Switching Biologic Treatment in Asthma

Raffi Tachdjian, MD, MPH, FAAAAI, FACAAI: Dr Chase, you’ve initiated therapy, and the patient is on this course for weeks, months, or years. Are there situations where you decide you need to switch biologics? If so, how do you determine that? How do you come to the conclusion of which therapeutic to change to?

Nicole Chase, MD, FAAP, FACAAI, FAAAAI: That’s a tough question. When I think about starting someone on a biologic, I try my best to set very clear treatment expectations so that the patient knows what they’re hoping to get out of this new treatment, and I know what I’m hoping that they’ll get out of this treatment. For many patients, the easiest ways to think about that would be to decrease exacerbations; improve ability to breathe better, in terms of FEV1 [forced expiratory volume in 1 second]; a reduction in systemic steroid use; and if they have activities of daily living that they may not have been able to do.

At any point, if a patient is on a biologic, I’ll often tell them, “I’m going to ask your insurance to cover this for a year, and then I’m going to ask you to give me anywhere between 3 to 6 months.” I try to decide on those numbers, not arbitrarily but by looking at the clinical trials to see when the initial end points were studied. For example, there are very good data with most of these respiratory biologics, except maybe omalizumab, that you’ll see improvement within the first, second, or third dose. I’ll often ask patients to agree to stay on the medication for at least 3 months and then reevaluate, in terms of not only how they’re feeling about their asthma and their symptoms but also how the treatment is going—injections and whatnot.

At any point, if a patient is on a biologic and it seems they’re starting to regress, I like to reevaluate. I ask “Are you taking the medication as prescribed? Has there been any confusion about it? Are you able to access the medication? What else is going on?” I almost revisit my initial diagnosis, asking, “Did you get a new pet in the house? Is there something else that doesn’t explain this? Have you started to smoke again?” Maybe the person had previously not been smoking. We revisit the whole endotype and phenotype of the patient, reassess, get biomarkers again, and then go through the same decision process. I like to treat to almost complete control.

If a patient could be on a biologic for their asthma with a short-acting bronchodilator before exertion, or let’s say they have something on hand that they could use for a severe illness, we’re all looking forward to seeing data about patients hopefully able to come off other medications. For now, patients stay on their inhaled therapies, but that should be our goal—knocking it out of the park in some sense. Picking the newest 1 is the same thing we’ve all been talking about. It’s about shared decision-making, the endotype, and the phenotype and then trying our best to see if we can match that up with a therapy that seems acceptable to the patient.

Raffi Tachdjian, MD, MPH, FAAAAI, FACAAI: I dig your high standards.

Nicole Chase, MD, FAAP, FACAAI, FAAAAI: Thanks.

Raffi Tachdjian, MD, MPH, FAAAAI, FACAAI: Dr Siri, are there scenarios or situations where you might combine the biologic with a corticosteroid or other therapeutics for that matter?

Dareen D. Siri, MD, FAAAAI, FACAAI: I’m going to remind you that these studies were done with standard-of-care therapy. If we’re talking about inhaled corticosteroids, those are always part of the baseline. Could we get to a different stage of the game at some point? As it stands, those are required because these are add-on treatments to the standard of care, which are inhaled corticosteroids.

As far as things like systemic steroids, in this era of corticosteroid stewardship, we’re trying to reduce the patient’s exposure to corticosteroids because we know how harmful multiple courses are. Even 2 exacerbations in a year can be to the entire body. In that respect, it was well illustrated, particularly by VOYAGE and VENTURE, which showed adolescents and children having corticosteroid-dependent asthma concurrently taking dupilumab and still having equal safety features. The most important is injection site reactions. There may be an increase in respiratory infections. But it’s largely well tolerated even when they were on systemic corticosteroids and reduce their level of systemic corticosteroids while having a reduction in asthma exacerbation rate. It’s not unreasonable to think a patient may be on both with the goal of reducing systemic corticosteroids and getting off them if possible. This was demonstrated in some of the clinical trials as with no increase in adverse outcomes when you have to use that. We have to take those particular patient factors into account.

Transcript edited for clarity