Endotype-driven treatment in chronic upper airway diseases

Abstract

Rhinitis and rhinosinusitis are the two major clinical entities of chronic upper airway disease. Chronic rhinosinusitis (CRS) and allergic rhinitis (AR) affect respectively up to 10 and 30% of the total population, hence being associated with an important socio-economic burden. Different phenotypes of rhinitis and CRS have been described based on symptom severity and duration, atopy status, level of control, comorbidities and presence or absence of nasal polyps in CRS. The underlying pathophysiological mechanisms are diverse, with different, and sometimes overlapping, endotypes being recognized. Type 2 inflammation is well characterized in both AR and CRS with nasal polyps (CRSwNP), whereas type 1 inflammation is found in infectious rhinitis and CRS without nasal polyps (CRSsNP). The neurogenic endotype has been demonstrated in some forms of non-allergic rhinitis. Epithelial barrier dysfunction is shown in AR and CRSwNP. Emerging therapies are targeting one specific pathophysiological pathway or endotype. This endotype-driven treatment approach requires careful selection of the patient population who might benefit from a specific treatment. Personalized medicine is addressing the issue of providing targeted treatment for the right patient and should be seen as one aspect of the promising trend towards precision medicine. This review provides a comprehensive overview of the current state of endotypes, biomarkers and targeted treatments in chronic inflammatory conditions of the nose and paranasal sinuses.

EUFOREA consensus on biologics for CRSwNP with or without asthma

“…15,16 Both CRSwNP and asthma share common underlying pathophysiological mechanisms driving the disease (endotype), of which type 2 inflammation is the most prominent. 13,[17][18][19] Type 2 inflammation is characterized by the presence of eosinophilic airway inflammation associated with type 2-related cytokines (IL4, IL5, and/or IL13) and circulating and/or local IgE. 13,20 The management guideline in Europe for CRS, the European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS), has been developed to provide physicians with comprehensive tables of levels of evidence and helpful management algorithms.…”

A Precision Medicine Approach to Rhinitis Evaluation and Management

“…In the case of extremely low total serum IgE levels, the basophil activation test (BAT) allows a highly sensitive indirect demonstration of allergen-specific IgE on the surface of human effector cells from fresh blood [26,27]. Both BAT and nasal-specific IgE quantification are useful tests for the diagnosis of LAR [28]. Nasal allergen provocation test (NAPT) has the capability of differentiating between allergic (AR and LAR) and nonallergic individuals (healthy controls and NAR), as well as between relevant and nonrelevant allergen sensitization in atopic subjects [29].…”

“…Chronic rhinosinusitis without nasal polyps (CRSsNP) seems to involve Th1 mucosal inflammation and overexpression of transforming growth factor beta resulting in tissue remodeling [35,36]. Neutrophils infiltrating nasal biopsy samples as well as nasal fluids IL-6, IL-8, and MPO might be considered as potential biomarkers [28].…”

Electronic Clinical Decision Support System for allergic rhinitis management: MASK e‐CDSS

“…It is an important tool for precision medicine. 9,10 Within the AR CDSS, the VAS is used to assess AR control and to assist in making management decisions, assisting patients and healthcare providers to jointly determine AR treatment and its step-up or step-down strategy depending on the status of AR control. 2 The next step is to integrate the AR CDSS into an app for providers called Allergy Diary Companion, by producing an electronic version of it (e-CDSS).…”