What Determines Biologic Selection in Asthma and COPD in 2026?

Advanced practice providers (APPs) — nurse practitioners and physician assistants — represent an increasingly significant share of the clinical workforce managing patients with severe asthma and chronic obstructive pulmonary disease (COPD), yet their perspectives on real-world biologic use are rarely the primary subject of clinician-facing education. Across the portfolio of 7 currently approved asthma biologics, from omalizumab to the recently approved twice-yearly depemokimab, treatment decisions hinge not only on biomarkers and phenotype but on insurance formulary placement, institutional infrastructure, and the practitioner-level experience that takes years to accumulate.¹˒²

The SWIFT-1 and SWIFT-2 trials established that depemokimab achieves approximately 60% annualized exacerbation reduction with a 52-week profile of eosinophil suppression — with eosinophil counts falling approximately 80% within two weeks of the first dose and remaining suppressed through the end of the trial — extending the IL-5 class into a twice-yearly dosing paradigm that carries distinct clinical and logistical implications for the APP-managed patient.² In COPD, dupilumab and mepolizumab have broadened the treatment toolkit for eosinophilic disease, each with differential eligibility thresholds — dupilumab requiring eos ≥300 cells/µL and mepolizumab approvable in patients with eos ≥150 cells/µL within the prior year — that in practice determine not only which patients are candidates but which prescriptions get approved.³˒⁴˒⁵

Against this backdrop, HCPLive convened a virtual clinical forum in May 2026 moderated by Sarah Tomashefski, NP, a pulmonary nurse practitioner at Prisma Health in Greenville, South Carolina, who also directs an APP fellowship program and serves on the board of the Association of Pulmonary and Critical Care APPs (APAPP). The panel comprised 9 advanced practice providers — nurse practitioners and physician assistants — representing outpatient pulmonology practices in Idaho, North Carolina, Maryland, and Pennsylvania; a primary care PA in Florida; inpatient critical care and ICU NPs in South Carolina; and fellowship-trained APP colleagues of the moderator. The panel spanned primary care to ECMO management, rural private practice to academic medical centers, reflecting the full range of clinical contexts in which biologic prescribing decisions are made by APPs rather than physicians.

The forum convened as depemokimab had been on the market for approximately 5 months, generating early but substantive real-world APP experience, and as CT-based mucus plug scoring data from the VESTIGE and CASCADE trials had elevated mucus plugging as a candidate imaging biomarker in asthma that the moderator predicted will define clinical practice by 2027.⁶˒⁷ Both the GOLD 2026 report's formal incorporation of biologics into COPD escalation algorithms and the parallel challenge of meeting eosinophil eligibility criteria under real-world insurance review conditions were active discussion points.⁸ The group's stated objectives — to examine real-world biomarker use, OCS tracking, biologic selection, and access barriers — mapped directly onto the administrative and clinical realities that define APP practice in respiratory medicine.

The asthma portion of the forum was anchored by an unusually candid discussion of how insurance overrides clinical reasoning in day-to-day prescribing. Panelists described formulary-driven selection as the rule rather than the exception: one NP described initiating insurance-preferred agents as samples to document inadequate response before appealing for clinically preferred agents, while another described using ChatGPT alongside GINA guidelines to generate detailed prior authorization letters — an approach she reported has produced no denials. Short-acting beta-agonist overuse, OCS steroid tracking via Epic pharmacy data, and the importance of post-hospitalization follow-up were identified as practical touchpoints for identifying undertreated patients, with panelists noting that patients reliably under-report or fail to recall OCS courses received outside the specialist office.¹

Dupilumab generated the most positive panelist feedback, with one NP describing it as her most effective agent for OCS-weaning in steroid-dependent patients, consistent with the VENTURE trial's demonstration of approximately 80% OCS reduction with concurrent FEV1 improvement.⁹ The group flagged an emerging signal of dental and tooth pain in patients on dupilumab — discussed at a recent APAPP regional conference — as an adverse event that APPs are positioned to identify and report earlier than trial data alone would suggest. Depemokimab drew real-world enthusiasm from 2 panelists who had already prescribed it: 1 for a college student switched from mepolizumab to eliminate monthly in-office injection logistics during the academic year, and another for a non-compliant patient with a prior ICU intubation for whom the 6-month interval provides both a compliance scaffold and a guaranteed biannual clinical touchpoint. Tezepelumab's positioning was nuanced: used most comfortably by an NP whose patient population has low rates of eosinophilia and for whom the upstream TSLP mechanism is the only approved option, but described by others as historically reserved for the most refractory patients — a selection pattern that may underestimate its utility in earlier lines.

