided support in the form of salaries for authors [insert relevant initials], but did not have any additional role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. The specific roles of these authors are articulated in the ‘author contributions’ section.”

If your commercial affiliation did play a role in your study, please state and explain this role within your updated Funding Statement.

(2) Please also provide an updated Competing Interests Statement declaring this commercial affiliation along with any other relevant declarations relating to employment, consultancy, patents, products in development, or marketed products, etc.  

Within your Competing Interests Statement, please confirm that this commercial affiliation does not alter your adherence to all PLOS ONE policies on sharing data and materials by including the following statement: "This does not alter our adherence to  PLOS ONE policies on sharing data and materials.” (as detailed online in our guide for authors http://journals.plos.org/plosone/s/competing-interests) . If this adherence statement is not accurate and  there are restrictions on sharing of data and/or materials, please state these. Please note that we cannot proceed with consideration of your article until this information has been declared.

Please include both an updated Funding Statement and Competing Interests Statement in your cover letter. We will change the online submission form on your behalf.

Please know it is PLOS ONE policy for corresponding authors to declare, on behalf of all authors, all potential competing interests for the purposes of transparency. PLOS defines a competing interest as anything that interferes with, or could reasonably be perceived as interfering with, the full and objective presentation, peer review, editorial decision-making, or publication of research or non-research articles submitted to one of the journals. Competing interests can be financial or non-financial, professional, or personal. Competing interests can arise in relationship to an organization or another person. Please follow this link to our website for more details on competing interests: http://journals.plos.org/plosone/s/competing-interests

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Partly

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: N/A

Reviewer #2: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Hideyasu Yamada et al, tried to indentify distinct phenotypes related to benralizumab responsiveness in patients with severe eosinophilic asthma on a real world basis study and found 5 phenotypes according to FEV1 responsiveness.

Although it is an interesting study with clinical significance regarding every day clinical practice, there are issues that have to be clarified:

1. The study population section is incomplete as basic characteristics are missing even from the Table 1. It is not clarified if patients have received other kind of biological in the past. What was the number of exacerbations in the previous 1 or 2 years? Besides allergic rhinitis, did they have nasal polyposis as well, and in what percentage?

2. The cut off value of 173 IU/mL for IgE is rather arbitrary and high, as there are many references of 100 IU/mL as normal values. Furthermore, no information is provided about positive skin prick or Rast tests in order to better characterize the phenotype of severe allergic asthma.

3. There is no reference regarding changes in OCS use as almost 18 of the patients were under this treatment. OCS sparing is a major parameter of responsiveness to a biologic agent besides FEV1 improvement. The same applies for the number of exacerbations which should be included in the final analysis.

4. Authors should make a comment comparing their results to those based on pool data of the initial phase III studies of Benralizumab (Bleecker ER, et al. Baseline patient factors impact on the clinical efficacy of benralizumab for severe asthma. Eur Respir J 2018; 52: 1800936) as there are both similarities and differences.

5. The conclusion should be more clear about which phenotypes relate to benralizumab responsiveness.

Minor comments

1. Reference 1 does not support the first paragraph of the introduction section and the same applies for reference 7

2. References 24, 25 at the end of the first paragraph of introduction should be omitted

3. PSL abbreviation in Table 2 is not explained

4. Table 3 is rather confusing and most of the comparisons are not statistically significant, so it is suggested to be omitted. Table 5 could be omitted as Figure 3 is more informative

5. Statistical significant p values lower than 0,05 would better be written as p<0,001 instead of e.g. 3,1 x10-5

Reviewer #2: Thank you for asking me to review this paper.

Cluster analysis was used to investigate benralizumab’ treatment response in a small real-world data set. The study deals with an interest aspect of severe asthma management for a tailored therapy. The paper is well written and easy to follow. My main concerns are the small sample size and the low generalizability of the results.

Comments:

1) Abstract: The paper is about identifying clusters of benralizumab treatment response. However, the Results summary does not clearly define which clusters were identified.

2) Introduction is very generical and not informative. I would emphasize the importance of identifying clusters responding to benralizumab treatment outside clinical trials and to have information from real world settings.

3) Methods: Why not taking into account airway reversibility and post-bronchodilator FEV1? Please specify

4) Results: Table 2 please describe all the abbreviations

5) Discussion needs improvements. Please discuss in detail the published literature in light of the results of your research.

6) Discussion: tables and figures should not be referenced in the Discussion section

7) Discussion: I would suggest adding a paragraph developing the potential usefulness of the study results and their generalizability.

