Speaker's Highlight

• Don Sin University of British Columbia, St. Paul Hospital (Canada)
  Kenneth R. Chapman Toronto General Hospital Research Institute (Canada)
• Parameswaran Nair McMaster University (Canada)
  Carolyn Calfee UCSF (U.S.A.)
• Gregory P. Downey University of Colorado School of Medicine (U.S.A.)
  David A. Schwartz University of Colorado School of Medicine (U.S.A.)
• Neil Schluger Tuberculosis Control Branch, California Department of Public Health (U.S.A.)
  Nick Kim Critical Care & Sleep Medicine, University of California San Diego (U.S.A.)
• Nicola Hananiah Baylor College of Medicine (U.S.A.)
  Jae-Joon Yim Seoul National University College of Medicine (Republic of Korea)
• Koichiro Asano Tokai University School of Medicine (Japan)
  Diahn-Warng Perng Taipei Veterans General Hospital (Taiwan)
• Konstantinos Kostikas University of Ioannina (Greece)
  Karin Klooster University Medical Center Groningen (Kingdom of the Netherlands)

• Eosinophilic Asthma Phenotypes And Targeted Therapies

  Eosinophilic asthma is a form of type 2 airway inflammation in which eosinophils help drive swelling, mucus production and bronchial hyper-responsiveness. It can affect children or adults, and symptoms may remain poorly controlled even when inhaled corticosteroids are used correctly. Recognising this inflammatory pattern helps clinicians select treatment more precisely.

  The phenotype is identified through a combination of clinical history, exacerbation frequency, blood eosinophil counts, fractional exhaled nitric oxide (FeNO), allergy testing and, in selected cases, induced sputum. For Australians living in cities, regional centres or remote communities, diagnosis also needs to account for pollen seasons, smoke exposure, access to respiratory specialists and the practicalities of treatment funded through the PBS.

  Recognising The Eosinophilic Pattern

  Patients may report wheeze, chest tightness, cough and shortness of breath, often with flare-ups requiring oral corticosteroids. Some have adult-onset disease, chronic rhinosinusitis with nasal polyps, aspirin-exacerbated respiratory disease or a history of atopic conditions. Others have little obvious allergy but still show raised eosinophilic inflammation.

  A full blood count can provide a useful biomarker, although eosinophil levels vary over time. FeNO may support a type 2 inflammatory profile, while sputum eosinophils offer a more direct airway measurement when available. Recent steroid use, infection and seasonal exposures can alter results, so a single low reading does not always exclude eosinophilic disease.

  Why Phenotype Matters In Asthma Care

  Asthma severity and asthma phenotype are different concepts. A person may have severe symptoms because of poor inhaler technique, smoking, untreated reflux, obesity, occupational exposure or an incorrect diagnosis. Before escalating therapy, clinicians generally check adherence, inhaler use, comorbidities and lung function.

  Eosinophilic inflammation is clinically important because it is associated with a higher risk of exacerbations and corticosteroid dependence. It can also respond particularly well to medicines that block specific immune pathways. This approach is often called precision medicine or biomarker-guided asthma care.

  At a respiratory clinic in Melbourne or Sydney, assessment may involve spirometry, FeNO and blood tests, while a patient in regional Queensland or Western Australia may need coordinated testing through a GP and visiting specialist service. The core principles remain the same, but travel, appointment availability and pathology access can shape the care plan.

  Targeted Biologic Therapies

  Biologic medicines are injectable treatments designed for people with severe asthma that remains uncontrolled despite optimised standard therapy. Anti-interleukin-5 therapies, including mepolizumab and reslizumab, reduce eosinophil production or survival. Benralizumab targets the IL-5 receptor and produces rapid eosinophil depletion.

  Dupilumab blocks signalling through the IL-4 receptor alpha pathway, reducing type 2 inflammation and often helping people with coexisting nasal polyps or atopic dermatitis. Omalizumab targets immunoglobulin E and is generally considered when allergic sensitisation and other eligibility factors fit the clinical picture. Tezepelumab acts higher in the inflammatory pathway and may be considered across a broader range of severe asthma profiles.

  These medicines are add-on treatments, not replacements for preventer inhalers, trigger management or an asthma action plan. Choice depends on biomarkers, exacerbation history, comorbidities, dosing schedule, age, previous response and local reimbursement criteria. The APSR 2022 congress reflects the wider international focus on respiratory research, specialist collaboration and emerging treatment strategies.

