Selecting Among Asthma Biologics<\/p>\n
Participants said comorbidities such as nasal polyps, atopy, eczema, and eosinophilic esophagitis often guide selection when several agents are appropriate, alongside dosing interval and patient preference. Several noted that insurer formularies increasingly determine which agent is started. At 1 participant’s center, an internal prescribing algorithm and a monthly case conference guide decisions for patients who have cycled through multiple biologics.<\/p>\n
Participants who use dupilumab frequently cited its use in steroid-dependent asthma, patients with elevated IgE, and its relative ease of approval. Another participant described avoiding dupilumab when eosinophil counts approach 1000 cells\/\u00b5L or when patients have autoimmune or inflammatory conditions such as psoriatic arthritis or sarcoidosis, citing case reports of immune shifts.<\/p>\n
Within the IL-5 class, some participants favored mepolizumab for its broad indications and the familiarity of its safety data, while others preferred benralizumab for more complete eosinophil depletion and every-8-week maintenance dosing. Participants who have prescribed depemokimab described using it for patients with severe eosinophilic asthma without major comorbidities who prefer twice-yearly dosing. Tezepelumab was described as an option for patients who do not meet biomarker thresholds for other agents, and mucus plugging data for both dupilumab and tezepelumab were reviewed, though most participants said plugging does not yet change their selection.<\/p>\n
Eosinophilic COPD and Biologic Escalation<\/p>\n
Khabbaza noted that an estimated 20% to 40% of patients with COPD have type 2 inflammation. In the BOREAS and NOTUS trials, dupilumab reduced exacerbations and improved prebronchodilator FEV1 in patients with eosinophil counts of 300 cells\/\u00b5L or higher despite triple therapy, and in MATINEE, mepolizumab reduced exacerbations with a safety profile similar to placebo.2-4 Before escalation, participants emphasized confirming inhaler adherence and addressing other drivers, including noninvasive ventilation for hypercapnic respiratory failure and endobronchial valves for hyperinflation.<\/p>\n
Some participants favored mepolizumab, citing its eligibility threshold of 150 cells\/\u00b5L, while others favored dupilumab for patients with chronic bronchitis, counts above 300 cells\/\u00b5L, or a priority on preserving FEV1. Khabbaza said dupilumab remains his first choice in COPD, though payer barriers have led him to start mepolizumab earlier in some patients. Participants described responses in COPD as more modest than in asthma, though 1 participant reported fewer hospitalizations after starting dupilumab and described both agents as well tolerated.<\/p>\n
For unmet needs, participants cited earlier identification of frequent exacerbators, better inhaler education resources, and therapies for patients without type 2 inflammation. <\/p>\n
“I think anything, less steroids, less hospital, and less symptoms are all going to be big victories,” Khabbaza said.<\/p>\n
ReferencesJackson DJ, Wechsler ME, Jackson DJ, et al. Twice-yearly depemokimab in severe asthma with an eosinophilic phenotype. N Engl J Med. 2024;391(24):2337-2349. doi:10.1056\/NEJMoa2406673Bhatt SP, Rabe KF, Hanania NA, et al. Dupilumab for COPD with type 2 inflammation indicated by eosinophil counts. N Engl J Med. 2023;389(3):205-214. doi:10.1056\/NEJMoa2303951Bhatt SP, Rabe KF, Hanania NA, et al. Dupilumab for COPD with blood eosinophil evidence of type 2 inflammation. N Engl J Med. 2024;390(24):2274-2283. doi:10.1056\/NEJMoa2401304Sciurba FC, Criner GJ, Christenson SA, et al. Mepolizumab to prevent exacerbations of COPD with an eosinophilic phenotype. N Engl J Med. 2025;392(17):1710-1720. doi:10.1056\/NEJMoa2413181 <\/p>\n","protected":false},"excerpt":{"rendered":"Selecting Among Asthma Biologics Participants said comorbidities such as nasal polyps, atopy, eczema, and eosinophilic esophagitis often guide…\n","protected":false},"author":2,"featured_media":631844,"comment_status":"","ping_status":"","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[10],"tags":[134,111,139,69],"class_list":["post-631843","post","type-post","status-publish","format-standard","has-post-thumbnail","category-health","tag-health","tag-new-zealand","tag-newzealand","tag-nz"],"_links":{"self":[{"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/posts\/631843","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/comments?post=631843"}],"version-history":[{"count":0,"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/posts\/631843\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/media\/631844"}],"wp:attachment":[{"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/media?parent=631843"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/categories?post=631843"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/tags?post=631843"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}