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)

• The promise of biologic therapies for severe asthma

  Severe asthma remains one of the most demanding conditions in respiratory medicine. Even with high-dose inhaled corticosteroids, long-acting bronchodilators, and careful adherence support, some patients experience frequent exacerbations, persistent symptoms, airflow limitation, and substantial treatment-related burdens. Their disease can disrupt sleep, employment, education, and daily activity while increasing the risk of emergency care and hospitalization.

  Biologic therapies have changed the outlook for many of these patients. By targeting specific immune pathways involved in type 2 inflammation, newer treatments can reduce asthma attacks, lower the need for oral corticosteroids, and improve disease control. Their promise lies in moving care beyond repeated rescue treatment toward a more precise understanding of each patient’s biology.

  For respiratory specialists, the central issue is patient selection. Biomarkers, clinical history, comorbidities, previous treatment response, and practical access all influence whether a biologic is appropriate. The evolving evidence base makes multidisciplinary discussion and continuing education especially valuable for clinicians working across the APSR and KATRD communities.

  Why severe asthma needs targeted treatment

  Severe asthma is diagnosed after confirming that symptoms are truly caused by asthma and remain uncontrolled despite optimized standard therapy. Poor inhaler technique, inconsistent adherence, smoking exposure, untreated rhinitis, gastroesophageal reflux, obesity, and occupational triggers can all mimic treatment resistance. Addressing these factors is essential before escalating to advanced therapies.

  Among patients with genuinely severe disease, inflammation may be driven by different pathways. Type 2-high asthma is commonly associated with eosinophilia, elevated fractional exhaled nitric oxide, allergic sensitization, or increased immunoglobulin E. Other patients have less obvious biomarker signals and may require a broader assessment of exacerbation history and treatment dependence.

  How biologics alter the treatment pathway

  Biologic medicines are designed to interrupt specific molecular signals. Anti-IgE treatment can reduce allergic activation, while anti-IL-5 and anti-IL-5 receptor therapies reduce eosinophil development, survival, or activity. Dupilumab blocks signaling linked to interleukin-4 and interleukin-13, and tezepelumab targets thymic stromal lymphopoietin, an upstream epithelial cytokine.

  Clinical trials have shown meaningful reductions in severe exacerbations for appropriately selected patients. Some people also achieve improved lung function, fewer symptoms, and reduced maintenance oral corticosteroid exposure. These outcomes matter because repeated systemic steroid courses are associated with diabetes, osteoporosis, hypertension, infection risk, cataracts, and other long-term complications.

  Choosing treatment through precision phenotyping

  Selecting a biologic should involve more than a single blood test. Clinicians generally review blood eosinophil counts, FeNO, total IgE, allergy testing, exacerbation frequency, current corticosteroid use, nasal polyps, atopic dermatitis, and the timing of previous therapies. Biomarkers can vary over time and may be suppressed by systemic corticosteroids, so results require clinical context.

  Comorbid disease can help guide selection. A patient with severe asthma and chronic rhinosinusitis with nasal polyps may benefit from a therapy that addresses both conditions. Similarly, coexisting atopic dermatitis or marked eosinophilia may make a particular mechanism more attractive. Shared decision-making should also consider injection frequency, administration setting, local availability, cost, and the patient’s preferences.

  Biologic pathway	Common clinical signals	Potential treatment value
  Anti-IgE	Allergic asthma, sensitization, qualifying IgE range	Fewer exacerbations and improved allergic disease control
  Anti-IL-5 or anti-IL-5R	Raised eosinophils, recurrent exacerbations	Reduced eosinophilic inflammation and steroid exposure
  Anti-IL-4Rα	Type 2 inflammation, raised FeNO, atopic comorbidity	Improved control across several type 2 conditions
  Anti-TSLP	Severe uncontrolled asthma across varied biomarker profiles	Reduced exacerbations, including in some lower-biomarker groups

  Measuring outcomes beyond attack reduction

  Exacerbation prevention is a major endpoint, but it is not the sole measure of success. A useful review includes symptom scores, rescue inhaler use, nighttime awakenings, activity limitation, lung function, work or school attendance, and patient-reported quality of life. For people receiving oral corticosteroids, the ability to taper safely is particularly important.

  Biologic response should be assessed at a defined interval rather than assumed after the first dose. Some patients notice improvement quickly, while others require several months. If the response is inadequate, clinicians should revisit adherence, exposure, diagnosis, comorbidities, dosing, and the original treatment target before deciding whether to continue, switch, or stop therapy.

  Addressing safety, access, and long-term use

  Most biologics have favorable safety profiles, but monitoring remains necessary. Injection-site reactions, transient systemic symptoms, hypersensitivity reactions, and rare serious events should be discussed before treatment begins. Vaccination status, parasitic infection risk in relevant settings, pregnancy considerations, and coexisting conditions may affect the care plan.

  Access can be as influential as pharmacology. Prior authorization, cold-chain logistics, clinic capacity, home administration rules, and travel requirements may determine whether a treatment is sustainable. Clear education helps patients recognize expected reactions, maintain dosing schedules, and understand why controller therapy should generally continue unless a specialist provides a structured adjustment plan.

  Practical priorities for respiratory teams

  Successful biologic programs depend on organized care rather than prescribing alone. Clinics can improve consistency by using a standardized severe asthma assessment, recording baseline outcomes, and documenting the reason for selecting a specific mechanism. Collaboration among pulmonologists, allergists, nurses, pharmacists, and primary care clinicians strengthens follow-up.

  Useful priorities include:

  • Confirm the diagnosis and optimize inhaler technique, adherence, and comorbidity management.
  • Record baseline exacerbations, lung function, biomarkers, steroid exposure, and patient-reported outcomes.
  • Match the biologic to the dominant inflammatory phenotype and relevant comorbid conditions.
  • Review response at a planned interval using clinical, physiological, and quality-of-life measures.
  • Create a clear plan for missed doses, adverse reactions, corticosteroid tapering, and long-term reassessment.

  From emerging evidence to everyday care

  The promise of biologic therapies for severe asthma is increasingly visible in clinical practice: fewer attacks, less dependence on systemic steroids, and a more individualized approach to respiratory disease. Yet these medicines work best within a complete management strategy that includes diagnosis, education, trigger reduction, rehabilitation where appropriate, and regular review.

  As evidence continues to develop, congresses connected with APSR and KATRD provide an important setting for comparing regional experience, discussing access barriers, and refining patient selection. Respiratory professionals can help translate advances in immunology into safer, more responsive care by sharing outcomes, examining real-world evidence, and keeping severe asthma management firmly centered on the patient.

  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)