Management of Patients with Severe Asthma and Chronic Rhinosinusitis with Nasal Polyps: A Multidisciplinary Shared Approach

Abstract

Chronic rhinosinusitis (CRS) is one of the most frequent comorbidities associated with asthma and it contributes to an amplified global disease burden in asthmatics. CRS prevalence is much higher in asthmatic patients compared to the general population and it is more frequently related to severe asthma, especially in presence of nasal polyps (chronic rhinosinusitis with nasal polyps, CRSwNP). Moreover, asthma exacerbation has a higher occurrence in CRSwNP. From a pathologic point of view, CRS and asthma share similar and connected mechanisms (e.g., type-2 inflammation). A multidisciplinary approach represents a crucial aspect for the optimal management of patients with concomitant asthma and CRSwNP and improvement of patient quality of life. An Italian panel of clinicians with different clinical expertise (pulmonologists, ear, nose and throat specialists, immunologists and allergy physicians) identified three different profiles of patients with coexisting asthma and nasal symptoms and discussed the specific tracks to guide a comprehensive approach to their diagnostic and therapeutic management. Currently available biological agents for the treatment of severe asthma act either on eosinophil-centered signaling network or type-2 inflammation, resulting to be effective also in CRSwNP and representing a valid option for patients with concomitant conditions.

Proposal for a Structured Outpatient Clinic for Dupilumab Treatment in Chronic Rhinosinusitis with Nasal Polyps in the First Year of Treatment

“…Our data confirm the effectiveness of dupilumab in a real-life setting: as already stated in our previous experience [ 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 ], the results in real life seem to be better than the results in the trials.…”

“…After collecting the patient’s case history, the first ENT examination (Time 0 or T0) focuses on confirming the presence of a severe and resistant CRSwNP and defining the endotype in each patient based on international guidelines [ 1 , 2 , 3 , 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 ].…”

“…Based on this, dupilumab is largely used in several T2-related diseases, including asthma and atopic dermatitis. In this context, the necessity of taking charge of this category of patients is clear, allowing us to thoroughly study the problems of each patient and to present the most effective pathway of care [ 9 , 10 ]. Based on these considerations, in our hospitals, we created an otolaryngological outpatient clinic dedicated to CRSwNP patients (with or without associated T2-comorbidities) who were candidates for dupilumab treatment and connected to a multi-specialist clinical network, aiming at globally evaluating all patients with any type 2 disorder.…”

Real‐world effectiveness of mepolizumab in severe asthma and chronic rhinosinusitis in the United States: Impact of comorbidity and sinus surgery

“…Nonetheless, all cohorts responded to mepolizumab, which suggests that T2 inflammation and IL-5 are features of severe asthma in a substantial proportion of patients regardless of CRS and sinus surgery status. 30,31 Although elevated blood eosinophil count is part of the EUFOREA (European Forum for Research and Education in Allergy and Airway Diseases) criteria for biologic therapy initiation in patients with CRSwNP, it is not used as either a predictor or marker for clinical response. 8 However, in severe asthma, peripheral/circulating blood eosinophil count has a more established role.…”

How to manage recurrences after surgery in CRSwNP patients in the biologic era: a narrative review

“…In patients who underwent multiple surgeries without reaching adequate control or reported major complications after ESS, or in case of coexisting disabling type 2 disease such as asthma, contraindication to surgery, high need of systemic corticosteroids, the shift to biologics is strongly recommended 55 . In this context, collaboration with asthma specialists (pulmonologist/allergologist) appears to be crucial, not only at baseline but also during treatment; especially if the patient has severe asthma, regular follow-ups are required, bearing in mind that in case of uncontrolled asthma a shift to a biologic may be required 56 . On the other hand, in case of poor control of sinonasal symptoms, salvage surgery or a shift to another biologic should be considered after 4-6 months of treatment with biologics.…”