Chronic rhinosinusitis with nasal polyps (CRSwNP) is a chronic inflammatory condition of the sinonasal cavities [1-3]. It is frequently comorbid with asthma and both diseases share common underlying pathophysiological mechanisms driving the disease, including type 2 inflammation [3-9].

CRSwNP severely impacts quality of life and has a significant burden on society [10-12]. When symptoms are persistent or when there is a long-term need for antibiotics or systemic steroids, it is considered uncontrolled disease [13-15]. The goal of CRSwNP management is clinical control with minimal use of medication or surgery, but this is challenging [16-19]. However, type 2 inflammation-targeting biologics have entered the market for selected pheno/endotypes of asthma and may soon become available for CRSwNP patients [20-21]. Omalizumab and other biologics (anti-IL5, anti-IL5R, and anti-Il4Rα) are effective for the treatment of asthma with a type 2 inflammatory signature [20-21]. The first studies with these biologics in CRSwNP have shown promising results and a positive impact on quality of life [22-25].

Careful selection of patients is highly recommended [26]. The European Forum for Research and Education in Allergy and Airway Diseases (EUFOREA) organised a multidisciplinary Expert Board Meeting to discuss the positioning of biologics into care pathways for CRSwNP patients with and without comorbid asthma. They have put forward 5 criteria for careful selection of patients to whom biologics should be prescribed (see Figure), as well as criteria to define the response to biological therapy after 1 year [26]. It is likely that biologics will become a valid alternative to sinus surgery [25,27].

Afbeelding met schermafbeelding Automatisch gegenereerde beschrijving

Figure: Indications for biological treatment in patients with CRSwNP: proposal of the multidisciplinary EUFOREA Expert Board Meeting (Modified from Fokkens et al [26])

References:

