Today, we continue our review of the Global Initiative for Asthma (GINA) guidelines on asthma. We’ve covered asthma diagnosis and phenotyping, and the initial approach to therapy. On today’s episode we’re talking about biologic therapies for asthma and will cover everything from when to consider starting them, which to choose, and what to monitor for after a patient is started. To help us with this exciting topic we’re joined by an expert in the field. We again have a great infographic prepared along with the episode, and a boards-style question for your review.

 

Meet Our Guest

Megan Conroy is an Assistant Professor of Medicine at The Ohio State University, and is also the associate program director for curriculum and quality in the Pulmonary and Critical Care Medicine Fellowship. Megan’s clinical area of expertise involves asthma and biologic therapies and she was recently recognized for her work in this area as the 2024 CHEST Airway Disorders Network Rising Star Award. 

Meet Our Co-Hosts

Rupali Sood  grew up in Las Vegas, Nevada and made her way over to Baltimore for medical school at Johns Hopkins. She then completed her internal medicine residency training at Massachusetts General Hospital before returning back to Johns Hopkins, where she is currently a second year pulmonary and critical care medicine fellow alongside Tom. Rupali’s interests include interstitial lung disease, particularly as related to oncologic drugs. And she also loves bedside medical education.

Tom Di Vitantonio  is originally from New Jersey and attended medical school at Rutgers, New Jersey Medical School in Newark. He then completed his internal medicine residency at Weill Cornell, where he also served as a chief resident. He currently is a second year pulmonary and critical care medicine fellow at Johns Hopkins, and he’s passionate about caring for critically ill patients, how we approach the management of pulmonary embolism, and also about medical education of trainees to help them be more confident and patient centered in the care they have going forward.

 

Key Learning Points

Core Themes and Clinical Relevance

Biologic therapies represent a paradigm shift in managing severe asthma, especially those with type 2 inflammation.
Understanding how to select and monitor biologics is crucial for pulmonary fellows and practicing clinicians.Key Concepts and DefinitionDifficult-to-control asthma ≠ severe asthma:

• 
  
• ~20% of asthma patients have difficult-to-control asthma.
  
• Only ~5% have severe asthma after optimizing inhaler use, addressing comorbidities, and ensuring adherence.

Type 2 inflammation: Driven by eosinophils, IgE, IL-4, IL-5, IL-13, and TSLP. Markers include:

• 
  
• Elevated eosinophils (≥150/µL)
  
• High IgE
  
• High fractional exhaled nitric oxide (FeNO)

Choosing the Right BiologicClinical phenotype + biomarkers + comorbidities are used together.
Example considerations:

• 
  
• Nasal polyps, EoE, atopic dermatitis → Dupilumab
  
• Strong allergic sensitization → Omalizumab
  
• T2-low or mixed features → Tezepelumab

Consider patient lifestyle, needle aversion, travel, and insurance in decision-making.

Monitoring and Follow-Up

Reassess at 3 and 6 months:

• 
  
• Look for ≥50% reduction in exacerbations or steroid use
  
• Check spirometry, asthma control, and side effects

Special considerations:

• 
  
• Dupilumab → monitor eosinophils (risk of HES)
  
• Omalizumab → ensure access to epinephrine auto-injector

Special PopulationsPregnancy:

• 
  
• Limited data, but omalizumab has most evidence supporting safety.
  
• Expert consensus supports continuing or initiating biologics if benefits outweigh risks.

T2-low asthma:

• 
  
• Only Tezepelumab is indicated.

Clinical Pearls

Always reassess inhaler technique and adherence before escalating to biologics.
Shared decision-making is vital when choosing therapies.
Biologics take time—avoid early discontinuation without a full trial (4–6 months).
New biologics are on the horizon (e.g., ultra-long-acting anti-IL-5 agents).
Infographic

 

Boards Style Question

 

 

 

References:

Mauer Y, Taliercio RM. Managing adult asthma: The 2019 GINA guidelines. Cleve Clin J Med. 2020 Aug 31;87(9):569-575. doi: 10.3949/ccjm.87a.19136. PMID: 32868307.

Viswanathan RK, Busse WW. Biologic Therapy and Asthma. Semin Respir Crit Care Med. 2018 Feb;39(1):100-114. doi: 10.1055/s-0037-1606218. Epub 2018 Feb 10. PMID: 29427990.

Brusselle GG, Koppelman GH. Biologic Therapies for Severe Asthma. N Engl J Med. 2022 Jan 13;386(2):157-171. doi: 10.1056/NEJMra2032506. PMID: 35020986.