This case series highlights the need for a personalized, biomarker-driven approach when selecting biologic therapies for severe asthma. Patients with type 2 high-inflammation asthma (eg, elevated eosinophils, high Feno, atopy) benefit from targeted therapies, with choices influenced by factors such as pregnancy plans, comorbidities, and steroid dependence. For a young woman with allergic, early-onset asthma, omalizumab is preferred if pregnancy is imminent; otherwise, dupilumab or tezepelumab may offer broader benefits. For patients with type 2 low-inflammation asthma and ongoing exacerbations, tezepelumab is the recommended option. Adults with corticosteroid-dependent, type 2-high asthma and nasal polyposis are often best treated with dupilumab for its dual airway and sinus benefits.
Patients who lose response to an initial biologic, like mepolizumab, require reassessment of adherence, inflammation patterns, and biomarkers. Persistent airway eosinophilia and high Feno suggest the need to switch to a different pathway, such as targeting IL-4/IL-13 with dupilumab or epithelial alarmins with tezepelumab. Choosing a biologic also involves practical factors like dosing schedules, insurance, and patient preferences. Shared decision-making is critical, especially for women of childbearing age where balancing asthma control and pregnancy safety is vital. As biologic options expand, better research on switching strategies and pathway-specific therapies is needed.
Reference: Couillard S, Jackson DJ, Pavord ID, et al. Choosing the Right Biologic for the Right Patient With Severe Asthma. Chest. 2025 Feb;167(2):330-342. doi: 10.1016/j.chest.2024.08.045. Epub 2024 Sep 6. PMID: 39245321; PMCID: PMC11867899.
