Seven Biologics, Up to $47,000 a Year, and 89 Percent of Europe's Severe Asthmatics Still Aren't in Remission

For most of my life I filed asthma under “manageable.” A blue puffer in a backpack, a wheeze at the end of a hard run, an inhaler you were a little embarrassed to reach for in front of people. That is the asthma most of us picture, and for most people it is roughly right. Then you meet the number that does not fit the picture: more than 400,000 people die of asthma every year, and for the 5 to 10 percent who live with the severe form, the puffer was never going to be enough.

This week the Lancet ran an editorial titled, plainly, “The unmet needs of people living with severe asthma.” It lays out the stakes honestly: more than 260 million people worldwide live with asthma, and the severe minority carries an outsized load of exacerbations, wrecked lung function, and what the editors call a widespread dependence on corticosteroids. All true. But “unmet need” has a second life. In pharmaceutical strategy decks it is the polite name for a market that has not been fully sold yet, so when an unmet-needs editorial lands I have trained myself to ask a second question before I nod along: unmet for whom, and who profits from meeting it?

The uncomfortable answer arrived the same month, in the same journal family. A registry study led out of Sweden’s Karolinska Institutet, drawn from the European Severe Asthma Registry, followed 13,455 adults with severe asthma across 22 European countries. Seventy-nine percent were already on biologics, the precision injectables that are supposed to be the answer to exactly this unmet need. And 89 percent of the patients they could assess still had at least one active domain of disease. Two-thirds had two or more. Sixty-two percent had lung function below 80 percent of predicted. In this registry, roughly four in five of the sickest asthmatics were on the newest drugs, and nine in ten still had active disease.

To feel why that lands so hard, you have to know what these patients were on before, and what many are still on underneath the biologic: oral corticosteroids. Prednisone and its cousins. This is the part where the biology grabbed me by the collar. Steroids work on asthma for the same reason they quietly damage almost everything else, because nearly every cell in your body carries a glucocorticoid receptor. When you swallow prednisone, it does not politely knock on the airway door. It pours through the bloodstream and sits down in nearly every tissue you own, turning inflammation down everywhere at once. Wait, why would a drug that calms your airways also thin your bones and drive up your blood sugar? Because to your cells it was never an “asthma drug” at all. It is a flood of cortisol signal, and your skeleton, your pancreas, and your adrenal glands all read the same message. Bones surrender mineral. Blood sugar climbs. The adrenal glands, watching all that cortisol arrive from outside, gradually stop bothering to make their own.

That is not hand-waving, because the harm has a body count. A UK cohort of 9,413 asthma patients, tracked for a mean of nine years, found a clean dose-response line between lifetime steroid exposure and death. Patients who had taken 10 grams or more of prednisolone-equivalent over the years carried more than double the mortality risk, a hazard ratio of 2.17, compared with the lowest-exposure group, and people holding at 7.5 mg a day or more ran 4.5 times the risk. Diabetes, osteoporosis, and cardiovascular disease all tracked the same grim slope. So getting severe asthmatics off chronic steroids is a genuine, life-or-death unmet need. That part is not marketing.

Then I reread the fine print, and stopped. That corticosteroid-harm study was funded by AstraZeneca, and three of its authors were AstraZeneca employees. AstraZeneca, together with Amgen, also makes tezepelumab, brand name Tezspire, one of the biologics positioned precisely as the way to get patients off steroids, and it lists at roughly $47,000 a year. I am not saying the harm data is wrong; the dose-response is consistent with decades of independent work. I am saying you should notice when the company documenting how dangerous the old, cheap drug is happens to be the same company selling the expensive new one. That is not a conspiracy. It is a business model, and it is sitting right there in the acknowledgments.

So do the biologics earn the price? Partly, and I want to be fair to the patients they genuinely help. In the SUNRISE trial, tezepelumab helped 69 percent of steroid-dependent patients cut their oral steroid dose by at least half, and 35 percent came off oral steroids entirely over 28 weeks. Real people, real reductions, real bones and pancreases spared the flood. But look at the placebo arm first. On a dummy injection plus a structured taper, 44 percent cut their dose in half and 21 percent quit steroids entirely. A large slice of the “miracle” is simply what happens when someone finally sits a patient down and carefully walks them off steroids they had been stacked on for years. The drug adds a margin on top of that, but it is not conjuring the whole result out of thin air.

And that margin costs. When the independent Institute for Clinical and Economic Review ran the math, tezepelumab came in at about $430,000 per quality-adjusted life-year gained, nearly three times ICER’s own $150,000-per-QALY benchmark for value, and that figure was calculated at a placeholder price well below what the drug actually lists for. The panel could not even distinguish its benefit from dupilumab (Dupixent, roughly $42,000 a year, from Sanofi and Regeneron). Seven of these monoclonal antibodies are now approved, each aimed at a slightly different cytokine, each priced like a second car payment. And the European registry says most of the people taking them are still not in remission.

This is the trap folded inside the phrase “unmet need.” The patients’ need is real and urgent: to breathe, and to get off the drug that is quietly mining their bones. The industry’s need is also real: to move more of a very expensive product. Those two needs overlap just enough to make a moving editorial, but they are not the same need. If the biologics were truly meeting the patients’ need, 89 percent of the people on them would not still have active disease.

So if severe asthma were mine, or my mother’s, here is what I would carry into the prescribing room. I would refuse to treat the injectable as the finish line the unmet-needs framing invites me to see, and I would ask first about the boring, cheap thing the placebo arm quietly proved works: a real, supervised steroid taper, because a chunk of the benefit is sitting right there for free. I would ask for my exacerbation counts and my lung function in absolute numbers, before and after anything injected, not the relative percentages the brochure leads with. And I would keep one question on the table that nobody selling me the drug will raise on my behalf: if I end up in the 89 percent, what exactly am I paying $47,000 a year for? I would want that answered before the first needle, not after the tenth.

Sources

1. The Lancet – “The unmet needs of people living with severe asthma” (editorial, 2026)
2. European Severe Asthma Registry – severe asthma remains active in most despite widespread biologic treatment (13,455 patients, 2026)
3. ERJ Open Research – systemic corticosteroid dose-response effects on mortality and morbidity in asthma (UK cohort, 9,413 patients; AstraZeneca-funded)
4. Institute for Clinical and Economic Review – effectiveness and value of tezepelumab for severe asthma ($430,000 per QALY vs a $150,000 benchmark)
5. SUNRISE trial – tezepelumab reduces oral corticosteroid use in steroid-dependent asthma (28 weeks)