Asthma Biologic Adherence Shaped by Psychological, Clinical, Systemic Factors

A scoping review found that real-world adherence to biologic therapies in asthma is influenced by a combination of systemic barriers, clinical factors, and underrecognized psychological determinants.1

“This review highlights that adherence to biologic therapies in asthma is a multidimensional phenomenon that cannot be fully understood through a purely biomedical lens,” wrote study investigators Valentina Poletti, PhD candidate, and Eleonora Volpato, PhD, both from the Università Cattolica del Sacro Cuore in Italy. “While biologics have markedly improved the management of severe asthma, their effectiveness relies on sustained, long-term use, an aspect influenced by far more than pharmacological efficacy alone.”

In this review, investigators sought to answer the question: “What are the psychosocial and related factors that influence adherence to biologic therapies in patients with asthma?” The team conducted a methodical search of PubMed, Scopus, and APA PsycINFO of studies between April 1 and May 31, 2025, and included studies if they focused on patients with asthma undergoing biologic treatment and addressed adherence-related outcomes regarding psychosocial or behavioral factors. In total, the review included 12 studies, published between 2018 and 2015, with most conducted in the United States (70%).

Adherence rates to biologic therapies for moderate-to-severe asthma varied across studies. PDC was a common measure for treatment adherence, which assesses the percentage of days within a defined period during which the patient had access to the prescribed medication.

Many US-based retrospective studies reported good, albeit suboptimal, adherence levels. One study reported a median PDC of 87%; adherence varied among specific biologics, with dupilumab showing the lowest adherence.2 Another study reported a mean PDC of 0.76 during the first 6 months of treatment, with 61% of patients reaching a PDC ≥ 0.75; here, dupilumab showed the greatest adherence (98.15%), followed by reslizumab (92.04%) and omalizumab (71.89%).3

When examining all the studies, adherence ranged anywhere from 84.9% to 95%.1 One study did not report PDC values but highlighted low overall biologic utilization due to systemic, socioeconomic, and insurance-related issues. Another study reported that 29.8% of patients discontinued treatment due to perceived lack of efficacy.

The review identified perceived treatment benefit, disease control beliefs, and collaborative decision-making processes as facilitators of adherence. Individuals had poorer adherence if they did not experience symptom relief and if symptoms were under control without treatment. Conversely, individuals with frequent exacerbations, increased oral corticosteroid use, or recent asthma-related hospitalizations were more likely to adhere to biologics.

“These findings reinforce that the therapeutic relationship, communication quality, and patient involvement are not ancillary aspects of care but central determinants of long-term engagement,” investigators wrote.1 “Treatment settings perceived as supportive—whether in specialist clinics or structured home-care models—can further enhance adherence by reducing psychological and organizational burden.”

The study found that comorbid psychological conditions, especially depression, may diminish motivation to remain on treatment. This coincides with studies that have shown that the presence of depression is negatively associated with adherence to biologics.

Investigators noted that factors such as treatment-related anxiety (for example, needle phobia), illness denial, and stigma suggest that adherence is shaped by both medication-related concerns, such as long-term adverse events, and the emotional and symbolic meanings patients attach to biologic therapy. These influences are often unaddressed in asthma clinical care but can strongly affect treatment behavior.

“Together, these findings suggest that clinicians must go beyond the prescription,” investigators wrote.1 “Understanding how patients make sense of their illness, what meanings they assign to biologic therapies, and how they emotionally and cognitively respond to the idea of long-term treatment is essential. Adherence is not merely a matter of instruction and compliance—it is embedded in the patient’s subjective experience and day-to-day reality. Recognizing this dimension can help clinicians identify vulnerabilities, tailor interventions, and better support sustained engagement with biologic therapy.”

The team acknowledged several limitations, including restriction to peer-reviewed literature, a predominance of observational studies conducted in Western countries, heterogeneous definitions and measures of adherence, and the frequent assessment of psychosocial determinants as secondary outcomes, which limited quantitative synthesis.

“From a clinical standpoint, this scoping review calls for a paradigm shift in asthma care,” investigators concluded.1 “Beyond assessing biological eligibility (e.g., eosinophil counts, exacerbation history), it is crucial to evaluate psychological readiness, health beliefs, emotional distress, and contextual challenges.”

References

1. Poletti V, Volpato E. Psychological and Related Factors Influencing Adherence to Biologic Therapies in Asthma: A Scoping Review. Curr Allergy Asthma Rep. 2025;25(1):60. Published 2025 Dec 17. doi:10.1007/s11882-025-01242-5

2. Ledford D, Soong W, Carr W, Trevor J, LT-A of A. Real-world severe asthma biologic administration and adherence differs by biologic: CHRONICLE study results. 2023. Elsevier n.d.

3. Osazuwa-Peters O, Greiner M. AO-TJ of A. Factors related to biologic adherence and outcomes among moderate-to-severe asthma patients. 2022. Elsevier n.d.