APP Experts Discuss Earlier Biologic Use in Asthma and COPD

For patients with severe asthma or chronic obstructive pulmonary disease (COPD) and type 2 inflammation, advanced practice providers (APPs) are often the clinicians tracking exacerbations, reviewing biomarkers, and writing the appeal letters that biologic therapy requires. The range of options has widened with approvals of dupilumab and mepolizumab for eosinophilic COPD and of depemokimab, a twice-yearly anti-interleukin (IL)-5 agent, for severe asthma.1-4 How quickly patients reach these therapies depends heavily on recognition, documentation, and payer policy.

In October 2026, Haley Hoy, PhD, CRNP, a nurse practitioner who practices at the University of Alabama in Huntsville and Vanderbilt University Medical Center, moderated a virtual clinical forum for APPs on type 2 inflammation and biologic therapy. Participants included nurse practitioners and physician assistants from pulmonary practices in Virginia, Georgia, Alabama, Massachusetts, Colorado, and Missouri, including clinicians in pediatric, bronchiectasis, rural, and lung transplant settings. The discussion covered escalation triggers, biologic selection, mucus plugging, and unmet needs in COPD.

Earlier Recognition of Type 2 Asthma

Participants said type 2 biomarkers have allowed them to escalate therapy sooner rather than cycling through inhalers and steroid bursts. Several described documenting eosinophil counts and baseline IgE at the first visit so that a biologic option is ready if control worsens. Participants cited 2 or more oral corticosteroid (OCS) courses, sometimes within 3 to 6 months, as a common threshold, and 1 noted that this matches what payers typically require.

Participants described searching electronic health records for urgent care and emergency department steroid prescriptions to document exacerbation patterns in appeal letters. Others said claims-based prior authorization reviews miss sample inhalers given in clinic, and 1 participant described "sample-dependent" patients who exacerbate when they cannot afford maintenance inhalers. Participants also stressed quality of life, noting that many patients have accepted activity limitations as normal.

Biologic Selection and Payer Barriers

In polling, 63% of participants cited clinical phenotype and 36% cited biomarkers as the main driver of biologic choice. Participants said comorbidities such as chronic rhinosinusitis with nasal polyps and atopic dermatitis often guide selection, and several described dupilumab as a frequent choice given its range of indications. Others said very high eosinophil counts lead them first to rule out eosinophilic granulomatosis with polyangiitis and hypereosinophilic syndrome and then to favor an anti-IL-5 agent.

Participants described strong responses to anti-IL-5 agents in severe eosinophilic asthma and said longer dosing intervals, including benralizumab's every-8-week maintenance and twice-yearly depemokimab, can improve adherence in adolescents and young adults. Tezepelumab was described as an option for patients without biomarkers for other agents or after failure of other biologics, and 1 pediatric participant described a patient with cystic fibrosis and severe asthma whose admissions declined after more than a year of work to secure coverage. Most participants said insurance ultimately determines the agent.

Participants said radiologists at some centers routinely report mucus plugging, and others request it when ordering computed tomography. Mucus plugging data for dupilumab and tezepelumab were reviewed, and participants in bronchiectasis care said plugging influences their biologic selection.

COPD Biologics and Specialty Pharmacy Support

Participants described a shift toward identifying eosinophilic COPD, including in patients with asthma-COPD overlap. In BOREAS and NOTUS, dupilumab reduced exacerbations and improved prebronchodilator FEV1 in patients with eosinophil counts of 300 cells/µL or higher, and in MATINEE, mepolizumab reduced moderate or severe exacerbations on top of triple therapy.2-4 Participants who commented on the data generally described the dupilumab trials as more robust, citing replication and secondary end points, while noting that insurer formularies largely determine which agent patients receive.

Participants said roflumilast and azithromycin remain more familiar to patients than biologics, and older patients on multiple injectables can be reluctant to add another. Participants with embedded specialty pharmacists said they handle benefit checks, prior authorizations, and follow-up, while a rural participant described a system pharmacy unwilling to manage injectables until approval is obtained. Some described using an AI-based clinical reference tool to draft appeal letters.

For unmet needs, participants cited better exacerbation predictors, faster diagnosis, biomarkers for patients below current eosinophil thresholds, and access to pulmonary rehabilitation, including virtual programs that Medicare Advantage plans may not cover. Hoy called for trial end points that capture health care use.

"I think if we could, as a secondary endpoint in a study, look at trips to the physician's office, trips to our office, trips to urgent care, calls to the office for the dreaded Friday afternoon prednisone, antibiotic, that would be huge, not only for the patient but for us," Hoy said.

References

1. Jackson DJ, Wechsler ME, Jackson DJ, et al. Twice-yearly depemokimab in severe asthma with an eosinophilic phenotype. N Engl J Med. 2024;391(24):2337-2349. doi:10.1056/NEJMoa2406673

2. Bhatt SP, Rabe KF, Hanania NA, et al. Dupilumab for COPD with type 2 inflammation indicated by eosinophil counts. N Engl J Med. 2023;389(3):205-214. doi:10.1056/NEJMoa2303951

3. Bhatt SP, Rabe KF, Hanania NA, et al. Dupilumab for COPD with blood eosinophil evidence of type 2 inflammation. N Engl J Med. 2024;390(24):2274-2283. doi:10.1056/NEJMoa2401304

4. Sciurba FC, Criner GJ, Christenson SA, et al. Mepolizumab to prevent exacerbations of COPD with an eosinophilic phenotype. N Engl J Med. 2025;392(17):1710-1720. doi:10.1056/NEJMoa2413181