Severe asthma biologic selection
Phenotype/biomarker-driven choice of add-on biologic for severe asthma, including the non-type-2 option.
Evidence tier: Guideline-derived.
| Biologic (target) | Phenotype / biomarker | Notes & coexisting disease |
|---|---|---|
| Omalizumab (anti-IgE) | Allergic: perennial aeroallergen sensitization + baseline total IgE within the US ASTHMA dosing table, 30-700 IU/mL for age >=12 y, 30-1300 IU/mL for age 6-11 y (weight/IgE-dosed). Note 30-1500 is the NASAL POLYP range, not asthma. | Also approved for chronic spontaneous urticaria and nasal polyps |
| Mepolizumab / reslizumab (anti–IL-5) | Eosinophilic: blood eos ≥150-300/µL | Mepolizumab also for EGPA, hypereosinophilic syndrome, CRSwNP |
| Benralizumab (anti–IL-5Rα) | Eosinophilic: blood eos ≥300/µL | Near-complete eosinophil depletion; every-8-week maintenance |
| Dupilumab (anti–IL-4Rα) | Type-2: blood eos ≥150/µL OR FeNO ≥25 ppb (or OCS-dependent) | Best when coexisting CRSwNP, atopic dermatitis, or EoE. Caution if eos >1500; transient hypereosinophilia can occur |
| Tezepelumab (anti-TSLP) | Broad, severe asthma REGARDLESS of type-2 status; no biomarker threshold required | Only biologic with efficacy shown in the non-type-2 (low-eos, low-FeNO) population; upstream epithelial alarmin |
Notes
- Confirm the diagnosis, adherence, inhaler technique, and comorbidities before escalating to any biologic.
- Measure type-2 biomarkers (blood eosinophils, FeNO, allergen sensitization) BEFORE starting, and ideally before long courses of oral steroids, which suppress them.
- Tezepelumab is the evidence-based choice when type-2 biomarkers are low; do NOT assume a patient is "biologic-ineligible" just because eosinophils/FeNO are normal.
- Choose among overlapping eligibilities by the dominant coexisting type-2 disease and dosing/route preference.
Evidence & citations
- Holguin F, Cardet JC, Chung KF, et al. Management of severe asthma: a European Respiratory Society/American Thoracic Society guideline. Eur Respir J. 2020;55(1):1900588. PMID 31558662
- Menzies-Gow A, Corren J, Bourdin A, et al. Tezepelumab in adults and adolescents with severe, uncontrolled asthma. N Engl J Med. 2021;384(19):1800-1809. PMID 33979488
- Castro M, Corren J, Pavord ID, et al. Dupilumab efficacy and safety in moderate-to-severe uncontrolled asthma. N Engl J Med. 2018;378(26):2486-2496. PMID 29782217
Clinician decision support. Verify against the cited source. Not a substitute for clinical judgment. 100% on-device; no patient data is stored or transmitted.