Viewpoint: Pathway-sensitive eligibility for biologic therapy in COPD: The role of primary care, phenotyping, and eosinophil-guided management.

There is currently increasing interest in the heterogeneity of airway inflammation in COPD, to implement precision medicine that individualizes treatment based on clinical and biological characteristics. The recognition of T2 inflammation is important, since it describes a distinct subgroup of COPD patients with different biological mechanisms, different clinical presentation, accelerated lung function decline and increased exacerbation risk. Currently approved biological treatments refer to COPD patients, who experience frequent exacerbations despite triple therapy and also have elevated blood eosinophils, either with or without clinical manifestations of chronic bronchitis. In this viewpoint, we discuss how differences between primary care and hospital-based care pathways influence the identification of patients eligible for biologics. In primary care settings there is often delayed diagnosis, inconsistent exacerbation recording, suboptimal treatment with inhaled medication, and fragmented eosinophil monitoring. In contrast, hospital admissions often facilitate phenotyping and treatment escalation but may identify candidates only after severe exacerbations occur. Thus, biologic eligibility is highly pathway-sensitive, while standardized exacerbation documentation, eosinophil assessment, and optimization of maintenance therapy are essential for timely implementation of precision-guided COPD management. As COPD biologics emerge, recognition of eligibility remains pathway-sensitive and candidates may be missed or identified only after severe events. For this reason, we also present two different algorithms for the recognition of COPD patients eligible for biologics in primary care and in hospital settings.