Treatable Traits in Asthma and COPD: Clinical Forum Perspectives

Pulmonologists increasingly approach asthma and chronic obstructive pulmonary disease (COPD) as a spectrum of treatable traits rather than as fixed diagnoses, with blood eosinophils serving as the most practical marker of type 2 inflammation. The available options for that phenotype have expanded with approvals of dupilumab and mepolizumab for eosinophilic COPD and of depemokimab, a twice-yearly anti-interleukin (IL)-5 agent, for severe asthma.^1-4 Payer criteria, however, do not always align with how clinicians define uncontrolled disease.

In September 2026, Ravi Kalhan, MD, MS, professor of medicine in pulmonary and critical care at Northwestern University Feinberg School of Medicine, moderated a virtual clinical forum on biologic therapy in asthma and COPD. Participants included pulmonary and critical care physicians from Northwestern, Endeavor Health, the Medical College of Wisconsin, and Advocate Health Care. The discussion covered biomarker strategy, oral corticosteroid (OCS) tracking, payer requirements, agent selection, and patient selection in COPD.

Type 2 Biomarkers and Payer Criteria in Asthma

Participants described reviewing 2 to 5 years of prior blood counts and repeating low eosinophil measurements, sometimes at different times of day, to capture type 2 inflammation. Several also order regional allergen panels and total IgE, and Kalhan said persistently low eosinophils and IgE can prompt reconsideration of the asthma diagnosis. Participants said they still identify outside OCS courses manually through the electronic health record and pharmacy fill databases, and Kalhan suggested automated alerts for repeated courses as an opportunity.

Several participants described difficulty obtaining coverage for patients with poor symptom control who do not have OCS-treated exacerbations, citing payer FEV1 cutoffs and peer-to-peer requirements. Kalhan noted that biologic labels vary in how they define eligibility, while payers tend to require exacerbation history. Some participants said documenting frequent rescue inhaler use as evidence of uncontrolled disease has supported approval.

Participants also described payers denying continued biologic coverage when well-controlled patients stop filling maintenance inhalers. In 1 participant's practice, step-down of biologic therapy is offered after about 6 months of control, while Kalhan noted that no evidence base currently guides biologic withdrawal.

Selecting Among Asthma Biologics

Most participants said insurance coverage ultimately determines the agent, though several described a first choice based on phenotype. Participants cited nasal polyps, atopic dermatitis, and dosing interval as common drivers, with several describing dupilumab as their choice for atopic dermatitis and others favoring longer-interval agents for patients averse to injections. Kalhan said his own first choice is often mepolizumab, reflecting his longest experience with it, and noted that mepolizumab's development program included an OCS-reduction study.

On tolerability, Kalhan said he perceives more issues with dupilumab, while noting it may reflect a single patient and that real-world evidence has not shown a different intolerance signal across agents. Another participant said flu-like symptoms and myalgias are the most common limiting adverse effects she sees across biologics. Some participants also raised uncertainty about combining multiple monoclonal antibodies, while others cited long-standing experience with biologics in inflammatory bowel disease and rheumatology.

Participants who have discussed depemokimab described it as an option for frequent travelers and patients who prefer not to self-administer, though views were mixed on bundling office administration with comprehensive asthma care. Several participants questioned whether tezepelumab is effective in patients with truly low eosinophil counts, and 1 suggested type 2 inflammation may be present but undetected by current biomarkers. Mucus plugging data for dupilumab and tezepelumab drew varied responses, with Kalhan describing plugging as an objective marker of treatment response and others questioning its correlation with symptoms.

Eosinophilic COPD and Shared Decision-Making

Participants described COPD and asthma as a continuum, and several said they measure eosinophils routinely in COPD, sometimes repeatedly. In BOREAS and NOTUS, dupilumab reduced exacerbation rates with rate ratios of 0.70 and 0.66, respectively, alongside modest FEV1 gains, while mepolizumab reduced exacerbations in MATINEE among patients with counts of 300 cells/µL or higher.^2-4 Participants said they place more weight on symptoms than on small FEV1 changes, and described responses to both biologics as variable.

Participants said shared decision-making is harder in COPD because biologics are framed around preventing future exacerbations rather than improving daily symptoms, and some described setting expectations accordingly. A prior hospitalization was described as raising therapeutic urgency compared with outpatient exacerbations, and 1 participant cited azithromycin as a lower-cost, well-tolerated alternative for some patients.

Participants identified pulmonary rehabilitation access as a leading unmet need. "If everyone could get to pulmonary rehab, everyone would be better off," Kalhan 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