“When I started in pulmonary 7 years ago, my mentor… [and] older physicians were like, these biologics, they're nothing to jump into. But nowadays, we need to think of them more as preventative in some patients, preventing another exacerbation because we know what exacerbations lead to. So I think just looking at the whole picture, making sure the patient's compliant and… being educated and having the material to educate patients on these types of medications is really kind of where we're at,” panelist Justine Sicari, DNP, Allegheny Health Network, said.

The COPD segment revealed a practical prescribing asymmetry not captured in guidelines: mepolizumab's lower eosinophil eligibility threshold — ≥150 cells/µL within the prior year versus dupilumab's ≥300 cells/µL at screening — is functioning as a real-world prior authorization advantage that drives agent selection independent of clinical phenotype considerations. One panelist described a patient with eos 289 cells/µL for whom a dupilumab appeal was denied on the basis of a single missing cell, while mepolizumab approval is routinely achievable for that population. This observation extends the prior findings from this forum series that payer support and clearer patient selection algorithms are the changes practitioners most need — a finding replicated in polling for the fifth consecutive forum.

Despite these barriers, real-world COPD biologic outcomes described by panelists were compelling: one NP described an end-stage COPD patient on maintenance prednisone and all available therapies who has not been hospitalized since starting dupilumab. Mucus plugging in COPD was raised as a clinical reality panelists encounter regularly — patients requiring bronchoscopy for mucus clearance, atelectasis on imaging, vest therapy denials — and as an area where biologic therapy and emerging quantification tools may eventually converge. The forum closed with Tomashefski's call for APP-specific prescribing algorithms: as more practitioners enter pulmonary medicine without the years of biologic exposure that have made seasoned NPs confident prescribers, the field needs decision support tools tailored to the APP clinical context.

References

1. Larsson K, Stallberg B, Lisspers K, et al. Overuse of short-acting β2-agonists in asthma is associated with increased risk of exacerbation and mortality: a nationwide cohort study of the global SABINA programme. Eur Respir J. 2020;55(4):1901872. doi:10.1183/13993003.01872-2019

2. Jackson DJ, Wechsler ME, Menzies-Gow A, et al; SWIFT-1 and SWIFT-2 Investigators. Twice-yearly depemokimab in severe asthma with an eosinophilic phenotype. N Engl J Med. 2024;391(24):2337-2349. doi:10.1056/NEJMoa2406673

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

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

5. Criner GJ, Celli BR, Bhatt SP, et al. Mepolizumab for COPD with exacerbations and eosinophilia. N Engl J Med. 2023;389(23):2127-2138. doi:10.1056/NEJMoa2303120

6. Porsbjerg CM, Dunican EM, Lugogo NL, et al. Effect of dupilumab on mucus burden in patients with moderate-to-severe asthma: the VESTIGE trial. Am J Respir Crit Care Med. Published online October 27, 2025. doi:10.1164/rccm.202410-1894OC

7. Diver S, McDowell PJ, Siddiqui S, et al. Tezepelumab and mucus plugs in patients with moderate-to-severe asthma. NEJM Evid. 2024;3(3):EVIDoa2300135. doi:10.1056/EVIDoa2300135

8. Global Initiative for Chronic Obstructive Lung Disease. Global Strategy for Prevention, Diagnosis and Management of COPD: 2026 Report. GOLD; 2026. https://goldcopd.org. Accessed May 22, 2026.

9. Rabe KF, Nair P, Brusselle G, et al. Efficacy and safety of dupilumab in glucocorticoid-dependent severe asthma. N Engl J Med. 2018;378(26):2475-2485. doi:10.1056/NEJMoa1804093