Impact of omalizumab therapy on medication requirements for chronic rhinosinusitis

[Treatment of chronic rhinosinusitis with nasal polyps (CRSwNP) with monoclonal antibodies (biologics): S2k guideline of the German Society of Oto-Rhino-Laryngology, Head and Neck Surgery (DGHNO-KHC), and the German College of General Practitioners and Family Physicians (DEGAM)]

Monoclonal antibodies (so-called biologics) can be prescribed for chronic rhinosinusitis with nasal polyps (CRSwNP) within the scope of their market authorization. However, their prescription is limited to severe CRSwNP without disease control, whereby certain requirements must be met. Dupilumab, omalizumab, and mepolizumab have currently gained market authorization, with adequate evidence for their efficacy and safety available in the literature. It can be assumed that other biologics will be approved for this indication in the future. The severity of disease and the efficacy of treatment should be assessed objectively and subjectively before treatment initiation and after an appropriate duration, respectively. The documentation sheet proposed in this guideline chapter can be used for the assessments. In the presence of relative contraindications, a treatment should only be initiated after differentiated consideration by an experienced physician in the sense of a case-by-case decision. In summary, this guideline chapter aims to contribute to high-quality care of adult patients with these therapies in view of the increasing evidence for treatment with these substances and the increasing number of market authorizations of different biologics.

Impact of type 2 targeting biologics on acute exacerbations of chronic rhinosinusitis

Background: Acute exacerbations of chronic rhinosinusitis (AECRS) are associated with significant morbidity and decreased quality of life. There are sparse data assessing the real-world impact of biologics on AECRS. Objectives: We sought to determine the impact of type 2-targeting biologics on the frequency of medication use for AECRS episodes. Methods: Antibiotic and/or systemic corticosteroid courses for AECRS were identified in a retrospective study from November 2015 to February 2020, at a single academic health system. The estimated yearly rates for antibiotic and corticosteroid courses were evaluated before and after initiation of type 2 biologics. Results: One-hundred and sixty-five patients with chronic rhinosinusitis (CRS) had received either omalizumab (n = 12), mepolizumab (n = 42), benralizumab (n = 44), dupilumab (n = 61), or reslizumab (n = 6). Seventy percent had CRS with nasal polyps, and 30% had CRS without nasal polyps. All the patients had asthma. When all the biologics were combined, the estimated yearly rate for antibiotics for AECRS decreased from 1.34 (95% confidence interval [CI], 1.12-1.59) to 0.68 (95% CI, 0.52-0.88) with biologic use (49% reduction, p < 0.001). Those with frequent AECRS (three or more courses of antibiotics in the 1 year before biologic use) had a larger degree of reduction, with an estimated yearly rate of 4.15 (95% CI, 3.79-4.55) to 1.58 (95% CI, 1.06-2.35) with biologic use (n = 27; 62% reduction; p < 0.001). Within the total cohort, the estimated yearly rate for systemic corticosteroids for AECRS decreased from 1.69 (95% CI, 1.42-2.02) to 0.68 (95% CI, 0.53-0.88) with biologic use (60% reduction; p < 0.001). Conclusion: Type 2-targeting biologics reduced medication use for AECRS. This suggested that biologics may be a therapeutic option for patients with frequent AECRS.

Self-Reported Improvement for Chronic Rhinosinusitis Major Symptoms in Patients Treated with Omalizumab

