Biologic Access in Asthma and COPD: Clinical Forum Perspectives

Advanced practice providers (APPs) manage a growing share of patients with asthma and chronic obstructive pulmonary disease (COPD), often handling maintenance care, biomarker workup, and the prior authorizations that biologic therapy requires. Recent approvals have expanded the available options, including dupilumab and mepolizumab for eosinophilic COPD and depemokimab, a twice-yearly anti-interleukin (IL)-5 agent, for severe asthma.^1-4 Access, dosing frequency, and adherence increasingly shape which of these therapies patients receive.

In September 2026, Melissa Dolbec, FNP-C, a nurse practitioner in pulmonary medicine at The Oregon Clinic in Portland, moderated a virtual clinical forum for APPs on type 2 inflammation and biologic therapy. Participants included nurse practitioners and physician assistants from the World Trade Center Health Program at Mount Sinai, NewYork-Presbyterian, and pulmonary, internal medicine, and heart failure practices in Texas, Tennessee, Montana, and California. The discussion covered biomarker workup, oral corticosteroid (OCS) thresholds, agent selection, and the logistics of securing coverage.

Eosinophils, FeNO, and OCS Thresholds in Asthma

Participants said blood eosinophil counts drive most qualification decisions, and several described reviewing records years back, or rechecking during allergy season, to document an elevated count. Few participants had access to fractional exhaled nitric oxide (FeNO), and 1 whose clinic offers it said staffing limits have discouraged its use. Where FeNO is available, 1 participant said it is used to monitor response rather than to qualify patients.

Most participants said more than 2 OCS courses per year signals inadequate control. According to 1 participant, documenting repeated bursts or steroid dependence as evidence of uncontrolled disease when steroids suppress eosinophil counts has not drawn reimbursement pushback. Participants said patients are often unreliable reporters of steroid use and described relying on Epic dispense history, Care Everywhere, and family members, while those serving rural, Indian Health Service, or VA populations described having to request outside records.

Several participants emphasized confirming the diagnosis with spirometry, methacholine challenge, or imaging before escalation, noting that many referred patients have never had pulmonary function testing and that pulmonary hypertension can mimic obstructive disease. In 1 participant's practice, phenotyping and allergy testing begin at diagnosis rather than at Global Initiative for Asthma step 5, since some biologics are approved for moderate asthma.

Selecting Asthma Biologics: Access, Dosing, and Comorbidities

In polling, 54.5% of participants cited biomarkers as the main driver of biologic choice, though in discussion, participants said dosing frequency, payer coverage, and comorbidities such as chronic rhinosinusitis often decide among eligible agents. Participants with in-house specialty pharmacy teams said they often start dupilumab because those teams can secure affordable access, and others cited lower perceived payer pushback and benefit for coexisting rhinosinusitis. Other participants described benralizumab as a frequent choice for its every-8-week maintenance dosing and low out-of-pocket cost in some plans, and anti-IL-5 agents as preferred for eosinophilic granulomatosis with polyangiitis.

For depemokimab, participants described buy-and-bill administration and inconsistent insurance coverage. According to 1 participant, a needle-averse patient with recurrent emergency department visits has had none since starting twice-yearly therapy. Tezepelumab was described as useful when elevated eosinophil counts cannot be captured, though 1 participant said obtaining coverage requires extensive work.

Participants also said payer fill-history requirements limit inhaler de-escalation, with 1 participant reporting a biologic denial after a patient stopped filling maintenance inhalers.

COPD Biologics and Specialty Pharmacy Support

Dolbec noted that an estimated 20% to 40% of patients with COPD have an eosinophilic phenotype. In BOREAS and NOTUS, dupilumab reduced exacerbations and improved lung function in patients with eosinophil counts of 300 cells/µL or higher, and in MATINEE, mepolizumab reduced exacerbations compared with placebo.^2-4 Participants in primary care and maintenance roles said they typically refer patients with frequent exacerbations to pulmonologists for biologic initiation, and Dolbec said she has not observed a difference in benefit between the 2 COPD biologics in her practice.

In polling, access and logistics were the most common nonclinical factors altering escalation decisions, and payer support and reimbursement guidance was the most requested resource. Participants with dedicated pharmacists or nurses handling prior authorizations said this support removed much of the administrative burden, while 1 described a difficult transition to a system pharmacy team unfamiliar with pulmonary medications. Another participant recommended reviewing each agent's prescribing information to align documentation with payer criteria.

For unmet needs, participants cited limited access to pulmonary rehabilitation, inconsistent coverage for virtual programs, and the need for COPD navigators to track patients between hospitalizations. "Just the fact that in some states it has to be a physician to order pulmonary rehab, I think, is so ridiculous, and that there's just not enough access, physical access, to pulmonary rehab," Dolbec said.

References

1. Jackson DJ, Wechsler ME, Jackson DJ, et al. Twice-yearly depemokimab in severe asthma with an eosinophilic phenotype. N Engl J Med. 2024;391(24):2337-2349. doi:10.1056/NEJMoa2406673

2. Bhatt SP, Rabe KF, Hanania NA, et al. Dupilumab for COPD with type 2 inflammation indicated by eosinophil counts. N Engl J Med. 2023;389(3):205-214. doi:10.1056/NEJMoa2303951

3. Bhatt SP, Rabe KF, Hanania NA, et al. Dupilumab for COPD with blood eosinophil evidence of type 2 inflammation. N Engl J Med. 2024;390(24):2274-2283. doi:10.1056/NEJMoa2401304

4. Sciurba FC, Criner GJ, Christenson SA, et al. Mepolizumab to prevent exacerbations of COPD with an eosinophilic phenotype. N Engl J Med. 2025;392(17):1710-1720. doi:10.1056/NEJMoa2413181