Steroid Stewardship in Severe Airway Disease: The Case for Earlier Biologic Escalation

The therapeutic revolution in severe asthma has not arrived evenly across care settings. While academic pulmonologists have been prescribing IL-5 antagonists and IL-4/IL-13 blockers for nearly a decade, the translation of that expertise into primary care, advanced practice, and multi-specialty clinical teams has lagged — shaped by differing prescribing privileges, patient populations, payer dynamics, and familiarity with rapidly evolving evidence. That translation gap matters enormously, because primary care and advanced practice providers represent the front line where severe asthma and chronic obstructive pulmonary disease (COPD) are most often first encountered, undertreated, and repeatedly managed with the short-term tool that remains most dangerous in the aggregate: oral corticosteroids (OCS).

The approval of mepolizumab in 2015 established the first durable eosinophil-targeting option for severe asthma, followed by dupilumab's landmark FDA approvals — first for atopic dermatitis, then asthma in 2018, and most significantly for COPD in 2023, the first biologic ever cleared for that indication.1,2 These milestones have changed what is pharmacologically possible; the harder task is ensuring that the right providers, across the full breadth of clinical practice, know when and how to deploy them.

To further explore potential gaps in care, HCPLive convened a clinical forum discussing the evolving landscape of targeted therapy in asthma and COPD, moderated by Alanna Kavanaugh, MSN, BSN, CCRN, Assistant Dean of Graduate Nursing and Chair of the Family Nurse Practitioner Program, College of Mount Saint Vincent, and attended by a diverse group of nurse practitioners, advanced practice providers, and clinical educators from institutions including Weill Cornell, Stanford, Mount Sinai's World Trade Center Health Program, and a range of primary care and integrative practices across the Northeast. The forum touched on a number of subjects, particularly the cumulative harm of OCS use, the practicalities of biologic selection, and the growing need for structured steroid stewardship in outpatient practice.3

The discussion arrived at a moment when the biologic toolbox has never been more full. Dupilumab's long-term data continues to accumulate across asthma, nasal polyps, and now COPD; tezepelumab has established itself as the agent for biomarker-negative severe asthma; and the December 2024 approval of depemokimab — a 6-month IL-5 agent — has introduced a dosing interval that could meaningfully change the adherence calculus for certain patient populations.4 At the same time, GOLD 2026 guidelines have stiffened COPD escalation criteria, removing prior tolerance for a single moderate-to-severe exacerbation and pushing the field toward earlier biologic consideration.5 The forum's participants reviewed clinical trial data, debated real-world prescribing strategies, and shared cases that illustrated both the transformative potential of these therapies and the persistent systemic barriers — insurance, infrastructure, patient reluctance, and incomplete provider awareness — that continue to leave eligible patients undertreated.

The forum's most viscerally impactful discussion centered not on biologic selection but on what precedes it: the cumulative harm of oral corticosteroids and the lack of systematic infrastructure to track it. Maureen George, PhD, AE-C, RN, Columbia School of Nursing’s framing of lifetime milligram thresholds — 500 mg as a caution zone, 1,000 mg as a serious-risk threshold reachable in as few as three high-dose courses — was new information for several primary care panelists, some of whom acknowledged they had not previously thought in cumulative terms. Panelists proposed a dedicated OCS tracking system analogous to New York's I-STOP narcotics registry, and the concept of "steroid stewardship" resonated broadly.

“First of all, when you're getting a lot of prednisone, looking at the anxiety and the other type of dysregulation that takes place I think we need to be looking that here and seeing if a person responds in that way as well. I know it's not something that people usually talk about because we're so busy looking at the biomarkers because we want to get rid of the disease, but there is a relationship that exists between the dysregulation and the disease,” one participant said.

The group reviewed the full approved biologic landscape for asthma — dupilumab, mepolizumab, benralizumab, omalizumab, tezepelumab, and depemokimab — with dupilumab generating the most vivid clinical anecdotes, including a patient who regained their sense of smell after 20 years and another whose externally visible nasal polyps resolved within 4 to 6 months. Tezepelumab drew attention for its efficacy in biomarker-negative patients, with 1 panelist describing an oxygen-dependent patient who came off daytime oxygen entirely after starting the drug. Depemokimab's 6-month dosing was discussed primarily through the lens of adherence — specifically for college students, travelers, elderly patients, and those with logistical barriers to frequent injections.

In COPD, the conversation reflected both growing momentum and persistent uncertainty. The GOLD 2026 update — which now places any single moderate-to-severe exacerbation into Group E, eliminating prior tolerance — was highlighted as a meaningful escalation of urgency, and several panelists noted they are actively working to capture eligible patients before exacerbations compound. Dupilumab remained the preferred COPD biologic based on stronger FEV1 improvement data from BOREAS and NOTUS; mepolizumab's lower EOS threshold of 150 was noted as potentially useful in borderline patients, though FEV1 gains were comparatively modest. The forum's final polling question found that clinical workflow tools and training — followed closely by clearer patient selection algorithms — were the resources practitioners most needed to prescribe COPD biologics with confidence.

Closing takeaways revealed an appetite for expanded scope: attendees raised questions about biologics in cystic fibrosis, the potential for probiotic/prebiotic co-therapy to reduce the immune suppression side effects of biologics, and the urgent need for long-term lung function trajectory data. For many in the room, the night's most durable lesson was simpler: far too many patients who would benefit from these therapies are still receiving repeat prednisone instead.

References

1. Eger K, Hashimoto S, Braunstahl GJ, et al. Mepolizumab for eosinophilic COPD with exacerbations (MATINEE). N Engl J Med. 2024;391(1):21-31. doi:10.1056/NEJMoa2401300

2. Bhatt SP, Rabe KF, Hanania NA, et al; NOTUS Investigators. Dupilumab for COPD with type 2 inflammation. N Engl J Med. 2024;390(24):2275-2283. doi:10.1056/NEJMoa2401304

3. Price DB, Trudo F, Voorham J, et al. Adverse outcomes from initiation of systemic corticosteroids for asthma: long-term observational study. J Asthma Allergy. 2018;11:193-204. doi:10.2147/JAA.S176026

4. Wechsler ME, Menzies-Gow A, Brightling CE, et al. Evaluation of the efficacy and safety of depemokimab in patients with severe asthma with an eosinophilic phenotype (SWIFT-1 and SWIFT-2). Lancet. 2024;404(10471):2373-2385. doi:10.1016/S0140-6736(24)02063-4

5. Global Initiative for Chronic Obstructive Lung Disease. Global Strategy for Prevention, Diagnosis and Management of COPD: 2026 Report. GOLD; 2025. Accessed March 11, 2026. https://goldcopd.org/2025-gold-report/