  Comparing Treatment Pathways

  Treatment approach	Best suited to	Main benefits	Points to review
  Optimised inhaled therapy	Uncontrolled asthma from technique, adherence or insufficient preventer dose	Improves baseline control and remains foundational	Check device use, access, side effects and action plan
  Anti-IL-5 or anti-IL-5R biologic	Recurrent exacerbations with raised eosinophils	Can reduce flare-ups and oral steroid exposure	Biomarker thresholds and PBS eligibility may apply
  Anti-IL-4R biologic	Type 2 inflammation, especially with nasal polyps or dermatitis	May improve asthma and related upper-airway disease	Monitor eosinophils and injection reactions
  Anti-IgE biologic	Severe allergic asthma with qualifying IgE and sensitisation	Reduces allergic exacerbations for suitable patients	Dosing depends on weight and IgE range
  Broader upstream biologic	Severe asthma with persistent exacerbations and variable biomarkers	May help when conventional markers are inconsistent	Specialist assessment and long-term response review are essential

  Biomarkers support decision-making rather than replacing clinical judgement. A person with severe asthma may have mixed inflammatory features, and results can change after corticosteroid treatment. The most appropriate medicine is therefore the one that matches the overall pattern, not simply the highest laboratory value.

  Access And Delivery In Australia

  In Australia, biologic access commonly involves a respiratory physician, hospital-based severe asthma service or specialist clinic, with eligibility assessed against current Therapeutic Goods Administration and Pharmaceutical Benefits Scheme requirements. PBS rules can change, so clinicians and patients need to check current criteria rather than rely on older approval thresholds.

  Administration may occur in hospital, a specialist centre or, where appropriate, through an supported home-injection arrangement. Patients in Brisbane, Adelaide or Perth may have several service options, while people in the Northern Territory, rural New South Wales or remote parts of Australia may face longer travel distances. Telehealth can help with review, but pathology, spirometry and supervised administration still require local planning.

  Australia’s seasonal environment also matters. Grass pollen and thunderstorm asthma are especially relevant in Victoria, while bushfire smoke can worsen respiratory symptoms across the country. A biologic does not remove the need to reduce smoke exposure, manage allergic rhinitis and maintain an up-to-date written asthma action plan.

  Monitoring Response And Safety

  Treatment response is assessed over months rather than after one injection. Useful measures include exacerbation frequency, emergency presentations, courses of oral corticosteroids, lung function, symptom scores, reliever use, work or school attendance and the patient’s ability to exercise. A meaningful response may be fewer severe flare-ups even when daily symptoms improve only modestly.

  Clinical Checks That Matter

  • Confirm inhaler technique and preventer adherence
  • Record oral steroid courses and hospital visits
  • Review nasal polyps, eczema and allergic rhinitis
  • Repeat relevant biomarkers when treatment decisions require them

  Safety monitoring includes injection-site reactions, hypersensitivity symptoms and changes in eosinophil counts where clinically relevant. Vaccination status, parasitic infection risk and coexisting conditions should be considered before and during treatment. Patients should seek urgent care for severe breathing difficulty, rapid deterioration or poor response to their reliever.

  Signs The Plan Needs Review

  • Ongoing night waking or frequent reliever use
  • Two or more significant exacerbations in a year
  • Continuing oral steroid dependence
  • Reduced activity, work capacity or exercise tolerance

  A specialist may reassess the diagnosis, exposure history, adherence and biologic choice when improvement is limited. Some people need a different targeted pathway; others need treatment for vocal cord dysfunction, bronchiectasis, chronic sinus disease or another condition that resembles severe asthma.

  Building A Practical Long-Term Plan

  Effective care combines anti-inflammatory treatment with education and prevention. Patients should know which inhaler is the daily preventer, which is the reliever, how to use a spacer when prescribed and when to start their written action plan. Families, schools and workplaces may also need clear instructions, particularly for young people or those with previous rapid attacks.

  Shared decisions are important because injection frequency, travel to a clinic, needle concerns and medicine costs can influence persistence. In Australia, the plan may need to accommodate shift work, farming conditions, seasonal harvesting, bushfire periods or long journeys to a specialist. Reviewing goals in plain language makes it easier to judge whether a therapy is delivering meaningful value.

  The practical takeaway is to confirm the inflammatory pattern, optimise inhaled treatment, address triggers and comorbidities, then match persistent severe eosinophilic disease with a specialist-guided biologic pathway and regular outcome review.

  Richard Russell Nuffield Department of Clinical Medicine, University of Oxford (United Kingdom)
• Mona Bafadhel King’s College London (United Kingdom)
  David Jackson Guy’s and St Thomas’ Hospital, King’s College London (United Kingdom)
• James Chalmers University of Dundee (United Kingdom)
  David Price University of Aberdeen (United Kingdom)