Fasenra vs. Nucala: Differences, similarities & side effects

In this article:

• Key differences
• Conditions treated
• Is Nucala better than Fasenra?
• Insurance coverage and cost
• Side effects
• Drug interactions
• Drug warnings
• Fasenra vs. Nucala vs. Dupixent

In this article

• Key differences
• Conditions treated
• Is Nucala better than Fasenra?
• Insurance coverage and cost
• Side effects
• Drug interactions
• Drug warnings
• Fasenra vs. Nucala vs. Dupixent

Biologics are a burgeoning drug category being used, among other things, to reduce bronchial inflammation with asthma. We will be breaking down the differences between two major biologics for asthma: Fasenra (benralizumab) and Nucala (mepolizumab). They are both injectable monoclonal antibodies that lessen the effects of interleukin-5 (IL-5), a key messenger within our immune system. Choosing between Fasenra and Nucala to manage severe asthma requires complex decision-making and communication with your healthcare provider, but having an understanding of how the drugs work can help you understand why they may prescribe one over the other. 

Fasenra vs. Nucala: Key differences

Both drugs work by preventing IL-5 from doing its job, namely signaling immune cells called eosinophils, which are partially responsible for asthma and allergies. Fasenra is an antibody that targets the IL-5 receptor, and Nucala is an antibody that goes after IL-5 itself. The subtle mechanistic difference could explain some of the differences between the two.

The Food and Drug Administration (FDA) has approved Fasenra for maintenance treatment of severe asthma. Nucala has a more robust array of indications and has been FDA approved to treat severe eosinophilic asthma, eosinophilic granulomatosis with polyangiitis (EGPA), hypereosinophilic conditions, and rhinosinusitis with nasal polyps. 

They are both given by subcutaneous injection under the skin, which can be given at home by most patients after they learn the proper technique. The intervals are a bit different though. Nucala requires administration every four weeks. Fasenra therapy starts with injections every four weeks, but after three doses, it can be changed to every eight weeks, making it a bit more convenient.

Fasenra vs. Nucala: Conditions treated

The biologics are the big guns when it comes to asthma treatment. They are not go-to drugs for mild to moderate cases of asthma; they may not even work well in this setting or be worth the danger of immune suppression. Selecting which asthma medication patients should use is complicated and typically requires a pulmonary or allergy and immunology specialist. 

Conventional asthma controllers, such as inhaled corticosteroids, long-acting beta agonists, and leukotriene receptor antagonists, are typically prescribed first. Biologics are then a potential add-on therapy if needed for frequent asthma exacerbations or persistent symptoms in the setting of eosinophilic asthma.

A patient with asthma coupled with additional diagnoses like eczema, EGPA, and rhinosinusitis with nasal polyps, may be a better candidate for biologics like Fasenra and Nucala. Diagnostic studies like lung function testing and biomarkers like blood eosinophil counts are necessary to identify who might benefit from these drugs. Age can be an important determinant since adults seem to respond better than children. In addition, attempting to reduce or discontinue chronic steroids for asthma because of their long-term detriments, can be another compelling reason to consider biologics like Nucala and Fasenra for asthma.

Fasenra and Nucala are both options for those with severe asthma and elevated eosinophil counts. Nucala has indications for additional eosinophil-mediated medical problems, too.

Is Nucala better than Fasenra?

For the treatment of severe eosinophilic asthma, choosing between Nucala and Fasenra based on efficacy is a challenge. There are no direct head-to-head comparisons of the products. Moreover, there is no direct evidence of superiority between the three IL-5 antagonists (Fasenra, Nucala, and Cinqair [reslizumab]) and other biologics for asthma. Such biologic alternatives include Xolair (omalizumab), Dupixent (dupilumab), and Tezspire (tezepelumab).

