Severe asthma biologics: which patients are still being left out?
Type-2 biologics have transformed severe eosinophilic asthma management, but a meaningful subset of severe-asthma patients - those without high eosinophils, FeNO, or specific allergic phenotypes - still lack a biomarker-aligned biologic option.
The severe-asthma biologic class - anti-IgE, anti-IL5, anti-IL5R, anti-IL4Ra, anti-TSLP - is now broad enough that most patients with a clear type-2 (T2-high) inflammatory phenotype have at least one matched option. The remaining gap is in T2-low severe asthma, a smaller but real population that the trial-eligibility criteria have largely excluded.
The practical question for pulmonologists is what to offer T2-low severe asthma patients beyond high-dose ICS-LABA-LAMA. The pipeline (anti-TSLP and a small number of pathway-agnostic agents) addresses some of this gap; payer coverage of the same agents in T2-low patients lags the trial evidence.
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