Type 2 Phenotyping in Asthma and COPD: Clinical Forum Perspectives

For patients with severe asthma and chronic obstructive pulmonary disease (COPD), recognizing type 2 inflammation now shapes decisions well before guideline step 5, and advanced practice providers (APPs) increasingly make those calls. Recent approvals have widened the options, including dupilumab and mepolizumab for eosinophilic COPD and depemokimab, a twice-yearly anti-interleukin (IL)-5 agent, for severe asthma.^1-4 How clinicians track steroid exposure, document control, and secure coverage often determines how quickly patients reach these therapies.

In September 2026, Alanna Kavanaugh, EdD, APRN, a pulmonary nurse practitioner and assistant dean of graduate programs at the University of Mount Saint Vincent, moderated a virtual clinical forum for APPs on asthma and COPD. Participants included nurse practitioners and physician assistants from the World Trade Center Health Program at Mount Sinai, NYU Langone, academic and community pulmonary practices in New York, Idaho, and Florida, and nursing faculty. The discussion covered type 2 biomarkers, oral corticosteroid (OCS) exposure, biologic selection, and patient-reported outcomes.

Type 2 Phenotyping and OCS Exposure in Asthma

Participants said they check eosinophil counts and IgE for patients with moderate to severe asthma before escalating inhaled therapy. Access to fractional exhaled nitric oxide varied, and some participants said institutional billing rules restrict its use to formal pulmonary function testing. According to 1 participant, serum allergen-specific IgE indicates sensitization rather than clinical allergy, and skin testing better reflects true reactivity.

Participants described estimating steroid exposure by asking about annual courses and reviewing pharmacy fill histories, since patients tend to underestimate use. Several described patients who keep standing prednisone supplies and self-dose, and 1 participant described patients who obtain prednisone and antibiotics abroad. According to 1 participant, a single OCS course signals a loss of control worth investigating, and another described a standing order for a complete blood count before any steroid course to capture eosinophils.

Participants also emphasized validated control tools. According to 1 participant, patients referred as "controlled" often score around 10 on the Asthma Control Test, and scores improve substantially after treatment optimization.

Biologic Selection in Severe Asthma

In polling, participants split nearly evenly among phenotype, biomarkers, comorbidities, and logistics as the main driver of biologic choice. Participants cited comorbid allergic rhinitis and mucus burden as reasons to choose dupilumab, and benralizumab's every-8-week dosing and eosinophil depletion as reasons to choose it. Several said dupilumab is their first-line biologic when patients qualify, while others reported headaches, transient conjunctivitis, and patients tiring of every-2-week dosing.

Kavanaugh said she has had difficulty obtaining coverage for depemokimab, while 1 participant described starting it in 2 patients through a specialty pharmacy. Participants suggested twice-yearly dosing for patients with mental health barriers to follow-up, college students, military personnel, and patients who relocate seasonally.

Others said prior authorization difficulties and limited manufacturer support have narrowed their use of some agents. Tezepelumab was most often described as a second-line option or a choice for patients without qualifying eosinophil counts, though 1 participant described first-line use in patients with chronic infections.

Mucus plugging data for dupilumab and tezepelumab were reviewed, but participants said they rarely image patients with asthma and find it difficult to distinguish airway mucus from postnasal drainage.

COPD Biologics and Patient-Reported Benefit

Participants said the COPD approvals prompted them to recheck eosinophils and IgE in existing patients. In BOREAS and NOTUS, dupilumab reduced exacerbations and improved lung function in patients with eosinophil counts of 300 cells/µL or higher on triple therapy, and in MATINEE, mepolizumab reduced exacerbations without significant improvements in lung function or quality of life.^2-4 Most participants described dupilumab as their more frequent choice in COPD, with mepolizumab considered for lower eosinophil counts or patients preferring monthly dosing, and insurance often deciding.

Participants said improvement in COPD is less dramatic than in asthma, and 1 participant reported reduced prednisone use across roughly 25 patients on biologics. To help patients recognize gradual gains, 1 participant reviews the pretreatment note at each 6-month follow-up, and Kavanaugh described a patient who returned to concerts and went 6 months without an exacerbation after starting a biologic. "So, I think sometimes reminding them of how far they've come is helpful," Kavanaugh said.

For unmet needs, participants cited willingness to escalate beyond inhaled therapy, broader eosinophil eligibility criteria, access to pulmonary rehabilitation, and real-world data on adherence.

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