Biologic Decision-Making in Asthma and COPD: Prioritizing Earlier, Precise Intervention

In recent years, respiratory medicine has entered a period of unprecedented progress, reshaping the way clinicians approach asthma and chronic obstructive pulmonary disease (COPD). Once dominated by generalized treatment strategies built around inhaled therapies, the field now prioritizes individualized care informed by disease phenotype, biomarker profiling, and a deeper understanding of airway inflammation. These shifts are not only expanding the treatment toolbox—they're fundamentally altering what long-term disease control looks like for patients who were once considered difficult to treat.

Biologic therapies have been central to this shift in asthma care. Approvals for agents such as dupilumab (Dupixent), benralizumab (Fasenra), and tezepelumab (Tezspire) have introduced new standards for what constitutes effective intervention. With tezepelumab’s 2021 approval breaking ground as the first biologic for severe asthma that is not limited by eosinophil count, clinicians now have broader options for tailoring treatment to individual patient profiles.1 These advances are also strengthening the collaboration between allergists and pulmonologists, as early identification of eligible patients becomes critical to optimizing outcomes and minimizing steroid exposure.

COPD, long seen as a more rigid disease to manage, is beginning to see similar innovation. The 2024 FDA approval of dupilumab for eosinophilic COPD marked a milestone in biologic therapy for this population, offering a targeted option in a space previously reliant on symptom-driven management.2 With new insights into inflammatory endotypes and the boundaries between asthma and COPD continuing to blur, clinicians face a growing need to reevaluate traditional treatment pathways.

To discuss these developments and their impact on clinical practice, HCPLive brought together a panel of pulmonologists and allergists for a clinical forum centered on the updates in respiratory care, led by pulmonologist Joseph Khabbaza, MD, of Cleveland Clinic.

The panelists discussed how biologics have become central to modern asthma management, especially in patients with type 2 inflammation. Supporting this shift, understanding and application of biomarkers like eosinophils and FeNO has grown substantially.

Another shift within the application of biologics is that pulmonologists increasingly manage biologics directly, with less reliance on allergists, as familiarity and comfort with these therapies increase. There’s also been a shift toward earlier initiation of biologics to reduce cumulative steroid burden and prevent long-term adverse outcomes, although this can be complicated by payer criteria.

“I've been more aggressive with, if my patient needs steroids more than twice in 6 months or so, I'm pulling the trigger faster and faster, even without long-acting muscarinic antagonist (LAMA), just because I first-hand know the major long-term side effects of steroids 10 years, 15 years down the road,” one participant said. “I'm not going to try and let anybody go through that. And I've been very quick with pulling the triggers on biologics in that sense.”

COPD management is beginning to adopt similar principles, with recognition that a subset of patients with type 2 inflammation may benefit from biologics. Of course, work remains to be done, with panelists pointing out longer-acting biologics, better phenotyping, and broader definitions of eligibility, particularly in the COPD population, as particular points to improve.

“Asthma and COPD have evolved over the last few years and with a lot of thinking about eosinophils and type 2 inflammation, and we now have more pathways and more treatments than ever before to try to help these patients. And we want to minimize prednisone, and minimize exacerbation. I think those are- If we can do those two things in asthma and COPD patients, that'll be good for everyone in the system,” Khabbaza closed the discussion.

REFERENCES

1. FDA Approves Tezspire™ (Tezepelumab-ekko) in the U.S. for Severe Asthma. News release. Amgen. December 17, 2021. https://www.amgen.com/newsroom/press-releases/2021/12/fda-approves-tezspire-tezepelumabekko-in-the-us-for-severe-asthma

2. Dupixent® (dupilumab) Approved in the U.S. as the First-ever Biologic Medicine for Patients with COPD. Regeneron Pharmaceuticals, Inc. September 27, 2024. https://www.globenewswire.com/news-release/2024/09/27/2954552/0/en/Dupixent-dupilumab-Approved-in-the-U-S-as-the-First-ever-Biologic-Medicine-for-Patients-with-COPD.html.