Eligibility for biological treatments in COPD patients experiencing a severe COPD exacerbation

Chronic obstructive pulmonary disease (COPD) exacerbations are important events in the natural history of the disease with debilitating consequences which include more rapid lung function decline, quality of life deterioration and increased risk of cardiovascular events and mortality. Inflammation in COPD is complex and is intrinsically less responsive to corticosteroids compared to asthma. Biologics could possibly reduce the burden of inflammation in selected patients.

In this single center retrospective study, we evaluated the eligibility of COPD patients hospitalized during the last 6 years in the respiratory department of a tertiary hospital for a severe COPD exacerbation, to receive either dupilumab or mepolizumab according to the inclusion criteria of their respective randomized controlled trials and GOLD 2026 recommendations.

496 patients were included in the study, 83 (16.7 %) patients were eligible for treatment with mepolizumab and 29 (5.8 %) for treatment with dupilumab, while 413 (83.3 %) were not eligible for any of the biologics currently approved for COPD treatment. Patients who were eligible for biologics had lower FEV₁/FVC ratio and had experienced more COPD exacerbations and more hospitalizations for COPD exacerbations in the previous year compared to those characterized as non-eligible. The main factor missing from non-eligible patients was treatment with triple inhaled medication, prior to hospitalization.

Only a minority of patients hospitalized due to severe COPD exacerbation would have been eligible to receive biologic therapy. Optimization of medical treatment including inhaled medication in addition to disease phenotyping are pivotal for the recognition of the patients which will benefit from the use of biologics.