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

PLoS One. 2021 Mar 11;16(3):e0248305. doi: 10.1371/journal.pone.0248305.r002

Author response to Decision Letter 0

11 Feb 2021

Responses to the reviewers’ comments

Reviewer: #1

COMMENT 1

The study population section is incomplete as basic characteristics are missing even from the Table 1. It is not clarified if patients have received other kind of biological in the past. What was the number of exacerbations in the previous 1 or 2 years? Besides allergic rhinitis, did they have nasal polyposis as well, and in what percentage?

RESPONSE 1

Thank you for the comment. In the revised manuscript, we have added the number of patients who had previous administration of other biologics at Table 1. We are afraid that information about previous exacerbation and nasal polyps is not available in this real-world cohort.

COMMENT 2

The cut off value of 173 IU/mL for IgE is rather arbitrary and high, as there are many references of 100 IU/mL as normal values. Furthermore, no information is provided about positive skin prick or Rast tests in order to better characterize the phenotype of severe allergic asthma.

RESPONSE 2

Thank you for the comment. According to the suggestion, in the revised manuscript, we have reanalyzed our data using the cut off value of 100 IU/mL, which showed no significant changes in the result. We agree that information about allergen specific IgE responses is important to better characterize each cluster of severe eosinophilic asthma; however, insufficient information about this in this real-world cohort did not allow us to do so.

COMMENT 3

There is no reference regarding changes in OCS use as almost 18 of the patients were under this treatment. OCS sparing is a major parameter of responsiveness to a biologic agent besides FEV1 improvement. The same applies for the number of exacerbations which should be included in the final analysis.

RESPONSE 3

Thank you for the comment. Although this study focused on the initial 4-month after starting benralizumab in a real-world setting, small but significant reduction in doses of maintenance OCS was noted during this period (Table 2). In terms of exacerbation, insufficient information about exacerbation history before starting benralizumab did not allow us to evaluate the effect of benralizumab.

COMMENT 4

Authors should make a comment comparing their results to those based on pool data of the initial phase III studies of Benralizumab (Bleecker ER, et al. Baseline patient factors impact on the clinical efficacy of benralizumab for severe asthma. Eur Respir J 2018; 52: 1800936) as there are both similarities and differences.

RESPONSE 4

Thank you for the comment. We have added a following sentence to the discussion in the revised manuscript.

“Pooled data analysis from the Phase III studies (SIROCCO and CALIMA) identified oral corticosteroid (OCS) use, nasal polyposis, pre-bronchodilator forced vital capacity (FVC), prior year exacerbations and age at diagnosis as baseline factors that influenced benralizumab efficacy (E1). In addition, the real-world effectiveness study of benralizumab also highlighted higher eosinophil counts, nasal polyposis, and adult-onset asthma as baseline characteristics associated with a superior response to benralizumab (E2). In the current study, in addition to elevated type-2 markers, lower FEV1 or OCS use appeared to be related to increased FEV1 response to benralizumab, which is in line with the previous studies. In contrast, age at disease onset was not related to the responsiveness in our study, which may be attributed to the rather older disease onset (57.8 years old) observed in our cohort.”

E1. Bleecker ER, Wechsler ME, FitzGerald JM, Menzies-Gow A, Wu Y, Hirsch I, et al. Baseline patient factors impact on the clinical efficacy of benralizumab for severe asthma. Eur Respir J 2018 Oct 18;52(4):1800936. doi: 10.1183/13993003.00936-2018.

E2. Joanne EK, Andrew PH, Jaideep D, Gráinne d'A, Abdel D, Cris R, et al. Real-World Effectiveness of Benralizumab in Severe Eosinophilic Asthma. Chest. Online ahead of print. DOI: https://doi.org/10.1016/j.chest.2020.08.2083

COMMENT 5

The conclusion should be more clear about which phenotypes relate to benralizumab responsiveness.

RESPONSE 5

Thank you for the comment. At the 1st paragraph of the discussion, we have now described clearly that the greatest response was found in the distinct phenotype of severe eosinophilic asthma, which was characterized by modest increases in total IgE and FeNO relative to blood eosinophils with least exposure to smoking.

MINOR　COMMENT

1. Reference 1 does not support the first paragraph of the introduction section and the same applies for reference 7

2. References 24, 25 at the end of the first paragraph of introduction should be omitted

3. PSL abbreviation in Table 2 is not explained

4. Table 3 is rather confusing and most of the comparisons are not statistically significant, so it is suggested to be omitted. Table 5 could be omitted as Figure 3 is more informative

5. Statistical significant p values lower than 0,05 would better be written as p<0,001 instead of e.g. 3,1 x10-5

RESPONSE to minor comment

The above has been corrected as appropriate. In the revised manuscript, we omitted Table 5, but not Table 3. We believe that Table 3 has some importance of showing the baseline predictive factors for FEV1 improvement in response to 4-month benralizumab.

