Personalized Management of Patients with Chronic Rhinosinusitis with Nasal Polyps in Clinical Practice: A Multidisciplinary Consensus Statement

Abstract

Chronic rhinosinusitis (CRS) is a sino-nasal chronic inflammatory disease, occurring in 5–15% of the general population. CRS with nasal polyps (CRSwNP) is present in up to 30% of the CRS population. One-third of CRSwNP patients suffer from disease that is uncontrolled by current standards of care. Biologics are an emerging treatment option for patients with severe uncontrolled CRSwNP, but their positioning in the treatment algorithm is under discussion. Effective endotyping of CRSwNP patients who could benefit from biologics treatment is required, as suggested by international guidelines. Other issues affecting management include comorbidities, such as allergy, non-steroidal anti-inflammatory drug–exacerbated respiratory disease, and asthma. Therefore, the choice of treatment in CRSwNP patients depends on many factors. A multidisciplinary approach may improve CRSwNP management in patients with comorbidities, but currently there is no shared management model. We summarize the outcomes of a Delphi process involving a multidisciplinary panel of otolaryngologists, pulmonologists, and allergist-immunologists involved in the management of CRSwNP, who attempted to reach consensus on key statements relating to the diagnosis, endotyping, classification and management (including the place of biologics) of CRSwNP patients.

Expert consensus on the use of systemic glucocorticoids for managing eosinophil-related diseases

“…Up to 30% of patients with CRS have nasal polyps. The symptoms of CRSwNP are uncontrolled by current standards of care in one-third of patients, especially in cases associated with high levels of eosinophils such as aspirin-exacerbated respiratory disease (31). Sinonasal surgeries and/or corticosteroids are the most common treatments for CRSwNP.…”

Practical recommendations for managing severe chronic rhinosinusitis with nasal polyps in the era of biologics

“…The evaluation of CRSwNP is usually performed by collecting information via medical history and scoring tools to determine disease severity and level of control 4 . Notably, endo-phenotyping is particularly relevant prior to the initiation of biologics 5 . This will be even more important in the future, given that, in addition to the anti-IL-4/13 dupilumab, the anti-IgE omalizumab is now available for prescription and that Italian Medicines Agency (AIFA) has approved the anti-IL-5 agent mepolizumab for CRSwNP.…”

“…However, the real-world utilisation of different diagnostics and their impact on the management of CRSwNP remain the object of discussion. Another aspect that should be investigated is the role of multidisciplinary referrals for this condition 5 .…”

Distinct eicosanoid patterns in severe recalcitrant nasal polyposis

“…[7][8][9] In recent years, monoclonal antibodies (mAbs) that target IL-5 or IL-4/IL-13 signaling pathways have been introduced as add-on treatment. 10 High tissue infiltration of eosinophils is commonly regarded as a hallmark of difficult-to-treat CRSwNP. However, studies have shown that pharmacological depletion of eosinophils in peripheral blood or NP tissue may not improve symptoms or affect disease severity.…”

“…CRSwNP is predominantly a type 2 T‐helper cell (Th2)‐driven inflammation characterized by interleukin (IL)‐4, IL‐5, IL‐13, as well as infiltrating eosinophils, mast cells, and type 2 innate lymphoid cells (ILC2s) 7–9 . In recent years, monoclonal antibodies (mAbs) that target IL‐5 or IL‐4/IL‐13 signaling pathways have been introduced as add‐on treatment 10 . High tissue infiltration of eosinophils is commonly regarded as a hallmark of difficult‐to‐treat CRSwNP.…”