Biologics for Nasal Polyps: Synthesizing Current Recommendations into a Practical Clinical Algorithm

Abstract

Background Chronic rhinosinusitis with nasal polyps (CRSwNP) has been traditionally managed with a combination of topical and systemic medical therapy as well as endoscopic sinus surgery. The emergence of biologic therapies that target specific aspects of the inflammatory cascade has ushered in a potentially new paradigm in the management options available for CRSwNP. Purpose To summarize the current literature and recommendations supporting the use of available biologic therapies for CRSwNP and to develop an algorithm to aid clinical decision-making regarding treatment selection. Methods A review of available literature and studies that demonstrated the clinical efficacy of biologic agents for the treatment of CRSwNP informing current CRSwNP consensus algorithms. Results Current biologic medications target immunoglobulin E, interleukins, or interleukin receptors implicated in the Th2 inflammatory cascade. Institution of biologic therapy is now an option for patients who have disease refractory to topical medical therapy and endoscopic sinus surgery, those who cannot tolerate surgery, or patients with other comorbid Th2 diseases. Response to treatment should be monitored at 4–6 months and 1 year after initiating therapy. Across multiple indirect comparisons, dupilumab appears to have the largest therapeutic benefit across multiple subjective and objective outcomes. The choice of therapeutic agent also depends on drug availability, patient tolerance, presence of comorbid illnesses, and cost. Conclusions Biologics are emerging as an important option in the management of patients with CRSwNP. While more data is required to fully inform indications, treatment selection, and health economics related to their use, biologics may offer robust symptom relief to patients who have failed other interventions.

Switching of biological therapy to dupilumab in comorbid patients with severe asthma and CRSwNP

“…Odor perception has considerably increased in our series, shifting from a median value of Sniffin' stick 3/16 at T0 to 12/16 at T4 (Table 2). Further olfactory measurement such as discrimination and threshold testing would be necessary to evaluate olfaction and olfactory gain under dupilumab, but our findings strengthen the literature's evidence of dupilumab as first choice in terms of smell improvement [16,18,23].…”

“…Accordingly, the last few years have seen an increase in systematic reviews and meta-analysis comparing the different monoclonal antibodies. Data analysis reveals dupilumab to be the most favorable in terms of efficacy and safety profile, considering NPS, SNOT-22, UPSIT, and NCS scores [16][17][18].…”