Monoclonal antibody therapy in patients with severe asthma and COPD: rethinking treatment pathways and success

The new National Institute for Health and Care Excellence (NICE) guidance on the use of dupilumab in chronic obstructive pulmonary disease (COPD) recommends using dupilumab as an add-on therapy for patients with uncontrolled COPD and raised blood eosinophils who either have one severe exacerbation or two moderate exacerbations despite triple therapy. This contrasts with the guidance for commencing and continuing monoclonal antibody therapy (MAb) in asthma and will have significant implications for severe asthma services caring for patients with coexisting asthma and COPD or those with asthma and a significant smoking history. Patients with asthma and COPD often experience poorer outcomes than patients with asthma or COPD alone. They are traditionally managed according to asthma pharmacotherapy guidelines; however, under the new guidance this may change. Our perspective is supported by local audit data helping us to reflect on our current practice as a large tertiary severe asthma service of initiating MAb in patients with coexisting asthma and COPD.Disparities in eligibility and access to dupilumab in asthma and COPD guidelines expose key challenges about the best clinical setting for managing patients with coexisting disease, the need for distinct treatment pathways and personalised definitions of treatment success, and whether the current positioning of dupilumab as a second-line therapy within severe asthma pathways in England remains appropriate. Addressing these issues will be critical to supporting equitable clinically appropriate access to monoclonal antibodies in patients with coexisting asthma and COPD in the future.