Biologics for Asthma and COPD: What Providers Need to Know

Biologics can offer a targeted approach to managing patients with asthma and COPD whose exacerbations are not controlled by inhalers and nebulizers. But stratifying these patients to make sure they’re matched to the right therapy is key, says Cleveland Clinic pulmonologist Vickram Tejwani, MD.

“These medications are developing rapidly in terms of overlapping and distinct mechanisms,” he says. “As they become more available, and awareness surrounding them increases, we hope that they’re deployed correctly.”

The overlap between asthma and COPD has been discussed for decades, and approaches to managing patients with both conditions continue to evolve, he notes.

Biologics have been used for asthma since the early 2000s, but have only been approved for COPD since 2024.

“It’s a rapidly moving field,” Dr. Tejwani says. “Reviews written three years ago are already dated.”

In addition, patients with asthma and COPD are frequently managed in internal medicine settings, making it especially important for primary care providers to be aware of additional therapeutic options for their patients.

Don’t overlook exacerbations

The most important takeaway is to take exacerbations seriously.

“Often a patient will get referred to me, and they’ll say, ‘My asthma or COPD is mild — I only take prednisone and have three exacerbations a year,’” Dr. Tejwani explains. “But that’s actually very bad in terms of lung function.”

Patients who are having exacerbations despite standard-of-care inhaled corticosteroids and bronchodilators should be considered for biologics. “That’s really where biologics are most effective — in reducing exacerbations,” he says. He adds that for patients who meet other criteria for asthma and COPD but aren’t exacerbating, biologics do not yet have evidence to support their use.

Of six biologic medications approved for asthma, two are currently also approved for COPD.

Dr. Tejwani outlines three main types of medications. These include an anti-IgE therapy, omalizumab, which is recommended for patients with classic allergic asthma. The second group, including mepolizumab, reslizumab, benralizumab and dupilumab, target various eosinophil-activating cytokines. These drugs are a fit for patients with eosinophilic asthma or COPD. Finally, tezepelumab, is a newer anti-TSLP therapy targeting inflammatory signals further upstream, which can be considered independent of eosinophil or IgE levels.

The importance of phenotyping patients

Dr. Tejwani reiterates that selecting the right medication is key.

“You really need to phenotype these patients,” he explains. “That means looking at eosinophil counts, exhaled nitric oxide and IgE, which all can help determine what type of biologic to use.”

Beyond biomarkers, symptoms can also help guide treatment. For patients with allergic asthma with exacerbations who also have atopic eczema or sinusitis disease with polyps, biologic therapy can provide significant relief, while also improving lung function, he notes.

“It will not only treat the airway disease, but some of these other manifestations of their allergies or eosinophil-mediated disease as well,” he says.

Other considerations for managing patients with asthma and COPD include reviewing current medications and making sure patients are on appropriate inhaler and nebulizer treatments before turning to biologics. That means evaluating not just the medicines themselves, but also the mechanism of delivery, he adds. For example, make sure that patients with arthritis in their hands can manage the inhaler they’ve been given.

Providers should also double-check diagnoses before starting biologics.

“These conditions are so common that patients often get the label added to their chart, and it’s not actually what they have,” Dr. Tejwani says. “So, you want to ensure that you’ve adequately looked at other possibilities for their symptoms and you’re confident that asthma or COPD really are what’s driving their disease.”

More Changes to Come

Dr. Tejwani anticipates even more advances in the field of asthma and COPD biologic medications in the years to come.

Studies are underway to evaluate using some asthma drugs in COPD patients; COPD-only biologics targeting different pathways, such as IL-33, are also in development. And while biologics aren’t yet approved for treating acute exacerbations, early evidence from studies testing them in emergency department settings is encouraging, he says.