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Dr William "Andy" Nish on When a Patient With Asthma Should Start a Biologic


William "Andy" Nish, MD, an allergist and immunologist at Northeast Georgia Physicians Group, discusses the factors that influence whether patients with asthma should be prescribed a biologic therapy.

William "Andy" Nish, MD, is a medical director and provider with a specialty in allergy and immunology at Northeast Georgia Physicians Group in Gainesville, Georgia.


What are some of the factors to consider when deciding whether to start a patient with asthma on a biologic?

Nish: Basically, biologics come into play when they're not doing well with other medicines, like maximal medical therapy. These days, maximum medical therapy would be double or combination medical therapy, like inhaled steroids with long-acting beta agonists, or even triple medical therapy, including anti-muscarinic or anticholinergic inhalers like Trelegy [fluticasone furoate, umeclidinium, and vilanterol]. So, we have 3 arrows of asthma treatment, if you will. Back in the day—and I'm dating myself when I say this—when I was training, we had theophen, albuterol, and steroids by mouth. Then, inhaled steroids came out and that was a huge advancement. And then, combination medicines came out when Advair [fluticasone propionate and salmeterol] came out and that was another huge advancement. Then, the biologics came out and gave us another treatment.

Whenever we have options like that, where we can treat people who otherwise weren't doing well, it's hard to serves as a tremendous advancement. Basically, it's based on the severity of their asthma. So, if they're doing well currently, for sure they don't need biologic. [But what] if they're not doing well in terms of severity and recurrent exacerbations? For instance, if they have 1 or more exacerbations and they go into the ER, they go into the acute care, or they're coming into the office acutely and/or they typically need steroids by mouth a couple times a year—that's not well controlled—if they can't sleep at night, if they can't exercise, if they're missing school, if they're missing work, those are all things that say that they're not well controlled.

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