Five biologic medications are approved in the United States for the treatment of
asthma that is not well controlled with other
therapies. All target
asthma with elevated type 2 inflammatory markers, such as elevated eosinophils, fractional exhaled
nitric oxide, or total and specific
IgE.
Asthma severity, phenotype, age,
biomarkers, treatment goals/outcomes, comorbid conditions, safety, and cost should all help guide the initial biologic choice. In addition, a shared decision-making process with the patient is needed to optimize adherence, with special attention to patient preference regarding outcomes, safety concerns, and medication administration options. After a biologic agent is initiated, sufficient time is needed to monitor efficacy and response. For patients who do not respond favorably, patient-, disease-, and medication-related factors should be considered and remedied, if possible. Persistent suboptimal responders necessitate a reexamination of
asthma phenotype,
biomarkers, and the suspected immune response pathways. For some patients, a change in
biologic therapy or other therapeutic options may be warranted. In this review, we examine the clinical approach for choosing an initial biologic for the treatment of
asthma, the assessment of response to biologics, and the process of troubleshooting and adjusting biologic treatment for those patients with suboptimal responses.