Objective: To evaluate the clinical effect of omalizumab therapy on the symptoms of patients with chronic rhinosinusitis (CRS). Methods: This cross-sectional study evaluated CRS major symptom improvement in patients with CRS on omalizumab therapy and patients who met omalizumab therapy indications, but could not access coverage for omalizumab. Changes in overall chronic rhinosinusitis symptom burden and each of the major symptoms of CRS were rated on a 10 cm visual analogue scale (VAS). The Mann–Whitney test was used to compare the symptom improvement between groups. Results: Omalizumab therapy provided a mean overall symptom improvement of 69.5% (individual symptom improvement: facial pain 78.5%, nasal obstruction 69.8%, rhinorrhea 56.2%, and olfaction 55.8%). For the control group, mean overall symptom improvement since omalizumab screening was 16.8% (individual symptom improvement: rhinorrhea 16.4%, nasal obstruction 15.3%, no improvement in facial pain or olfaction). Overall, and for each major symptom, improvement was significantly greater for omalizumab treated patients (p < 0.05). Conclusion: Omalizumab treatment provided significant improvement in every major clinical symptom of CRS in the treated cohort of patients with recalcitrant CRS, in comparison to the control cohort. A well-designed randomized clinical trial is needed to further assess the efficacy and safety of omalizumab treatment for CRS.

Use of biologics in chronic sinusitis with nasal polyps

PURPOSE OF REVIEW

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a heterogeneous inflammatory condition with different endotypes between patients from eastern or western countries. Targeted biologics are currently used to treat CRSwNP, but the outcomes widely vary. This review focuses on the present use of biologics for treating CRSwNP.

RECENT FINDINGS

Monoclonal biologics have been used as an innovative therapy for multiple allergic diseases and comorbid allergic conditions. Over the past several decades, numerous biomarkers have been investigated and were found to be closely correlated with CRSwNP, improving the understanding of inflammatory patterns and endotype classifications for CRSwNP and prompting discussion regarding the use of biologics in CRSwNP. Efficacies vary in reports of different research groups, but it has been found that patients with TH-2-driven inflammatory patterns respond better to the use of biologics than those with non-TH-2-driven CRSwNP. These findings suggest the importance and urgency of developing criteria for biologics in CRSwNP.

SUMMARY

Precisely determining patient criteria, identifying treatment biomarkers based on endotyping for CRSwNP and determinations of contraindications for long-term utilization may be useful for optimizing treatment strategies and improving the therapeutic efficacy of biologics to achieve long-term control starting at early stages.

Successful treatment of eosinophilic chronic rhinosinusitis and eosinophilic otitis media using the anti-IL-5 receptor monoclonal antibody benralizumab: A case report

Eosinophilic chronic rhinosinusitis (ECRS) is characterized by the presence of nasal polyps, dominant ethmoid shadows in computed tomography (CT) scans, and elevated levels of eosinophil infiltration into the nasal polyps and peripheral blood. ECRS is often accompanied by severe asthma. The recent development of monoclonal antibody-based biologics, including benralizumab, has offered new therapeutic approaches for the treatment of asthma and allergic diseases. Asthma and ECRS are closely related; hence, benralizumab could provide clinical benefit in ECRS patients with severe asthma. Herein, we report a case of a 47-year-old female patient with severe asthma that presented with nasal obstruction and hearing impairment. Nasal endoscopic and otoscopic examinations indicated the presence of bilateral nasal polyps in the middle nasal meatus, as well as a bilateral effusion in the tympanic cavity. Sinus and temporal CT images showed dominant ethmoid sinus and tympanic cavity shadows. Biopsy of nasal polyps revealed high numbers of eosinophils, which led to the diagnosis of ECRS; eosinophilic otitis media (EOM) with hypereosinophilia was also suspected. Treatment with benralizumab reduced the number of peripheral blood eosinophils and improved asthma symptoms. Prolonged benralizumab administration also resulted in a remarkable size reduction in bilateral middle nasal polyps and aeration of the tympanic cavity. In conclusion, benralizumab treatment improved the symptoms of severe asthma, ECRS, and EOM. Eosinophil depletion could be an important mechanism by which benralizumab improves ECRS and EOM. The use of benralizumab for the treatment of ECRS and EOM patients with severe asthma merits further investigation in large-cohort studies.

Clinical factors associated with acute exacerbations of chronic rhinosinusitis

BACKGROUND

Chronic rhinosinusitis (CRS) is complicated by frequent acute exacerbations leading to significant health care burden and impaired quality of life.

