Biologics in severe asthma: A pragmatic approach for choosing the right treatment for the right patient - 31/10/23

Doi : 10.1016/j.rmed.2023.107414

Linda Rogers ^a,^⁎ , Milos Jesenak ^b, Leif Bjermer ^c, Nicola A. Hanania ^d, Sven F. Seys ^e, Zuzana Diamant ^f,^g,^h,ⁱ
^a Mount Sinai National Jewish Health Respiratory Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
^b Department of Pediatrics, Department of Pulmonology and Phthisiology, Department of Allergology and Clinical Immunology, Jessenius Faculty of Medicine, Comenius University in Bratislava, University Teaching Hospital in Martin, Martin, Slovakia
^c Department of Respiratory Medicine and Allergology, Lund University, Lund, Sweden
^d Section of Pulmonary /Critical Care/Sleep Medicine, Baylor College of Medicine, Houston, TX, USA
^e Galenus Health, Hasselt, Belgium
^f Department Clin Pharm & Pharmacol, Univ Groningen, Univ Med Ctr Groningen, Groningen, Netherlands
^g Department of Microbiology Immunology & Transplantation, KU Leuven, Catholic University of Leuven, Belgium
^h Department of Respiratory Medicine, First Faculty of Medicine, Charles University and Thomayer Hospital, Prague, Czech Republic
ⁱ Department of Respiratory Medicine & Allergology, Institute for Clinical Science, Skane University Hospital, Lund University, Lund, Sweden

^∗Corresponding author.

Abstract

The development of monoclonal antibody therapies targeting specific components of the pathways relevant to asthma pathophysiology has revolutionized treatment of severe asthma both in adults and children and helped to further unravel the heterogeneity of this disease. However, the availability of multiple agents, often with overlapping eligibility criteria, creates a need for pragmatic guidance for specialists undertaking care of patients with severe asthma. In this review, we provide an overview of the data supporting the clinical efficacy of biologics in distinct asthma phenotypes/endotypes. We also focus on the role of biomarkers and treatable traits, including comorbidities, in the choice of asthma biologics, highlight which treatments have been demonstrated to be steroid sparing in corticosteroid dependent asthma, and provide practical guidance that can drive shared decision making on treatment choice with patients. In addition, we summarize what is known to date regarding long-term safety of these drugs, and lastly, discuss future directions in biologics research.

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Highlights

•	Biologics may be indicated for select patients with asthma uncontrolled on GINA Step 4–5 therapy.
•	Levels of FeNO, IgE, and eosinophils can identify presence or absence of T2 inflammation and guide selection of biologics.
•	Prior to prescribing biologics, adherence to therapy, correct inhaler technique, and related comorbidities should be addressed.
•	Factors such as comorbidities, patient preferences, and payor-related factors often guide selection of biologics.
•	Several expert panels have proposed definitions of clinical disease remission in asthma; harmonization is required.