A 32-year-old woman with severe asthma on high-dose ICS-LABA is poorly controlled (4 exacerbations/year requiring oral steroids, ACQ-6 score 2.8). Peripheral eosinophils are 520/µL and FeNO is 48 ppb. She is obese (BMI 38). What biologic add-on therapy is most appropriate?
- A Omalizumab (anti-IgE)
- B Mepolizumab (anti-IL-5)
- C Dupilumab (anti-IL-4Rα) ✓
- D Tezepelumab (anti-TSLP)
Explanation
Dupilumab (anti-IL-4Rα) blocks both IL-4 and IL-13 signaling and is effective in type 2 high severe asthma indicated by elevated eosinophils (≥150/µL) AND/OR elevated FeNO (≥25 ppb). The LIBERTY ASTHMA QUEST trial showed 70% reduction in severe exacerbations. Notably, dupilumab is effective irrespective of baseline IgE — unlike omalizumab (which requires IgE 30–1500 IU/mL and is more appropriate for allergic asthma). Mepolizumab targets IL-5 specifically; tezepelumab (anti-TSLP) is the broadest biologic effective even in non-type 2 asthma but dupilumab's dual IL-4/13 blockade is particularly relevant here given high FeNO.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.