Guideline offers recommendations on biologic management of severe asthma in adults

A clinical practice guideline offered seven evidence-based recommendations for choice of biologic agent in adult patients with severe asthma.

Characteristics such as quality-of-life impairment, baseline lung function, frequency of exacerbation, baseline oral corticosteroid use, asthma endotype, biomarkers, and comorbid conditions can guide the choice of biologic, according to the guideline. The American College of Chest Physicians developed the guideline, which was published Sept. 29 by CHEST.

Adult patients with moderate to severe allergic asthma and one or more exacerbations per year requiring oral corticosteroids should receive omalizumab or dupilumab (conditional recommendation, very low certainty of evidence), the guideline said. For patients with two or more exacerbations per year or any severe exacerbation requiring hospitalization, the panel suggested dupilumab over omalizumab (conditional recommendation, very low certainty of evidence). Patients with more severe impairments in quality of life and fewer than two exacerbations per year should receive omalizumab over dupilumab (conditional recommendation, very low certainty of evidence). For patients with a greater impairment in lung function (FEV_1<70% predicted), the panel suggested dupilumab over omalizumab (conditional recommendation, very low certainty of evidence).

Adult patients with severe asthma who depend on steroids should receive either anti-interleukin-5 receptor-alpha (IL5/5Rα) therapy or dupilumab (conditional recommendation, very low certainty of evidence). In cases where a patient's absolute eosinophil count is greater than 1,500 before oral corticosteroid dependency, a clinician may consider anti-IL5/5Rα due to the potential risk of hypereosinophilia with dupilumab.

When a patient has comorbid atopic dermatitis or eosinophilic esophagitis, physicians should consider dupilumab, and patients with chronic rhinosinusitis with nasal polyps may benefit from either dupilumab or mepolizumab, the statement said. Steroid dependency is one of the most pressing clinical problems in severe asthma, contributing significantly to morbidity over time, according to the guideline.

“Several biologics are effective and approved for clinical use for patients with poorly controlled severe asthma despite adhering to standard of care inhaled and oral therapies,” the guideline said. “Given that there are currently no comparative effectiveness studies, nor is there a validated, commonly agreed definition of clinical response, biological therapies can only be individualized in daily practice using indirect comparisons of data (delineated into conditional recommendations).”