Adjusting Asthma Management After Achieving Control on Long-Term Biologic Therapy

Long-term use of biologic therapy in asthma has enabled patients to achieve improved outcomes and even remission of their airway disease. These monoclonal antibodies target specific pathways involved in asthma pathogenesis, including immunoglobulin E, IL-5 or the IL-5 receptor, the IL-4 receptor α, or thymic stromal lymphopoietin. Improved outcomes include reduced exacerbations, symptom minimization, improved lung function (stable lung function for a year or more), and withdrawal of corticosteroid use.¹

Questions remain about whether biologics can be discontinued | Image credit: Orawan | stock.adobe.com

Despite these beneficial responses, patients and physicians alike are faced with what to do once remission is achieved and whether the biologic can be discontinued to avoid the risk of losing asthma control. Some issues patients face include the cost of therapy, fatigue with taking injections on a regular basis, and the small but unknown potential risks of long-term biologic use.²

A commentary published ahead of print in The Journal of Allergy and Clinical Immunology: In Practice in May 2025 poses 5 asthma management options once patients achieve control on long-term biologic therapy so as not to risk losing disease control²:

• Continuing the biologics and the background inhaled long-acting ß agonists (LABA)/inhaled corticosteroid (ICS) asthma therapy
• Stopping the biologics while continuing the background ICS/LABA controller therapy
• Stopping the background inhaled ICS/LABA while continuing the biologic
• Reducing the biologic dosing or increasing the biologic dosing interval
• Alternate approaches for special circumstances, such as seasonal administration

The commentary reviews existing data regarding safety and efficacy for each strategy to better inform caregivers and patients.

Evidence from limited randomized controlled studies involving omalizumab (Xolair; Genentech, Novartis) and mepolizumab (Nucala; GSK) suggests that while certain individuals can stop biologics and maintain asthma control, biologic therapy cannot be safely discontinued in a majority of patients.²

Limited data exist for continuing biologic therapy while tapering background controller therapy for patients whose asthma is well controlled on biologics. Discontinuing oral corticosteroids (OCS) is a major goal of starting biologics, and studies have shown that OCS should always be tapered in patients who are well controlled on biologics. Studies involving dupilumab (Dupixent; Sanofi, Regeneron) and benralizumab (Fasenra; AstraZeneca) have shown that although it may not be clear how to step down on inhalers, patients can indeed be stepped down when control is achieved.²

With regard to continuing inhalers and tapering biologics, limited data exist for using off-label dosing alterations for patients treated with asthma biologics. A phase 2 trial and a postmarketing study have suggested that asthma patients on dupilumab could increase the dosing interval from every 2 weeks to every 4 weeks, with reduced exacerbations.²

The PROSE study, a randomized, double-blind, placebo-controlled trial, addressed the seasonal increase in asthma exacerbations in the fall in school-aged children. In children who had previous exacerbations, seasonal use of omalizumab reduced exacerbations. However, for the whole group, there was no difference between omalizumab and an ICS boost. Questions also remain as to what a provider should do when a patient has an incomplete or a partial response to a biologic.

Limited available data show that some patients can safely adopt some of these asthma management approaches successfully. However, more research is needed to better inform who, how, and when to adopt these regimens, and for how long patients stay controlled after discontinuation. Shared decision-making between patient and provider is essential to navigating these challenges.

REFERENCES

1. Biologic therapy for severe asthma. Cleveland Clinic. Updated August 5, 2024. Accessed July 2, 2025. https://my.clevelandclinic.org/health/treatments/17711-biologic-therapy-for-severe-asthma

2. Wechsler ME, Jackson DJ, Moore WC et. al. How to adjust asthma management once asthma is controlled on long term biologic therapy. J Allergy Clin Immunol Pract. 2025;S2213-2198(25)00496-9. doi:10.1016/j.jaip.2025.05.031