CHEST Issues New Guidance on Biologics for Severe Asthma, Highlights When to Switch Therapies
USA: The American College of Chest Physicians (CHEST) has released new clinical guidelines outlining seven evidence-based recommendations for biologic management in severe adult asthma. These guidelines are designed to help pulmonologists, allergists, and immunologists make informed, individualized treatment decisions.
Key highlights include a strong emphasis on dupilumab, particularly in steroid-dependent asthma and in patients showing inadequate response to initial biologic therapy. The recommendations stress the importance of personalizing treatment based on patient characteristics and therapeutic response to optimize outcomes in severe asthma management.
- Dupilumab and Omalizumab in Exacerbation-Prone Asthma: For patients with moderate to severe allergic asthma and at least one exacerbation per year requiring oral corticosteroids (OCS), either omalizumab or dupilumab is recommended. Dupilumab is suggested for patients with frequent or severe exacerbations, reduced lung function, or steroid dependence, while omalizumab may be preferred for those with less frequent exacerbations but significant quality-of-life impairment.
- Anti-IL5/5Rα or Dupilumab in Steroid-Dependent Asthma: For adults dependent on OCS, both anti-IL5/5Rα therapies and dupilumab are recommended. Patients with comorbid conditions like atopic dermatitis or eosinophilic esophagitis may benefit more from dupilumab, whereas very high eosinophil counts could favor anti-IL5/5Rα therapy.
- Biologic Switching: Patients who do not respond clinically after 4–6 months on a biologic should be considered for switching. The guideline outlines sequential options:
- Omalizumab nonresponders: Switch to anti-IL5/5Rα therapy, dupilumab, or tezepelumab.
- Anti-IL5/5Rα nonresponders: Switch to dupilumab or tezepelumab, with dupilumab favored in steroid-dependent patients.
- Dupilumab nonresponders: Switch to anti-IL5/5Rα or tezepelumab, depending on baseline biomarkers such as eosinophil count and fractional exhaled nitric oxide (FENO). FENO ≥25 ppb can guide the switch to dupilumab.
- Role of Biomarkers and Comorbidities: Baseline eosinophil counts, FENO levels, asthma endotype, and comorbid conditions—including chronic rhinosinusitis with nasal polyposis—are crucial in guiding biologic selection and switching.
- Clinical Response Metrics: A “good response” is defined as ≥50% reduction in exacerbation rate and OCS dose. Patients failing to meet these criteria should be evaluated for adherence, inhaler technique, comorbidities, and potential biologic switching.
- Safety and Administration Considerations: All biologics have a favorable safety profile, with serious adverse events being rare. Injection frequency, patient preference, and access to care should inform therapy choice.
Oberle AJ, Abbas F, Adrish M, et al. Biologic management in severe asthma for adults: an American College of Chest Physicians clinical practice guideline. Chest. Published online September 24, 2025. doi:10.1016/j.chest.2025.08.042
