When to Switch Biologics in Severe Asthma, With Florence Schleich, MD, PhD

Switching biologics in severe asthma should follow careful phenotyping of residual exacerbations, according to Florence Schleich, MD, PhD, who outlined her approach to biologic switching, long-term treatment goals, and follow-up in an interview with HCPLive after the European Respiratory Society (ERS) Congress 2026 in Barcelona.¹

Schleich, a respiratory physician at the University of Liège in Belgium, presented on persistent exacerbations in patients receiving biologics at the congress. In the interview, she described when residual exacerbations justify a change in biologic therapy and when an add-on approach is more appropriate.¹

"[If] the patient is still exacerbating, presenting with type 2 exacerbations, I think we have to think about a switch to another biologic targeting type 2 inflammation, and according to the biomarkers, you could choose the right treatment for the right patient," Schleich said. "If the patient is still exacerbating, but the exacerbations are infectious, I wouldn't switch."

When to Switch Biologics in Severe Asthma

For patients with infection-driven exacerbations on a type 2–targeted biologic, Schleich said her first step would be adding a macrolide to the current biologic rather than changing agents.¹

Schleich also encouraged clinicians to set more ambitious goals for patients with severe asthma. A patient who fails to reach remission, continues to exacerbate, or shows accelerated lung function decline may warrant a different treatment, with the aim of preventing future exacerbations and eliminating exposure to systemic corticosteroids.¹ She said failure to taper maintenance systemic corticosteroids is another reason to consider a switch, provided the exacerbation phenotype has been characterized first.

Predictors of Biologic Response and Remission in Severe Asthma

Reaching these goals depends on matching each patient to the right biologic as early as possible, Schleich said. Randomized controlled trials show certain biomarkers predict response to individual biologics. The field lacks head-to-head comparisons showing whether a given patient will respond better to one agent or another.¹

"We need more biomarkers, more predictors of response, more predictors of remission with the different biologics," Schleich said. "We do not have a lot of head-to-head comparisons, and it's really a pity, because it's difficult to know."

Rather than relying on a single marker, Schleich said future prediction models could combine biomarkers with baseline characteristics, comorbidities, lung function testing, and lung function trajectory. Integrating these factors would help identify which treatment best suits a patient with a specific clinical profile.¹

Standardizing Follow-Up for Patients on Biologics

Schleich's main recommendation for pulmonologists centered on consistency. She called for agreement on what clinicians measure and when, and for harmonized management of patients with severe asthma across countries.¹ The ERS SHARP collaboration is developing a clinical protocol toward this goal.²

Her recommended approach pairs careful phenotyping at baseline with regular, structured follow-up. In line with the Global Initiative for Asthma (GINA) severe asthma guidance, she advised reviewing treatment efficacy 3 to 6 months after biologic initiation.¹,³ She said follow-up on a regular basis is essential, particularly for identifying patients who continue to exacerbate or remain dependent on maintenance systemic corticosteroids.

“I would also recommend to collaborate with other physicians and other specialties to search for comorbidities,” Schleich said. “It's really important because it could also change the way you choose the treatment.”

Watch part 1 of our interview with Schleich here: Residual Asthma Exacerbations on Biologics Vary by Mechanism

Editor’s note: Schleich has no reported disclosures.

References

1. Schleich F. Asthma: why do asthma exacerbations persist, even in well-treated patients on biologics? Presented at: European Respiratory Society Congress 2026; September 2026; Barcelona, Spain.

2. European Respiratory Society. SHARP: Severe Heterogeneous Asthma Research collaboration, Patient-centred. Accessed October 7, 2026. https://www.ersnet.org/science-and-research/clinical-research-collaboration-application-programme/sharp-severe-heterogeneous-asthma-research-collaboration-patient-centred/

3. Global Initiative for Asthma. 2026 GINA Severe Asthma Guide. Accessed October 7, 2026. https://ginasthma.org/2026-gina-severe-asthma-guide/