Exacerbation trajectories in biologic-eligible severe asthma patients.

Authors

Freda Yang, Dominic C Marshall, Imran Howell, Timothy S C Hinks, Kian Fan Chung, Ian D Pavord, David J Jackson, Chloe I Bloom

Published in

Chest. Oct 05, 2026. Epub Oct 05, 2026.

Abstract

Asthma biologics are highly effective in reducing exacerbations. Improvement in exacerbations after biologic initiation is often attributed to treatment effect.
What proportion of biologic-eligible severe asthma patients improve without biologic therapy, and what characterises those who remain frequent exacerbators?
Biologic-naïve adults with severe asthma were identified in nationwide UK electronic medical records. Year 0 was defined as the first year patients met severe asthma criteria with ≥3 systemic corticosteroid-treated exacerbations (biologic-eligible). Post-eligibility exacerbation trajectories were identified using longitudinal k-means. Sensitivity analyses included alternative k and a lower exacerbation threshold (≥2/year). Covariates included the highest blood eosinophil count, inhaled corticosteroid (ICS) dose and comorbidities.
Among 10,078 biologic-eligible adults (median age 51 years; 71% female), we identified three exacerbation trajectories: (1) Remitting-stable (70%, n=7,091), with sustained improvement to <3 exacerbations/year even though ICS reduced after peak exacerbation year; (2) Chronic-frequent (20%, n=1,969), with persistently frequent exacerbations (median 5/year); (3) Refractory-frequent (10%, n=1,018), with high ongoing oral corticosteroid exposure (median >10 courses/year). Results were consistent across sensitivity analyses. Remitting-stable patients were least likely to have bronchiectasis but were otherwise similar in demographics and allergic comorbidities. Blood eosinophil count was higher in the chronic-frequent group (Year 0 median 0.30×10⁹/L) compared with remitting-stable (0.23×10⁹/L) and refractory-frequent groups (0.21×10⁹/L, p<0.001); this was evident several years before meeting biologic exacerbation criteria.
Over two-thirds of biologic-eligible patients improved with standard care alone. Chronic-frequent exacerbators had higher blood eosinophil counts, even years before meeting biologic criteria, suggesting a distinct disease phenotype.

PMID:
42833547
Bibliographic data and abstract were imported from PubMed on 06 Oct 2026.

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