Optimizing Biologic Treatment Selection in Asthma

Raffi Tachdjian, MD, MPH, FAAAAI, FACAAI: Dr White, I’m going to give you a difficult question. How do you choose a biologic for a patient with severe asthma?

Andrew White, MD: That’s tough. It’s challenging. I’ll bet if you asked the others on the panel, you’d get slightly different answers. The beauty is that we have some great options. We’ve got some awesome tools. Our other specialties are probably a bit jealous of this crazy advancement that we’ve have. It’s a good problem to have. In terms of how we choose, the first step is thinking if the patient has evidence of type 2 inflammation. We’ve talked about that several ways. You can look at fractional exhaled nitric oxide, peripheral blood counts, and IgE level. All of those are biomarkers that help us predict patients who are going to have a good response. I start with that. Do they have type 2 inflammation? We have an option for treatment for patients who don’t have type 2 inflammation. That would be tezepelumab. One of the first branch points for me is thinking about tezepelumab in that situation.

Once we’ve looked at type 2 inflammation, I think a lot about the comorbidities. That’s come up a few times. Does the patient have nasal polyps? Do they have atopic dermatitis? Do they have allergic rhinitis? Those are all big factors because we have different expectations from the biologics or more evidence for their effectiveness. I’d definitely consider a patient who has comorbid nasal polyps, prioritizing 1 of the biologics that also has that indication. Think about a patient who has bad comorbid allergic rhinitis, who might consider putting on immunotherapy but you have a reason not to do it. That might be a good situation to consider omalizumab. Those are the main medical biomarker-driving factors that I think through.

The other part of the story is patient preference and their viewpoints on some of the options. These are all injectable medications with a slight variation of reslizumab, which is given intravenously. Patients are going to have thoughts about how often they want to self-administer. All these biologics we’ve talked about are given at different intervals: from every 2 weeks to every 4 weeks to even every 8 weeks. That can be a big factor that drives a patient’s preference. The final part of this is access. We need to pick something that the patient can afford and be able to use in the long term. These are intended for long-term use. That’s a big part of the decision, and we talk about this with the patient. That doesn’t happen during the first visit to the office, but we have to sort that out a little later. Those are the big factors that I put in. Every single time it’s a conversation the patient is part of. I don’t just order some lab tests and tell the patient that this is what I’ve decided to start them on.

Transcript edited for clarity