Endotype-driven decisions in choosing a biologic for airway diseases

The increasing availability of biologic therapies for allergic diseases has highlighted the need for more precise, mechanism-based patient selection. Traditional approaches based on disease phenotypes often fall short in predicting therapeutic response. Escalating healthcare costs together with questions about the efficacy of the current management of allergic diseases prompt to a shift toward endotype-driven and biomarker-guided strategies. This review explores the role of endotypes, defined by distinct immunologic, molecular, or cellular mechanisms, in guiding the use of targeted biologics in asthma and in chronic rhinosinusitis with nasal polyps. Endotype classification based on the type 1, type 2 and type 3 immune response is critical for selecting biologics targeting the IgE, IL-5, IL-4/IL-13, or TSLP pathways. The endotype-driven approach in allergic diseases has tremendous potential if incorporated into comprehensive care pathways, with endotype identification playing a key role in the management decision tree, with improved outcomes and greater patient satisfaction. To this purpose this review provides decision algorithms for the endotype-guided approach at the point of care and discusses the unmet needs with potential practical solutions to support a personalized precision approach.