The role of biologics in CRSwNP

Currently, 4 biologics targeting type2 inflammatory mechanisms have been approved for the treatment of chronic rhinosinusitis with nasal polyps (CRSwNP) and available in many Western countries, i.e. omalizumab, mepolizumab, benralizumab, and dupilumab. Their future positioning and use as non-surgical treatment for CRSwNP will heavily rely on their cost-effectiveness. “For a more accurate assessment of cost-effectiveness, both direct and indirect costs should be included in health-economic evaluations (including risks and side effects of current treatment options: corticosteroids and surgery) as well as concurrently treated comorbidities (e.g. asthma),” Prof. Lars-Olaf Cardell (Karolinska Institute, Sweden) explained.

A review by Patel et al., which involved omalizumab (n=12), mepolizumab (n=42), benralizumab (n=44), reslizumab (n=6), and dupilumab (n=61), demonstrated that type2–targeting biologics can reduce the use of medication (corticosteroids/antibiotics) for acute exacerbations of chronic rhinosinusitis (AECRS) in patients with asthma and CRSwNP (70% of patients) or chronic rhinosinusitis without nasal polyps (CRSsNP) (30% of patients). The estimated yearly rate for the use of systemic corticosteroids for AECRS decreased from 1.69 (95% CI 1.42–2.02) to 0.68 (95% CI 0.53–0.88), which translates into a reduction of 60% (P<0.001). The yearly rate for antibiotic use for AECRS following implementation of biologics decreased from 1.34 (95% CI 1.12–1.59) to 0.68 (95% CI 0.52–0.88); i.e. a 49% reduction (P<0.001). These findings suggest that these biologics may offer an effective therapeutic option for patients with type2 disease with frequent AECRS [1]. In this respect, Prof. Cardell also referred to the EPOS 2020 treatment scheme for diffuse/bilateral type2 CRS in which type2 inflammation targeting biologics have been allocated as add-on treatment [2].

More explicit guidance on the use of biologics in CRSwNP has been recently defined by expert panels [2,3]. “In these patients, specific criteria are required and should be at least 3 of the following: evidence of type2 inflammation, the need for systemic corticosteroids or a contraindication to systemic steroids, significantly impaired quality of life, loss of smell, or a diagnosis of comorbid asthma.” Response to biological treatment in CRSwNP is defined by evaluation of 5 outcome criteria (i.e. reduced nasal polyp size, reduced need for systemic corticosteroids, improved quality of life, improved sense of smell, and reduced impact of co-morbidities). If a patient fits all 5 criteria, this is considered an excellent response; 3-4 criteria is moderate response, 1-2 criteria is defined as poor response, and 0 criteria equals no response [2–4].

1. Patel G, et al. Allergy Asthma Proc. 2021;42:417-424.
2. Fokkens WJ, et al. Rhinology. 2020 Apr 1;58(2):82-111.
3. Hellings PW, et al. Rhinology 2020 Dec 1;58(6):618-622.
4. Cardell L-O. CRSwNP and biologic treatment. Nordic Lung Congress 2022, 01–03 June, Copenhagen, Denmark. Nordic Lung Congress 2022, 01–03 June, Copenhagen, Denmark.

 

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Posted on 17 August 202217 August 2022