Redefining Severe Airway Disease Care: Clinicians Weigh In on Biologics and Barriers

Over the past decade, the management of asthma and chronic obstructive pulmonary disease (COPD) has undergone a remarkable evolution, moving beyond broad anti-inflammatory and bronchodilator approaches toward targeted biologic therapies that address the root drivers of airway inflammation. Once limited to inhaled corticosteroids and long-acting bronchodilators, the therapeutic arsenal now includes a spectrum of monoclonal antibodies directed at type 2 inflammatory pathways—transforming outcomes for patients once resigned to frequent exacerbations and chronic steroid use. Approvals of agents such as dupilumab (Dupixent), tezepelumab (Tezspire), benralizumab (Fasenra), and mepolizumab (Nucala) have broadened the definition of treatable asthma, offering precision approaches that not only control symptoms but also reduce exacerbation rates and hospitalizations in previously refractory populations.1,2

At the same time, growing evidence for biologics in select COPD populations is reshaping conventional views of airway disease as distinct silos, emphasizing overlapping inflammatory mechanisms and shared therapeutic potential. Clinicians are increasingly focused on early identification of candidate patients, the integration of biomarkers like eosinophil counts and IgE, and real-world strategies for overcoming insurance and logistical barriers to care.

At a recent clinical forum convened by HCPLive in Chicago, Illinois, a group of pulmonologists, led by Joseph Khabbaza, MD, pulmonary and critical care physician at the Cleveland Clinic and a director of the non-cystic fibrosis bronchiectasis program, discussed the changing treatment landscape of severe airway disease, the clinical nuances of biologic selection, and how these advances are redefining what it means to achieve control in severe asthma and COPD.

"I think like wording is very important to patients for them to accept things. So I stopped using the word biologic because some people take that word and it's like I'm messing with their biology because I'm giving them biologic treatment. And I started [saying to] the patients I'm giving you targeted therapy. Like we gave you like the blanket therapy where you're getting the inhaled steroids. We suppressed on all inflammation and that's not enough. You're still having a lot of inflammation and we are going to use more targeted therapy so that we're blocking certain pathways that's [causing] your asthma. And I think the word targeted therapy has been more successful in my patients than using biologic," one participant said, advising on how to talk to patients about initiating biologic therapy.

Khabbaza and colleagues discussed barriers to precision therapy and guiding biomarkers, such as local lab practices, insurance requirements, and timing of tests. They concurred on using dupilumab as the preferred starting biologic due to its strong applicability, ease of home use, and strong efficacy; other biologics are chosen based on phenotype or coverage.

"[With targeted therapy] you're not just targeting their asthma. Most of these people have nasal polyps, they have allergic rhinitis, they have eczema. It's part of this prodrome. And then when you give them inhaled steroids, you're targeting their airways, but they're still suffering. And when they come back after targeted therapy, they come back and say, my eczema's much better. I don't have the itchy eyes and the crusting around my eyes anymore and I can breathe much better with my nose because a lot of these biologics are also been approved for nasal polyposis. It's a systemic disease and with these biologics, you're treating a systemic disease systemically versus locally with asthma inhalers," another participant said, stressing the multifaceted benefits of targeted therapy.

They also emphasized patient treatment goals that focus on reducing exacerbations, minimizing systemic steroid use, and improving daily quality of life. In general, they also praised the long-term safety and efficacy data seen in multiple extension studies. Lastly, they looked forward to a future of potentially ultra-long-acting drugs like depemokimab or combination therapies that can further personalize care.

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.