Biologics for severe asthma: deciphering what is best for the patient

INTRODUCTION: Choosing the right biologic for the right patient is challenging. It requires evaluating patient characteristics and disease manifestations, understanding the scientific evidence supporting each biologic's efficacy and safety, and using a shared decision-making strategy with the patient. AREAS COVERED: Based on a comprehensive review of the literature, in this narrative review we explore the latest approaches on the optimal selection of biologics in severe asthma. EXPERT OPINION: Biologics target different inflammatory pathways. The choice of biologic depends on biomarker profiles, clinical phenotype and endotype of the disease and its associated comorbidities. A structured approach using biomarkers is essential to guide personalized treatment decisions. Exacerbation history, corticosteroid dependence, and comorbidities all influence therapeutic selection. Asthma is challenging to treat because it is heterogeneous, symptoms change over time and biomarkers lack precision. Researchers are recognizing the need for combination biologic therapy and improved biomarker-driven strategies. However, biologic selection is complex due to overlapping inflammatory pathways and variable treatment response. Emerging strategies, including multi-biomarker panels, multi-omics approaches, and machine learning-driven decision making, aim to refine asthma phenotyping/endotyping and thus optimize treatment outcomes. Real-world studies, pragmatic clinical trials, and head-to-head comparisons of biologics are key to advancing precision medicine and improving long-term asthma management.