New CHEST guidelines offer evidence-based biologic selection for severe asthma

The American College of Chest Physicians^® (CHEST) recently released a new clinical guideline on biologic management in severe asthma. Published in the journal CHEST^®, the guideline contains seven evidence-based recommendations to provide a framework for pulmonologists, allergists, and immunologists to implement in their own practice. 

Severe asthma affects 5% to 10% of patients with asthma, which is defined as patients who require high-dose inhaled corticosteroids plus a second controller. Biologic agents have become a standard of care in those unresponsive to standard treatments, yet the choice of biologic agent remains highly complex. This CHEST guideline examines existing biologics and provides evidence-based recommendations for which biologics to consider for different patient populations. 

While there are studies available to help guide the clinician for initial biologic selection, to date, there is no published guideline to assist in biologic selection when a patient has tried and failed one or more biologics. In addition to following this guideline, decisions as to how to individualize biological therapy should occur under a shared decision-making process that carefully considers underlying asthma comorbidities, T2 biomarkers, injection frequency, mode of administration, and access to resources."

Amber J. Oberle, MD, lead author on the guideline

According to panel consensus, patients lacking a good clinical response after four to six months should switch to an alternative biologic. Characteristics such as baseline oral corticosteroid use, frequency of exacerbation, asthma endotype with available biomarker data, baseline lung function, and comorbid conditions can impact the biologic choice.

Of the seven recommendations, highlights include: 

• In adult patients with moderate to severe allergic asthma and a history of ≥ one exacerbation per year requiring oral corticosteroids, the panel suggests either omalizumab or dupilumab; however, for patients with more frequent or severe exacerbations requiring hospitalization, the panel recommends dupilumab over omalizumab. 

• In adult patients with severe asthma who are steroid dependent, the panel suggests anti-IL-5 therapy or dupilumab over tezepelumab.

• In adult patients with severe asthma who have not demonstrated a clinical response to an initial biologic agent, the switching of agents will be largely influenced by corticosteroid dependency and/or T2 biomarkers. 

• Specifically for patients who have failed to demonstrate a clinical response to anti-IL-5 therapy, obtaining posttreatment fractional exhaled nitric oxide is recommended to help guide decision-making. 

The entire list of recommendations included in the new guideline can be accessed through the CHEST journal website in the article titled, "Biologic Management in Severe Asthma for Adults: An American College of Chest Physicians Clinical Practice Guideline."