OBJECTIVE

The objective of this study was to identify clinical factors associated with frequent acute exacerbation of CRS (AECRS).

METHODS

This is a retrospective cohort study of patients with CRS from January 1, 2014, to May 31, 2016. Frequent AECRS was defined as at least 4 episodes over a 12-month period in which an antibiotic was prescribed for worsening sinus symptoms, and infrequent AECRS was defined as 0 to 3 episodes. Clinical factors, including asthma, allergic rhinitis, eosinophil count of at least 150 cells per microliter, and autoimmune disease, were evaluated for associations between the 2 groups.

RESULTS

Of the 3109 patients with CRS who were identified, 600 (19.3%) were classified as having frequent exacerbation. Asthma, allergic rhinitis, eosinophil count of at least 150 cells per microliter, and autoimmune disease were associated with frequent AECRS with statistically significant adjusted odds ratios (aORs) after controlling for age, race, and sex in multivariate analysis (asthma aOR = 2.61 [95% CI = 2.14-3.18]; allergic rhinitis aOR = 1.96 [95% CI = 1.58-2.42]; eosinophil count of at least 150 cells per microliter aOR = 1.54 [95% CI = 1.21-1.97]; and autoimmune disease aOR = 1.68 [95% CI = 1.36-2.07]). Antibody deficiency, antibiotic allergy, lower FEV₁, radiographic sinus disease severity, nasal polyposis, and systemic corticosteroid use were also associated with frequent AECRS.

CONCLUSION

Patients with frequent episodes of AECRS were characterized by a higher prevalence of asthma, allergic rhinitis, eosinophil count of at least 150 cells per microliter, autoimmune disease, and other allergic and immunologic diseases. These findings identify a high-risk phenotype of patients with CRS for preventive interventions to reduce exacerbation frequency.

Update on the Management of Nonsteroidal Anti-Inflammatory Drug Hypersensitivity

The clinical phenotypes of nonsteroidal anti-inflammatory drug (NSAID) hypersensitivity are heterogeneous with various presentations including time of symptom onset, organ involvements, and underlying pathophysiology. Having a correct diagnosis can be challenging. Understanding their respective mechanisms as well as developing a comprehensive classification and diagnostic algorithm are pivotal for appropriate management strategy. Treatment modalities are based on the subtypes and severity of hypersensitivity reactions. Insights into the phenotypes and endotypes of hypersensitivity reactions enable personalized management in patients with suboptimal control of disease. This review updated the recent evidence of pathophysiology, classification, diagnostic algorithm, and management of NSAID hypersensitivity reactions.

The use of biologics in children with allergic rhinitis and chronic rhinosinusitis: Current updates

The therapeutic goals of the treatment of allergic rhinitis (AR) and chronic rhinosinusitis (CRS) are symptom relief, avoiding complications, and improving quality of life. In the treatment of AR and CRS, several limitations of currently prescribed medicines have been identified. Antihistamine administration (both oral and topical) together with intranasal corticosteroids bring relief to the majority of patients, but their dependency on the medications and a necessity to maintain strict compliance with regular medication regimes pose a challenge. Immunotherapeutic agents are an option in some patients, but polysensitized patients, the risk of anaphylaxis, and the need for daily administration for years are limiting it from becoming the main therapy modality. Immunotherapy in any form requires commitment by the patient, which renders adherence and compliance issues particularly relevant. The procedure involved are generally time-consuming and entail an associated risk of severe adverse reactions. The use of biologics could overcome the limitations of other therapeutic modalities. They could be used as a monotherapy or combined with pre-existing medications. The benefits of targeted therapy include less adverse effects and optimal efficacy. The aim of the present review was to investigate the collective literature to date pertaining to the role of biologics in managing children with AR and CRS.

