The American College of Chest Physicians (CHEST) published a key clinical practice guideline in CHEST journal titled "Biologic Management in Severe Asthma for Adults: An American College of Chest Physicians Clinical Practice Guideline."
Severe asthma affects 5–10% of asthma patients but drives nearly half of asthma costs due to exacerbations and high corticosteroid use.
Biologics (omalizumab, dupilumab, anti-IL-5/IL-5Rα agents like mepolizumab/benralizumab, tezepelumab) are standard for refractory cases, but choosing or switching them is challenging without head-to-head data.
This is the first guideline focused on selecting or switching biologics after initial failure, offering 7 evidence-based (mostly conditional) recommendations for adults ≥18 years. It stresses shared decision-making based on T2 biomarkers (eosinophils, IgE, FeNO), comorbidities, exacerbation history, OCS dependence, lung function, QoL, and practical factors (injection frequency, access).
Key highlighted recommendations:
Moderate-severe allergic asthma with ≥1 OCS-requiring exacerbation/year: Suggest omalizumab or dupilumab; prefer dupilumab for more frequent/severe exacerbations or worse lung function; prefer omalizumab for greater QoL impact.
Steroid-dependent severe asthma: Suggest anti-IL-5/anti-IL-5Rα or dupilumab over tezepelumab.
After failure (no response in 4–6 months): Switch based on prior agent, OCS use, and biomarkers (e.g., post-anti-IL-5 FeNO helps guide next steps).
This provides pulmonologists and allergists a practical framework to personalize therapy, reduce exacerbations, spare steroids, and improve outcomes in high-burden severe asthma.
Asthma Treatment Options (click to enlarge the image).
References:
https://www.chestnet.org/newsroom/press-releases/2026/01/chest-releases-guideline-on-biologic-management-in-severe-asthma
journal.chestnet.org/article/S0012-3692(25)05380-2/fulltext