The Evolving Role of Biologics and TSLP Inhibition in Severe Asthma and Upper Airway Disease - Episode 10
Managing Both Upper and Lower Airway Diseases
Biologics have displaced a procedure that once filled the fellowship schedule. The panel weighs what replaced aspirin desensitization, and how sinus surgery rates changed with it.
This episode, "Both Upper and Lower Airway Diseases," features the panel on the patients they consider their sickest.
Dr. Chupp notes patients with both upper and lower disease can be the sickest, and asks Dr. Ross how aspirin desensitization fits in the biologic era. It has changed, she says. In fellowship it was weekly, done post-surgically, and cumbersome, requiring multiple consecutive days. Biologics now reduce mediators enough that a patient with cardiac risk factors may tolerate aspirin without exacerbating. She notes a partial revival: high prostaglandin D2 patients may respond well to desensitization. Still, once patients learn the alternative is lifelong high-dose aspirin with its own risks, they choose biologics.
Dr. Wechsler frames upper airway disease as one of the comorbidities that makes asthma difficult to control. He looks for it deliberately and treats both if he can, noting some therapies favor the upper airway, some the lower, and some work in both, which makes it a real decision point.
Dr. Hanania says his group stopped aspirin desensitization entirely, because the biologic literature is now convincing. Anti-IL-5, anti-TSLP, and anti-IL-4 all work in polyposis, and polyposis itself may predict better response to anti-IL-5. He co-manages with rhinologists and allergists, images with CT sinuses, and notes most patients who have surgery continue to have polyposis.
Dr. Chupp reports the same shift at his center, with a monthly ENT conference and review of surgical pathology for eosinophil levels, which guide agent choice alongside practical differences in dosing. The biggest impact, he says, has been a drop in sinonasal surgery. Dr. Ross adds that in her area ENTs now use biologics before surgery to reduce polyp burden and improve outcomes, and observes that as a solo allergist she lacks the multispecialty access her colleagues describe.
Up next, in " Biologics for Severe Asthma: Targets, Timing, and Outcomes," Dr. Wechsler lays out the full toolbox.