Atopy in chronic rhinosinusitis: impact on quality of life outcomes

BACKGROUND

Chronic rhinosinusitis (CRS), in particular with nasal polyps (CRSwNP), has been linked with skewed T-helper 2 and immunoglobulin E (IgE)-mediated allergic responses. The role of atopy in CRS, however, remains unclear. Correlations between immunological allergic markers and patient-reported outcomes measures (PROMs) were investigated.

METHODS

A cross-sectional study of adult patients with CRS undergoing endoscopic sinus surgery was conducted. Immunological allergic markers included automated immunoassay testing for serum-specific IgE to common allergens (house dust mite, grass, mold, animal epithelia) and total IgE. PROMs were assessed using the 22-item Sino-Nasal Outcome Test (SNOT-22). Patients were defined as atopic based on either a positive specific IgE or elevated total IgE (>160 kU/L).

RESULTS

A total of 446 patients (45.7% female, age 49.05 ± 14.96 years) were recruited, of which 42.8% had asthma, 51.6% had CRSwNP, and 63.0% had eosinophilic CRS. Positive allergen sensitization was detected in 52.9% patients. Total IgE levels were elevated in 28.0% with mean IgE level of 161 ± 269 kU/L. Atopy was associated with younger age at the time of surgery, CRSwNP, asthma, and eosinophilic CRS (eCRS). Atopy was also associated with increased severity in nasal symptom score (13.1 ± 6.4 vs 11.9 ± 6.0, p = 0.04), as well as worse scores in the loss of smell/taste (χ² (1) = 5.97, p = 0.02) and need to blow nose (χ² (1) = 4.26, p = 0.04) questions in the CRS population. In the CRSwNP population, there was no significant association between atopy and PROMs.

CONCLUSION

Comorbid atopy in CRS is associated with additional symptom burden, reflected mainly within the nasal symptom quality of life markers. Atopy assessment in CRS is important to ensure appropriate and successful treatment of the disease.

Recent advances in understanding chronic rhinosinusitis endotypes

Chronic rhinosinusitis (CRS) is a heterogeneous inflammatory disease with an as-yet-undefined etiology. The management of CRS has historically been phenotypically driven, and the presence or absence of nasal polyps has frequently guided diagnosis, prognosis, and treatment algorithms. Research over the last decade has begun to question the role of this distinction in disease management, and renewed attention has been placed on molecular and cellular endotyping and a more personalized approach to care. Current research exploring immunologic mechanisms, inflammatory endotypes, and molecular biomarkers has the potential to more effectively delineate distinct and clinically relevant subgroups of CRS. The focus of this review will be to discuss and summarize the endotypic characterization of CRS and the potential diagnostic and therapeutic implications of this approach to disease management.

Pharmacological Management of Chronic Rhinosinusitis: Current and Evolving Treatments

Chronic rhinosinusitis (CRS) is an inflammatory sinonasal condition with multiple etiologic factors that is associated with a vast economic cost. Treatment is most frequently pharmacologic and has centered on agents that ameliorate inflammation, decrease bacterial or pathogen load, and facilitate egress of mucus or purulence from the sinonasal cavity. Nasal saline irrigations, topical nasal steroids, certain antibiotics, and systemic steroids have shown some efficacy in the management of CRS. Recently, biologic therapeutics that target specific inflammatory pathways associated with subsets of CRS have been developed and evaluated. Early data evaluating these biologic treatments suggest a potential role in treating a subset of CRS with refractory, poorly controlled disease. Additional studies are necessary to identify which patients would benefit most from biologic therapies and to assess the cost of these therapies compared with the benefit they provide. This review describes the pathophysiology of CRS and summarizes both established and novel biologic pharmacologic treatments.

Immunomodulators in chronic rhinosinusitis

Objective

To provide new insight into how chronic rhinosinusitis (CRS) is conceptualized and treated with a focus on immunomodulator therapy.

Data sources

Pubmed, Medline, and Embase.

