Early Biologic Therapy in Asthma to Prevent Lung Function Decline

In "Early Biologic Therapy in Asthma to Prevent Lung Function Decline," our experts consider what is lost when biologic treatment is delayed.

Dr. Bernstein asks what is lost clinically when a biologic is delayed, or when a patient lives with severe asthma for years first. Dr. Wechsler explains that the goal is to identify patients who are exacerbating and losing lung function early. Airway inflammation, lung function decline, and exacerbations are closely intertwined.

He describes a self-reinforcing cycle. The more exacerbations a patient has, the lower lung function falls. The lower lung function falls, the greater the risk of further exacerbations.

His major goal is getting these therapies to patients early enough to prevent exacerbations, lung function deterioration, and potential airway remodeling. Clinicians, he says, should prevent the fires rather than put them out with steroids.

The patients at greatest risk usually have elevated biomarkers, such as higher blood eosinophil counts and exhaled nitric oxide levels. Those are the patients in whom early biologic therapy can prevent decline and remodeling.

Dr. Bernstein offers a scenario. A patient develops frequent exacerbations over a year and lacks control on inhaled corticosteroids plus a long-acting beta agonist. That, he suggests, is a patient to treat relatively early. Dr. Wechsler agrees and adds a second benefit: avoiding the side effects of steroid bursts used for exacerbations.

Dr. Mosnaim notes that biologics were once considered a last resort, reserved for when every other option was exhausted. Now clinicians aim to start them sooner.

She cites two reasons: the known harms of oral steroids and the lung function lost with every exacerbation. She highlights ongoing research comparing two strategies at the medium-dose inhaled corticosteroid plus long-acting beta agonist step. One adds a biologic, and the other increases the inhaled steroid dose.

While awaiting the data, she offers her personal view. She expects adding a biologic will prove safer and more effective than escalating inhaled steroids.

Up next, in "Addressing Patient Hesitancy Toward Biologic Therapy for Severe Asthma," Dr. Chupp explains how he approaches patients who are reluctant to begin injectable therapy.