At the last session of the last day of CHEST—which the session hosts playfully mentioned, realizing how tired everyone likely was—the room geared up to explore a pro-con debate around biologics and maintenance therapy.

The session included multiple perspectives on approaches to maintenance—meant to get the room thinking about what they’d do in certain scenarios. First up, Arjun Mohan, MD, discussed why the path to ultimately selecting biologics for patients should go through triple therapy for patients with severe asthma. Triple therapy includes inhaled steroids, plus long-acting beta-agonists (LABAs) and a long-acting muscarinic antagonist (LAMA). To jump into the discussion, Dr. Mohan shared a “patient” case—one he “we’re all probably familiar with” with the room:

“It’s encouraging to see the many options and thoughts here because doing nothing is not an option,” Dr. Arjun says. He also says there truly is no “best” option, putting “best” in air quotes. “We have moved away from a one-size-fits-all approach to asthma,” he stresses.

He also makes a joke about the history of asthma treatment, noting just how many options we have now that biologics are available. Going back to the 1900s, he says, remarking on the Victorian era’s belladonna cigarettes—a very real and somewhat hallucinogenic “treatment”—for asthma. 

Showcasing data, he makes the argument that LAMAs must be considered as a step prior to intuition of biologics in most asthma patients, and that LAMAs are shown to improve lung function. “Asthma subpopulations consistently associated with airflow obstruction are most likely to benefit from LAMA,” but further data is needed, he says. He also notes that LAMAs are also more practical. For example, biologics are costly, costing up to $3000 per dose, whereas inhalers are significantly less, he notes.

Patients are also comfortable with these medications. “I think patients have heard about LAMA in commercials—and they’re comfortable and they’ve been around longer [than biologics],” Dr. Arjun says. “With LAMA, you’re either going to get [a response] or not. With biologics, it’s a flip of a coin with how your patients will respond.” In the end, Dr. Arjun concluded his segment by saying, “I’m so curious what the other session hosts will argue as a counterpart!”

The path to biologics

Lastly, LAMAs may not be beneficial in patients dependent on oral corticosteroids and other coexisting indications for biologic therapy.

Maintenance therapy should be tapered while on biologics

Next up, Garbo Mak, MD, argued that background maintenance therapy should be tapered while on biologics. Dr. Mak says that by the time patients are being considered for a biologic, it’s probably in their best interest to be tapered off maintenance therapy. “When we reach step 5 [in the approach to treatment], our patients have been on a lot of drugs,” she says. “They’re on maximal therapy at this point.”

Though there isn’t an abundance of data on tapering LAMAs while on biologics, she says, there are some key benefits to tapering maintenance therapy, including minimizing medication burden, improving the effectiveness of treatment, and improving quality of life. Dr. Mak says tapering OCS and ICS can be done safely—and should be done in a patient-centered way. 

“Balance the risks of continued maintenance therapy (especially high dose) inhaled steroid against the risk of exacerbation with risk of tapering maintenance therapy in severe asthmatics on biologic,” she says, noting the steroid-sparing effects of steroids of biologics.

She notes that there is growing interest in clinical remission. “Control is reducing the severity of symptoms and complications. Remission means an absence of any active disease,” she says. “On biologics, studies show that a subset of our patients can achieve remission.” She also says that clinicians should consider the concept that biologics in severe asthma transition to being a “maintenance” therapy, which can also be adjusted over time. 

When it comes to tapering maintenance therapy, she says, “Consider this a treatment trial. If they’re failing the treatment trial, we can always step up if needed,” Dr. Mak says. 

Maintenance therapy shouldn’t necessarily be tapered while on biologics

Frederic Little, MD then argued the exact opposite, although he noted seeing his colleague’s points of view. “There is no question that risk of systemic steroids is a priority,” he adds, but clinicians should seriously consider when to taper their patient off maintenance medications.

He argues that biologics take a minimum of four months to reach a point where effectiveness can be assessed—something that must be taken into consideration. “The risk versus benefits of early ICS tapering in context of exacerbation risk favor tapering maintenance therapy after four months after initiation when there is clear clinical or objective evidence of improvement in control,” Dr. Little shares. He even thinks that biologics should eventually be tapered—but he says it must start with a patient-centered approach. “So my take home is caution and patience are warranted in all therapies,” he says.