  1. Hastan D, Fokkens WJ, Bachert C, et al. Chronic rhinosinusitis in Europe–an underestimated disease. A GA2LEN study. Allergy. 2011;66(9):1216‐1223.
  2. Hirsch AG, Stewart WF, Sundaresan AS, et al. Nasal and sinus symptoms and chronic rhinosinusitis in a population‐based sample. Allergy. 2017;72(2):274‐281.
  3. Khan A, Vandeplas G, Huynh T, et al. The global allergy and asthma European network (GALEN) rhinosinusitis cohort: a large European cross‐sectional study of chronic rhinosinusitis patients with and without nasal polyps. Rhinology. 2019;57(1):32‐42.
  4. Philpott CM, Erskine S, Hopkins C, et al. Prevalence of asthma, aspirin sensitivity and allergy in chronic rhinosinusitis: data from the UK National Chronic Rhinosinusitis Epidemiology Study. Respir Res. 2018;19(1):129.
  5. Tomassen P, Vandeplas G, Van Zele T, et al. Inflammatory endotypes of chronic rhinosinusitis based on cluster analysis of biomarkers. J Allergy Clin Immunol. 2016;137(5):1449‐1456.e4.
  6. Langdon C, Mullol J. Nasal polyps in patients with asthma: prevalence, impact, and management challenges. J Asthma Allergy. 2016;9:45‐53.
  7. Zhang Y, Derycke L, Holtappels G, et al. Th2 cytokines orchestrate the secretion of MUC5AC and MUC5B in IL‐5‐positive chronic rhinosinusitis with nasal polyps. Allergy. 2019;74(1):131‐140.
  8. De Greve G, Hellings PW, Fokkens WJ, Pugin B, Steelant B, Seys SF. Endotype‐driven treatment in chronic upper airway diseases. Clin Transl Allergy. 2017;7:22.
  9. Seys SF, Scheers H, Van den Brande P, et al. Cluster analysis of sputum cytokine‐high profiles reveals diversity in T(h)2‐high asthma patients. Respir Res 2017;18(1):39.
  10. Dudvarski Z, Djukic V, Janosevic L, Tomanovic N, Soldatovic I. Influence of asthma on quality of life and clinical characteristics of patients with nasal polyposis. Eur Arch Otorhinolaryngology 2013;270(4):1379‐1383
  11. Sahlstrand‐Johnson P, Hopkins C, Ohlsson B, Ahlner‐Elmqvist M. The effect of endoscopic sinus surgery on quality of life and absenteeism in patients with chronic rhinosinuitis ‐ a multi‐centre study. Rhinology. 2017;55(3):251‐261.
  12. Smith KA, Orlandi RR, Rudmik L. Cost of adult chronic rhinosinusitis: a systematic review. Laryngoscope. 2015;125(7):1547‐1556.
  13. Fokkens WJ, Lund VJ, Mullol J et al. European Position Paper on Rhinosinusitis and Nasal Polyps 2012. Rhinol Suppl. 2012;23:3 p preceding table of contents, 1‐298.
  14. Toma S, Hopkins C. Stratification of SNOT‐22 scores into mild, moderate or severe and relationship with other subjective instruments. Rhinology. 2016;54(2):129‐133.
  15. Hellings PW, Fokkens WJ, Akdis C, et al. Uncontrolled allergic rhinitis and chronic rhinosinusitis: where do we stand today? Allergy. 2013;68(1):1‐7.
  16. DeConde AS, Mace JC, Levy JM, Rudmik L, Alt JA, Smith TL. Prevalence of polyp recurrence after endoscopic sinus surgery for chronic rhinosinusitis with nasal polyposis. Laryngoscope. 2017;127(3):550‐555.
  17. Hopkins C, Slack R, Lund V, Brown P, Copley L, Browne J. Longterm outcomes from the English national comparative audit of surgery for nasal polyposis and chronic rhinosinusitis. Laryngoscope. 2009;119(12):2459‐2465.
  18. Vlaminck S, Vauterin T, Hellings PW, et al. The importance of local eosinophilia in the surgical outcome of chronic rhinosinusitis: a 3‐year prospective observational study. Am J Rhinol Allergy. 2014;28(3):260‐264.
  19. Wei B, Liu F, Zhang J, et al. Multivariate analysis of inflammatory endotypes in recurrent nasal polyposis in a Chinese population. Rhinology. 2018;56(3):216‐226.
  20. Magnan A, Bourdin A, Prazma CM, et al. Treatment response with mepolizumab in severe eosinophilic asthma patients with previous omalizumab treatment. Allergy. 2016;71(9):1335‐1344.
  21. Pepper AN, Renz H, Casale TB, Garn H. Biologic therapy and novel molecular targets of severe asthma. J Allergy Clin Immunol Pract. 2017;5(4):909‐916.
  22. Bachert C, Zhang L, Gevaert P. Current and future treatment options for adult chronic rhinosinusitis: focus on nasal polyposis. J Allergy Clin Immunol. 2015;136(6):1431‐1440.
  23. Gevaert P, Calus L, Van Zele T, et al. Omalizumab is effective in allergic and nonallergic patients with nasal polyps and asthma. J Allergy Clin Immunol. 2013;131(1):110‐6.e1.
  24. Bachert C, Mannent L, Naclerio RM, et al. Effect of subcutaneous dupilumab on nasal polyp burden in patients with chronic sinusitis and nasal polyposis: a randomized clinical trial. JAMA 2016;315(5):469‐479.
  25. Bachert C, Sousa AR, Lund VJ, et al. Reduced need for surgery in severe nasal polyposis with mepolizumab: randomized trial. J Allergy Clin Immunol. 2017;140(4):1024‐1031.e14.
  26. Fokkens WJ, Lund V, Bachert C, et al. EUFOREA consensus on biologics for CRSwNP with or without asthma. Allergy. 2019;74:2312–2319
  27. Bidder T, Sahota J, Rennie C, Lund VJ, Robinson DS, Kariyawasam HH. Omalizumab treats chronic rhinosinusitis with nasal polyps and asthma together‐a real life study. Rhinology. 2018;56(1):42‐45.