Shifting the Treatment Paradigm of Severe Asthma With Novel Biologics - Episode 9

Initiating Biologics in Patients With Severe Asthma

July 11, 2021
Reynold Panettieri, Jr, MD, Robert Wood Johnson Medical School

Sidney Braman, MD, Icahn School of Medicine

Geoffrey Chupp, MD, Yale School of Medicine

Nicola Hanania, MD, MS, Baylor College of Medicine

Experts in severe asthma treatment and management provide their experience with biologics and when to initiate them in patients.

Reynold Panettieri Jr, MD: Let’s move on. I’m going to ask each of you: How do you decide to go with a biologic? In my practice, I’m interested in using these sooner if I can—if the patient has severe asthma and insurance will reimburse. I’m just railed by precision medicine. I’m going to ask each of you just to sum up this part. Sid, what’s your feeling? When do you go to it?

Sidney Braman, MD: You know something? You know when you know. You see this patient. You’ve had a tough time with that patient: they’ve been in the emergency department a few times. They’re at maximum. They’ve been on and off corticosteroids over the last year. He or she is fed up. You’re exasperated. That’s the time to step up. You’ve tried the LAMAs [long-acting muscarinic antagonists], and you’ve tried maximizing their inhaler corticosteroid [ICS]. That’s the patient you need. I don’t even look at their lung function, which I know is going to be poor. That’s not going to be a determining factor. It’s really more about symptoms and these recurrent exacerbations.

Reynold Panettieri Jr, MD: Let’s be honest. If the patient doesn’t feel better, he or she is not likely to continue to adhere to treatment. There has to be a level of a patient-reported outcome measure in which they feel better, because I can impress them by saying, “Look how much your FEV1 [forced expiratory volume in 1 second] has improved.” But at the end of the day, if they can’t walk, can’t do things with their family, and can’t have a good quality of life, then they’re not going to adhere. Nic, when do you go to a biologic?

Nicola Hanania, MD, MS: Sidney summarized it very nicely. These are the patients for whom I definitely push for a biologic. Your question of whether we should start it early is a good 1. Not only a good 1, but it’s an intriguing 1 that we need to answer. If biologics are so good for blocking inflammation in the airway, then why wait till they have exacerbation? Why not start it earlier? Can biologics affect the natural history of the disease? We don’t know these answers. These need to be studied in large-population, long-term studies. But eventually, we may get to a point where biologics can be used earlier in the disease—if that’s the case. We know that there are some areas that may suggest that biologics may have an adverse effect on declining lung function, for example, with dupilumab [Dupixent]. We know they reduce exacerbation, so can they actually affect the natural history of asthma? We don’t know. There are some hints, and it may encourage us to use it early. Right now, I use it mostly in those patients with exacerbations who fail to respond to the usual therapy—medium to high-dose ICS, plus anyone else controller—who are adherent, and whose comorbidities have been well managed, at least as much as I can.

Reynold Panettieri Jr, MD: Great. Geoff, you have the last moment here: In summary for when you use a biologic. I use the imagery, “It’s like voting in Philadelphia, where we vote frequently, and we vote early.” Geoff, what do you think about biologics?

Geoffrey Chupp, MD: Well, I’m not going to add too much to my esteemed colleagues’ comments here, because they’ve captured it well. But 1 of the things that’s important is where our patients come from and the referral source, because my timing of initiation will change depending on whom the patient is referred from—a pulmonologist, an allergist, a specialist who has been trying to manage their disease, or somebody who really has not been properly phenotyped and followed over time—so we understand whether there are major comorbidities and things like that contributing to their disease. I believe the strongest threshold these days for initiating a biologic is probably anyone who’s flaring more than 1 a year chronically and has persistently poor control, despite maximal doses of inhaled therapies and treatment of any comorbidities. These are our standard thresholds. I totally agree that we really should be pushing the envelope toward more moderate patients who are still exposed to systemic steroids once a year, because our goal should be to have a steroid-free, systemic population of patients with asthma.

Reynold Panettieri Jr, MD: That’s fantastic. Thank you. This was a vibrant conversation about very important issues in targeted biologic therapy.

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Transcript Edited for Clarity