Delayed Dupilumab Raises Asthma Costs 32%: Nicola Hanania, MD

Delaying dupilumab initiation beyond 90 days after a severe asthma exacerbation was linked to a 32% increase in predicted cumulative asthma-related medical costs by 1 year, according to a retrospective study presented at the European Respiratory Society (ERS) 2026 International Congress in Barcelona, Spain.¹

The study underscored the importance of early biologic initiation since delayed initiation remains common in practice and what the cost findings mean for clinical guidelines, Nicola Hanania, MD, associate professor of medicine in the section of pulmonary and critical care medicine and director of the American Lung Association Airways Clinical Research Center (ACRC) at Baylor College of Medicine, said in an interview with The American Journal of Managed Care^® (AJMC^®).

This transcript was lightly edited for clarity.

AJMC: Biologics like dupilumab have been available for severe asthma for several years now—why do you think delayed initiation after an exacerbation is still so common in real-world practice, despite existing evidence?

Hanania: It's true that we've had biologics in asthma for many years. Now we have 7 approved biologics in the US, but we still see delayed initiation in appropriate patients. This can be due to several reasons. One is the physician's perspective—thinking about whether this is a patient who deserves to be referred to an allergist or asthma specialist to be evaluated.

There is some delay from that, but also some delay from the health care system: getting approvals, cost reimbursement, and prior authorization. Sometimes patients may be hesitant to go on shots. They want to continue on the inhalers and wait and see what happens. So it's a multifactorial reason why there may be a delay.

AJMC: From a clinical guidelines perspective, do you think data like this should push professional societies toward more explicit recommendations on when to start a biologic relative to an exacerbation, rather than just whether to start one?

Hanania: I think that's something that in the guidelines and also strategies like GINA [Global Initiative for Asthma] and others, they don't specifically mention the timing of initiation—rather, they talk about who would qualify. Patients with recurrent exacerbations, who have an appropriate biomarker profile, who are already on inhaled steroids and long-acting bronchodilators, and who continue to exacerbate. But the exact timing as to when to start—within 10 days, 30 days, or 90 days of an exacerbation—is not spelled out.

I think studies like the one we've done—and obviously it's an observational study—we looked at a large cohort of severe asthmatics in the United States, and we looked at the index periods where they had a severe exacerbation. They were all prescribed biologics, specifically dupilumab in our study, within a year after an exacerbation, but we wanted to look at whether receiving it early, within 90 days of the severe exacerbation or index period, matters. Does it matter regarding health care utilization and cost? And we showed that, indeed, when you look at asthma-related costs, starting early has an advantage.

Obviously, this is an observational study, so there are some potential confounders. However, it really pushes us to think outside the box: if your patient is a candidate, why wait? Because waiting may actually be associated with poorer outcomes than starting early. Yes, we need more guidance. We need to change how we do it. And studies like this may reinforce the fact that we should have a timely initiation rather than just wait and see.

AJMC: Your data show a roughly 32% increase in predicted cumulative asthma-related medical costs by 365 days when dupilumab initiation is delayed—was that magnitude of economic impact surprising to you, or does it match what you'd expect clinically?

Hanania: It was surprising to me. Now, the costs did not include the biologic costs—I just want to make sure that the people who read the poster know that. We looked at health care–related costs, which were mostly driven by health care utilization in the clinic and urgent care and unscheduled visits, which we know are important direct costs for asthma. We didn't look at work-related loss of workdays or school days because we looked at patients who are 6 years of age and older, although the majority of our patients were adults. But these are important costs that were not factored into our calculation. We only looked at health care costs, and the dollar amount was, as you saw from the poster, higher in those patients who started dupilumab more than 90 days out, which we used arbitrarily as a cut-off.

It was surprising because you would expect that starting a biologic any time would cut down ER visits and urgent care visits, but it seems like in our analysis, at least, starting it early has an advantage.

AJMC: The timely and delayed cohorts differed somewhat at baseline (for example, in asthma severity distribution and insurance type), even after weighting. How confident are you that the outcome differences reflect timing of initiation rather than residual confounding from those baseline differences?

Hanania: There were mild differences that we tried to correct with a robust statistical approach, which is above my pay grade to explain in detail, but we had a good statistician working with us. We acknowledge this in the poster and in the manuscript we are writing right now—that there are confounders. Because of the observational nature of the study, we cannot rule out that there may be other confounders that contribute. We tried to correct as much as possible to have similar populations.

AJMC: Looking beyond dupilumab, do you think "time to biologic initiation after an exacerbation" is an outcome measure the field should be tracking more systematically across other severe asthma biologics as well?

Hanania: I think so. I think more and more real-world studies are going to be looking at this. It's hard to do in a clinical trial. I'm a clinical trialist, so we do lots of intervention studies with biologics, and usually we have two arms: patients who receive the drug and patients who receive a placebo.

In a clinical trial, it's hard to prospectively look at timely vs delayed, but in real-world studies, now that we have thousands of patients on biologics, we can go back and look, in a design like our study, at whether, in the real world, a delay is associated with a poorer outcome. I think it should be replicated with other biologics. I don't think this is only seen with dupilumab. This happens to be the drug we looked at because we had that Optum database, but it should be looked at with other biologics as well.

References

1. Hanania NA, DuCharme M, Shams M, et al. Asthma-related healthcare resource utilization and associated costs of timely versus delayed initiation of dupilumab following a severe asthma exacerbation. Presented at the ERS 2026 International Congress; September 5-9, 2026; Barcelona, Spain.