Biologic Management in Severe Asthma for Adults: An American College of Chest Physicians Clinical Practice Guideline

Abstract

Background: Severe asthma affects 5% to 10% of patients with asthma but constitutes close to one-half of the medical costs related to asthma due to higher morbidity and health care utilization. Biologic agents have become a standard of care in those unresponsive to standard treatments yet the choice of biologic agent is complex due to the varying mechanisms of action, efficacies, and lack of head-to-head comparisons. Therefore, clinicians need further clinical guidance to optimize their use.

Study design and methods: Panelists developed key clinical questions utilizing the population, intervention, comparator, and outcome (PICO) format to address choice of a biologic agent in severe asthma for adult patients aged ≥ 18 years. A comprehensive systematic search was performed using MEDLINE (via OVID), EMBASE, Web of Science, and CINAHL to identify relevant articles, which were then screened for inclusion using document evaluation tools. Each included article underwent quality assessment, data extraction, and pooled analysis to support grade level recommendation for each of the PICO questions.

Results: Our systematic review and critical analysis of the literature on the 7 PICO questions related to choice of biologic agent in severe asthma patients resulted in 7 evidence-based recommendations.

Interpretation: Characteristics such as quality of life impairment, baseline lung function, frequency of exacerbation, baseline oral corticosteroid use, asthma endotype, biomarkers, and comorbid conditions can impact the biologic choice. Evidence for selecting biologic agents in severe asthma is limited by the absence of comparative effectiveness trials. Additional high-quality evidence is needed to inform choice of biologic agents in these patients.

Keywords: benralizumab; biologic; dupilumab; eosinophilic asthma; fractional exhaled nitric oxide; mepolizumab; monoclonal antibody; omalizumab; reslizumab; severe asthma; severe persistent asthma; tezepelumab.