Beyond Triple Therapy: How Pharmacists Can Identify COPD Patients Who Need a Biologic

In an interview with Pharmacy Times, Monica Dougherty, PharmD, BCACP, senior clinical pharmacy specialist at the University of Rochester Specialty Pharmacy, discussed key takeaways from the Immunology Day of Education 2026, held June 10, on the management of chronic obstructive pulmonary disease (COPD). She explained how the 2026 GOLD guideline updates use blood eosinophil counts to identify which patients on triple therapy may benefit from adding a biologic such as dupilumab (Dupixent; Sanofi, Regeneron Pharmaceuticals) or mepolizumab (Nucala; GSK). Dougherty noted that patients with persistent exacerbations despite adherence to triple therapy—particularly those with eosinophil counts at or above 300 cells/μL, or as low as 150 cells/μL for mepolizumab—are candidates for biologic escalation. She also highlighted opportunities for pharmacists to intervene proactively through inhaler adherence support, cost and formulary troubleshooting, the Medicare Prescription Payment Plan, and transitions-of-care follow-up after COPD-related hospitalizations.

Pharmacy Times: Can you please introduce yourself?

Monica Dougherty, PharmD, BCACP: My name is Monica Dougherty. I am a clinical pharmacy specialist with the University of Rochester Specialty Pharmacy up in Rochester, New York.

Pharmacy Times: How do the 2026 GOLD updates change the way pharmacists should be using blood eosinophil counts to identify COPD patients who may benefit from biologic therapy over triple therapy?

Dougherty: Well, for patients that are currently on triple therapy and are adherent to that therapy—and we know that they're filling their medicine and they know how to take it—if they're still having exacerbations, meaning one severe or two moderate exacerbations, then it would be time to consider a biologic. Once we consider a biologic, we'll need to obtain a blood eosinophil count, and that will guide kind of the rest of our therapy decisions. So, the GOLD guidelines do recommend starting a biologic in any patients that have a blood eosinophil count above 300 cells per microliter or equal to 300 cells per microliter, and then they can start dupilumab or mepilizumab if they have that level. It should be noted the FDA has approved mepilizumab down to 150 cells per microliter, so that could be an option for patients that fall just under 300. So that 150 to under 300, those patients can be considered for mepolisumab.

Pharmacy Times: When a patient is already on triple therapy but still exacerbating, what's the clinical and evidence-based case for escalating to a biologic—and how do you make that argument to the care team?

Dougherty: If a patient is currently on triple therapy and they're still having exacerbations and they have an elevated blood eosinophil count, then it would be time to start a biologic. Our two biologics are dupilumab and mepolizumab—they’re both FDA-approved for patients with COPD with an eosinophilic phenotype. These medications are proven to be safe and effective, and they've been shown to decrease exacerbations in patients with COPD. So, that's the big outcome for these medicines. They're also, even though they're biologics, again, very safe medications overall and, with the help of a pharmacist, can actually be very accessible and affordable for most patients.

Pharmacy Times: Where do you see the greatest opportunity for pharmacists to intervene proactively in COPD management, rather than just responding to exacerbations after the fact?

Dougherty: I think one way pharmacists can assess, kind of like low-hanging fruit, is to assist with inhaler adherence. So, first off, that might include inhaler education. We know that that can improve patient education outcomes and then inhaler adherence. Sometimes patients don't take their inhalers because they can't afford them, and they don't tell anybody that they couldn't afford them. So, the pharmacist can kind of intervene and ensure that they're taking their inhaler. If they're not, they could take a look at the cost—maybe it's a new calendar year, and a patient doesn't understand that their deductible is very high, or the insurance plan could have changed their inhaler formulary, their preferred inhaler—they could have changed that midway through the year, and the patient maybe didn't realize that, and that's why their medicine is all of a sudden very expensive. So, the pharmacist, I think, has an opportunity, if possible, to go kind of above and beyond and figure out what the formulary preferred agent is, and they can assist in that way. They can also kind of explain the Medicare prescription payment plan, which is a program that will divide a patient's cost up through the calendar year, so that in January they're not hit with that $600 copay. So, that's one way. And then, if a pharmacist is inpatient, those pharmacists that are involved with transitions of care can identify patients that are admitted for a COPD exacerbation, and on discharge, they can ideally quickly evaluate them if they might qualify for a biologic medication. They can then send this recommendation to the specialist to kind of follow up on the outpatient side, but hopefully this would get more patients on biologics and keep more patients out of the hospital.