Which biologic is better for asthma-COPD management?

Question

Hello doctor,

My father is 65 and has overlapping asthma and COPD. He has been admitted twice this year with severe attacks, and his eosinophil count is 520/μL. He uses a triple inhaler (ICS/LABA/LAMA), but still experiences daily wheezing. His doctor is considering starting biologics such as Dupilumab or Mepolizumab. But we have a few questions, such as:

How do we choose between them?
Do these help with both asthma and COPD symptoms?
Additionally, how soon can we expect to see improvement?
Should we get FeNO testing or blood IgE levels before starting?
He also has GERD; could that be worsening his symptoms, and should that be treated more aggressively?

Kindly suggest.

Thank you.

Answer 1

Hello,

Welcome to icliniq.com.

I understand your concern.

Given your father's case, it sounds complex but not uncommon, especially in older adults with overlapping asthma and COPD (chronic obstructive pulmonary disorder), sometimes referred to as ACO (asthma-COPD overlap).

His elevated eosinophil count (520/μL) suggests an eosinophilic phenotype, which tends to respond well to biologics like Mepolizumab or Dupilumab. Both target different inflammatory pathways:

Mepolizumab targets IL-5 (interleukin 5) and is specifically approved for eosinophilic asthma, while Dupilumab targets IL-4 and IL-13 and is effective for type 2 inflammation in asthma and potentially in some COPD patients with eosinophilic features.
The choice between them often depends on whether other features like nasal polyps, atopic dermatitis, or high IgE levels are present (which will favor Dupilumab), while a strong eosinophilic profile without other allergic traits will lean toward Mepolizumab.
Both can reduce exacerbations and daily symptoms, though improvement may take several weeks to months.
FeNO (fractional exhaled nitric oxide) testing and serum IgE (immunoglobulin E) levels can help clarify his inflammatory profile and guide therapy selection.
His GERD (gastroesophageal reflux disease) could be contributing to persistent wheeze and should be aggressively managed with dietary changes, timing of meals, and possibly medication adjustments.
Optimizing GERD treatment alongside respiratory therapy will improve his overall symptoms.

I hope this helps.

Thank you.