Which biologic is best for managing COPD and asthma at 62?

Question

Hello doctor,

I am a 62-year-old male, and I smoked for nearly 25 years, although I quit seven years ago. I have been told that I have both COPD and severe asthma, which the respiratory specialist calls overlap syndrome. My last PFT showed an FEV1 of 48% predicted, and the reversibility after bronchodilator was partial at 180 mL.

I am on triple inhaler therapy with Fluticasone, Umeclidinium, and Vilanterol, but I still get exacerbations almost every two months, during which I need oral Prednisolone and sometimes emergency care. Last year, I was hospitalized twice for severe asthma flares, and once my oxygen dropped to 88 % at home.

I also have an eosinophil count of 380, which my pulmonologist said may make me eligible for biologic therapy. My cardiologist recently found mild pulmonary hypertension on echo, with an estimated PAP of 42 mmHg, which he said is related to chronic lung disease.

My weight has gone up significantly from repeated steroid courses, and I now have steroid-induced diabetes with a fasting glucose of 148. The severe asthma attacks leave me so drained that I cannot do basic daily activities without breathlessness. Nighttime symptoms wake me up three to four times a week.

What biologic is best for someone who has both COPD and severe asthma together? Is pulmonary hypertension treatment separate from this?

Please suggest.

Thank you.

Answer 1

Hello,

Welcome to icliniq.com.

I have read your query and understand your concern.

You have a condition where both asthma and COPD (chronic obstructive pulmonary disease) are present together, and this is why your symptoms are more persistent, and flare-ups are frequent despite using good inhaler therapy.

Your lung function, frequent exacerbations, night symptoms, and eosinophil count clearly indicate that the inflammation in your lungs is still active and not fully controlled. This is also the reason you need repeated courses of steroids, which have already started affecting your weight and blood sugar.

In your situation, the most suitable biologic treatments are Benralizumab and Mepolizumab. Both target the eosinophils that are contributing to your attacks. Between the two, I would slightly favor Benralizumab in your case because of your frequent exacerbations and steroid dependence, as it tends to reduce eosinophils more completely and can lead to faster and more noticeable reduction in attacks.

Many patients in a similar situation have been able to significantly cut down or even stop repeated steroid use after starting this therapy, which also helps in improving energy levels and controlling steroid-induced diabetes.

Your pulmonary hypertension (based on the value you mentioned) is mild and is most likely secondary to your chronic lung disease. At this stage, it is not treated separately with specific pulmonary hypertension drugs.

The priority is to control your lung disease better, prevent oxygen drops, and reduce exacerbations. As your breathing stabilizes with better treatment, this pressure often remains stable and does not progress.

The main goal now is to break the cycle of repeated exacerbations and steroid use. Starting a biologic, along with continuing your inhalers correctly and regularly, gives you the best chance of improving your day-to-day breathlessness, reducing night symptoms, and avoiding further hospitalizations.

Hope I have addressed all of your queries and concerns. Do follow up whenever needed.

Thank you.