Methods

A current review of the evidence is provided for immunomodulators investigated for treatment of CRS with nasal polyps (CRSwNP).

Results

Biologic therapies targeting IgE, IL-4, IL-5, and IL-13 for the treatment of CRSwNP have shown promise and are currently in phase 3 trials. Anti-immunoglobin E (IgE) therapy with omalizumab was assessed in 6 studies, anti-interleukin (IL)-5 therapy in 3 studies (2 mepolizumab, 1 reslizumab) and anti IL-4/IL-13 (dupilumab) therapy in one study. Studied outcomes varied, but the majority of trials identified clinical benefit of therapy over placebo. Other potential targets include thymic stromal lymphopoetin (TSLP), IL-25, IL-33, and sialic acid-binding immunoglobulin-type lectin (Siglec)-8. Small molecule drugs that target the dysregulation of the immune system in CRS are also being investigated for their immunomodulatory effects on inflammation.

Conclusion

Immunomodulator therapies for CRS currently in development will likely provide another therapeutic option for patients who have severe disease unresponsive to corticosteroids and surgery. Targeted monoclonal antibody therapies have shown encouraging results and phase 3 trials are underway. IL-4/IL-13 inhibition has shown the most promise to date. Further larger, well-designed trials are needed to improve understanding of these molecules and to offer endotype-driven therapies in the management of CRS. None of these therapeutics have shown long-term immunomodulation when discontinued and therefore further investigation into the pathomechanism of disease continues to be needed.

Biologics in Chronic Rhinosinusitis: An Update and Thoughts for Future Directions

Background Potential biologic therapies for chronic rhinosinusitis (CRS) is a growing field of interest and research. Biologics target specific immune cells or inflammatory pathways within a disease process, increasing drug efficacy while reducing complications. The success of biologics in other inflammatory conditions such as asthma and atopic dermatitis has spurred much of the corresponding research in CRS. A rapid expansion in the volume of research concerning biologic therapies with potential crossover to treating CRS has made it difficult to stay current. Furthermore, much of the literature has been focused on allergy, asthma, and immunology subspecialties. As the role for biologic therapies in CRS continues to expand, it is increasingly important for otolaryngologists to remain up to date on their progression. Objective The objectives of this review are to provide an update on the growing field of biologics for otolaryngologists who treat CRS and discuss potential future areas of research. Methods A literature review of biologic therapies studied in CRS was performed. In addition, a detailed review of all biologic therapies targeting inflammatory markers involved in Th1-, Th2-, and Th17-mediated inflammation was performed to identify potential areas for future research. The role for biologic therapies in CRS, endotypes of CRS, current biologic therapies studies in CRS, and future areas for research were reviewed. Results Sixty-nine unique biologic therapies have been developed for Th1-, Th2-, and Th17-mediated inflammation. Five biologics are currently being investigated for use in patients with CRS with nasal polyposis. Conclusions As the field of biologics continues to expand, remaining up to date on the current literature may help clinicians identify patients who may benefit from biologic therapies. In addition, ongoing research in other inflammatory disorders with shared pathophysiology to CRS may reveal other potential therapies for CRS that have not previously been investigated.

Contemporary Pharmacotherapy for Allergic Rhinitis and Chronic Rhinosinusitis

Chronic rhinosinusitis (CRS) and allergic rhinitis (AR) are chronic conditions causing nasal inflammation. CRS is increasingly recognized as a chronic inflammatory process rather than a chronic infection. Although the primary initiating factors in CRS remain unclear, AR is driven by IgE-mediated hypersensitivity to environmental allergens. Understanding the underlying inflammatory pathways and disease endotypes are driving innovation toward novel pharmacotherapies targeting critical mediators implicated in CRS and AR, including IL-4, IL-13, IL-5, IgE, and epithelial initiators IL-33 and TSLP. Extensive investigations are needed to determine the role, timing, predictive prognostic factors and long-term safety and efficacy of these agents.