We can get an idea about efficacy expectations by looking at studies on individual drugs and making indirect comparisons. A systematic review published in 2020 did just that and included Fasenra and Nucala. Both drugs cut the rate of asthma exacerbations approximately in half and reduced the dependence on oral corticosteroids. Improvement in quality of life was not substantial enough to be considered statistically significant, though. Based on these findings, there’s no compelling reason to choose Fasenra over Nucala, and vice versa, based on effectiveness.

Fasenra vs. Nucala: Insurance coverage and cost comparison

The reality is that deciding between Fasenra and Nucala may be in the hands of your health insurance. If your insurance’s drug formulary includes one and not the other or designates a more preferred status to one of the drugs, your choice may come down to finances. Your out-of-pocket copay could be much less if a medication is listed as preferred, an important matter when it comes to pricey brand-name products. For example, Aetna’s Standard Control Plan categorizes Fasenra and Nucala as specialty preferred drugs.

Specialty drugs require special handling and need to be purchased from a specialty pharmacy, where pricing information is sometimes limited. The manufacturer’s list price for a single, 30 mg dose of Fasenra is $5,511, but patients don’t often pay the list price, which varies by pharmacy and insurance. The list price of Nucala is $3,689. Those are striking numbers, but savings opportunities for Nucala and Fasenra are available. Additionally, you may be able to show your SingleCare discount card to your pharmacist to make either biologic more affordable.

Fasenra vs. Nucala side effects

Side effects are similar between Fasenra and Nucala. Headache, back pain, and injection site reactions headline the list of common side effects from Nucala. Headache, fever, and sore throat are at the top for frequency on Fasenra’s side effect list. Although the following table lists a higher incidence of headache with Nucala, the rate of headache reported by those taking placebo (inactive pill) was much higher in the Nucala study than in the Fasenra study, suggesting that the difference might be based on study participants rather than the drugs.

In terms of severe side effects that are less common, they both carry risks of severe hypersensitivity allergic reactions and opportunistic infections, such as parasitic infections. Nucala can increase one’s risk of a shingle outbreak.

Source: Fasenra drug label and Nucala drug label

Fasenra and Nucala drug interactions

No drug interactions are posted on the labels for Fasenra or Nucala. While interactions may not be identified yet, caution is still needed when starting a new medicine. You should ask your healthcare provider and pharmacist to review your list of prescription drugs, over-the-counter pills, and supplements to look for drug-drug interactions. Even if they do not interact, additive side effects can be problematic. For instance, adding Fasenra or Nucala to a regimen that already includes an immunosuppressant would require particular caution regarding infection risk.

Fasenra and Nucala Drug warnings

The FDA has not applied any black box warnings or recalls to Fasenra or Nucala. Nonetheless, there are some matters of concern. For one, the drugs can both trigger a dangerous allergic reaction or acute bronchospasm. Infection risk is also a worry, particularly parasitic infections. Herpes zoster, known more commonly as shingles, is enough of a concern with Nucala that the drug’s label suggests considering shingles vaccination prior to starting the medication.

The safety of Fasenra and Nucala during pregnancy or while breastfeeding is unknown. At the same time, uncontrolled asthma is known to be a risk. Decisions about whether to use these monoclonal antibody therapies must take into account both benefits and risk, using shared decision-making between healthcare providers and patients.

Fasenra vs. Nucala vs. Dupixent

If you are considering Fasenra and Nucala, then including the biologic Dupixent in the comparison makes sense. Dupixent is a monoclonal antibody injected every two to four weeks that blocks the IL-4 receptor, so its frequency and mechanism are a little different from the IL-5 antagonists. Cost can be just as much of an issue with Dupixent, retailing at about $5,221 but coming down to $3,606 for 2, 300 mg/2 mL pens with a SingleCare Dupixent coupon.

Like Fasenra and Nucala, Dupixet is FDA approved to treat asthma, including moderate to severe eosinophilic or corticosteroid-dependent asthma. Dupixent has other approved uses as well: atopic dermatitis, eosinophilic esophagitis, rhinosinusitis with nasal polyps, and prurigo nodularis. Only a healthcare provider familiar with your symptoms and health history can recommend the best medication for you.

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