Selection of biologic agents for treatment of oral glucocorticoid-dependent severe asthma in adolescents and adults

GCs: glucocorticoids; IgE: immunoglobulin E; IL: interleukin; ICS: inhaled glucocorticoid (aka inhaled corticosteroid); LABA: long-acting beta-agonist; LAMA: long-acting muscarinic antagonist; FeNO: fraction of exhaled nitric oxide; EGPA: eosinophilic granulomatosis with polyangiitis; ABPA: allergic bronchopulmonary aspergillosis; BEC: blood eosinophil count; BMI: body mass index.

* Severe poorly controlled asthma includes both of the following: 1) Demonstrated variable airflow limitation based on historical or current spirometry or bronchoprovocation testing without an alternative explanation and 2) Frequent symptoms (eg, cough, wheezing, or dyspnea more than twice a week, activity limitation, night-time wakening) AND/OR frequent exacerbations (≥1 hospitalization or ≥2 exacerbations requiring systemic glucocorticoids per year) despite optimized inhaled therapies including high-dose ICS + LABA. Appropriate use of an asthma action plan, avoidance of environmental and medication triggers, and assessment and mitigation of common comorbidities (including potential helminthic infection) should be performed prior to initiating biologic therapy. Please refer to UpToDate content on severe asthma management for further discussion.

¶ Glucocorticoids can mask elevations in eosinophils, FeNO, and IgE. In patients taking oral glucocorticoids at the time of evaluation, historical lab data can be used to inform biologic selection. A taper of oral glucocorticoids followed by testing when symptoms manifest is appropriate in those without previous asthma phenotyping or oral glucocorticoid use for more than 24 months.

Δ BEC and FeNO thresholds are not absolute, but are used to indicate a predominant signal. They have not been fully established in the literature and should be used along with clinical judgment. Patient response to biologics should be considered along a similar continuum.