Anti-IgE and Anti-IL5 Biologic Therapy in the Treatment of Nasal Polyposis: A Systematic Review and Meta-analysis

OBJECTIVE

To determine the role of biologic therapy on sinonasal symptoms and objective outcomes in chronic rhinosinusitis with nasal polyposis (CRSwNP).

METHODS

PubMed, OVID MEDLINE, and Cochrane Central were reviewed from 2000 to 2015. Inclusion criteria included English-language studies containing original data on biologic therapy in CRSwNP patients with reported outcome measures. Two investigators independently reviewed all manuscripts and performed quality assessment and quantitative meta-analysis using validated tools.

RESULTS

Of 495 abstracts identified, 7 studies fulfilled eligibility: 4 randomized control trials (RCT), 1 case-control, and 2 case series. Outcome measures included nasal polyp score (NPS,6), computer tomography score (5), and symptom scores (5). Meta-analysis was performed on 5 studies: Anti-IL5 therapy (mepolizumab/reslizumab) and anti-IgE therapy (omalizumab) demonstrated a standard mean difference of NPS improvement of -0.66 (95% CI, -1.24 to -0.08) and -0.75 (95% CI, -1.93 to 0.44), respectively, between biologic therapy and placebo. Quality assessment indicated a low to moderate risk of bias for the RCTs.

CONCLUSION

Biologic therapies may prove beneficial in the treatment of recalcitrant nasal polyposis in select populations. In meta-analysis, anti-IL5 therapy demonstrates a reduction in nasal polyp score. Anti-IgE therapy reduces nasal polyp score in patients with severe comorbid asthma. Additional high-level evidence is needed to assess clinical efficacy.

Monoclonal Antibodies for the Treatment of Nasal Polyps

Biologics are novel therapeutic medications developed for the targeted therapy for a variety of inflammatory conditions. The biologics currently investigated for the treatment of chronic rhinosinusitis (CRS) with nasal polyps modulate specific inflammatory pathways involved in the pathogenesis of disease. Investigations have focused on the most severe form of the disease, namely, CRS with nasal polyps. It is hoped that specific targeted therapies using these biologics can significantly modulate the immune system, offering both disease control and symptomatic relief. This review summarizes those therapies that have been used to treat nasal polyps.

Thirty years of endoscopic sinus surgery: What have we learned?

Prior to adaptation of endoscopic approaches for sinonasal pathology, patients regularly endured significant morbidity from open approaches to the sinonasal cavity that were often fraught with failure. With improvements in transnasal endoscopy, functional endoscopic sinus surgery subsequently emerged from the work of Messerklinger and other pioneers in the field. The popularity of endoscopic sinus surgery quickly escalated and expanded to pathology other than inflammation. Here, we discuss the evolution of endoscopic sinus surgery as it relates to improvements in understanding disease pathogenesis, improvements in instrumentation and expansion of indications.

Dendritic cells in inflammatory sinonasal diseases

Dendritic cells (DCs) are critical in linking the innate and adaptive immune responses, which have been implicated in the pathogenesis of many immune and inflammatory diseases as well as the development of tumours. The role of DCs in the pathophysiology of lung diseases has been widely studied. However, the phenotype, subset and function of DCs in upper airways under physiological or pathological conditions remain largely undefined. Allergic rhinitis (AR) and chronic rhinosinusitis (CRS) are two important upper airway diseases with a high worldwide prevalence. Aberrant innate and adaptive immune responses have been considered to play an important role in the pathogenesis of AR and CRS. To this end, understanding the function of DCs in shaping the immune responses in sinonasal mucosa is critical in exploring the pathogenic mechanisms underlying AR and CRS as well as in developing novel therapeutic strategies. This review summarizes the phenotype, subset, function and regulation of DCs in sinonasal mucosa, particularly in the setting of AR and CRS. Furthermore, this review discusses the perspectives for future research and potential clinical utility focusing on DC pathways in the context of AR and CRS.