Reviewer: #2

COMMENT 1

Abstract: The paper is about identifying clusters of benralizumab treatment response. However, the Results summary does not clearly define which clusters were identified.

RESPONSE 1

Thank you for the comment. In the result section of abstract, we have now described clearly that the greatest response was found in the distinct phenotype of severe eosinophilic asthma, which was characterized by modest increases in total IgE and FeNO relative to blood eosinophils with least exposure to smoking.

COMMENT 2

Introduction is very generical and not informative. I would emphasize the importance of identifying clusters responding to benralizumab treatment outside clinical trials and to have information from real world settings.

RESPONSE 2

Thank you for the comment. We have revised the introduction accordingly.

COMMENT 3

Methods: Why not taking into account airway reversibility and post-bronchodilator FEV1? Please specify

RESPONSE 3

Thank you for the comment. We are afraid that we do not have sufficient information about airway reversibility and post-bronchodilator FEV1 in this cohort.

COMMENT 4

Results: Table 2 please describe all the abbreviations

RESPONSE 4

Thank you for the comment. We have revised Table 2 accordingly.

COMMENT 5

Discussion needs improvements. Please discuss in detail the published literature in light of the results of your research.

RESPONSE 5

We have added a following sentence to the 4th paragraph of the discussion in the revised manuscript.

“Pooled data analysis from the Phase III studies (SIROCCO and CALIMA) identified oral corticosteroid (OCS) use, nasal polyposis, pre-bronchodilator forced vital capacity (FVC), prior year exacerbations and age at diagnosis as baseline factors that influenced benralizumab efficacy (E1). In addition, the real-world effectiveness study of benralizumab also highlighted higher eosinophil counts, nasal polyposis, and adult-onset asthma as baseline characteristics associated with a superior response to benralizumab (E2). In the current study, in addition to elevated type-2 markers, lower FEV1 or OCS use appeared to be related to increased FEV1 response to benralizumab, which is in line with the previous studies. In contrast, age at disease onset was not related to the responsiveness in our study, which may be attributed to the rather older disease onset (57.8 years old) observed in our cohort.”

E1. Bleecker ER, Wechsler ME, FitzGerald JM, Menzies-Gow A, Wu Y, Hirsch I, et al. Baseline patient factors impact on the clinical efficacy of benralizumab for severe asthma. Eur Respir J 2018 Oct 18;52(4):1800936. doi: 10.1183/13993003.00936-2018.

E2. Joanne EK, Andrew PH, Jaideep D, Gráinne d'A, Abdel D, Cris R, et al. Real-World Effectiveness of Benralizumab in Severe Eosinophilic Asthma. Chest. Online ahead of print. DOI: https://doi.org/10.1016/j.chest.2020.08.2083

COMMENT 6

Discussion: tables and figures should not be referenced in the Discussion section

RESPONSE 6

Thank you for your comment. We have revised the manuscript accordingly.

COMMENT 7

Discussion: I would suggest adding a paragraph developing the potential usefulness of the study results and their generalizability.

RESPONSE 7

Thank you for your comment. Accordingly, we have added a sentence as the 3rd paragraph of the Discussion.

Attachment

Submitted filename: Response to reviewer ver.1.docx

Click here for additional data file. (41.5KB, docx)

Decision Letter 1

Stelios Loukides

24 Feb 2021

Identification of distinct phenotypes related to benralizumab responsiveness in patients with severe eosinophilic asthma

PONE-D-20-37996R1

Dear Dr. Yamada,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Stelios Loukides

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Although there are missing data to further supportthe final conclusion, the required questions have been answered and all responses meet formatting specifications

Reviewer #2: The authors addressed all the points raised. The manuscript adds interesting information in the field. I have no further comments.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

Acceptance letter

Stelios Loukides

3 Mar 2021

PONE-D-20-37996R1

Identification of distinct phenotypes related to benralizumab responsiveness in patients with severe eosinophilic asthma

Dear Dr. Yamada:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Stelios Loukides

Academic Editor

PLOS ONE

Associated Data

    This section collects any data citations, data availability statements, or supplementary materials included in this article.

    Supplementary Materials

    Attachment

    Submitted filename: Response to reviewer ver.1.docx

    Click here for additional data file. (41.5KB, docx)

    Data Availability Statement

    All relevant data are within the manuscript.

    Articles from PLoS ONE are provided here courtesy of PLOS

    RESOURCES