Mepolizumab for chronic rhinosinusitis with nasal polyps (SYNAPSE): a randomised, double-blind, placebo-controlled, phase 3 trial

Allergic Fungal Rhinosinusitis: A Contemporary Update

OBJECTIVES

To provide a contemporary update on the pathophysiology, diagnosis, and treatment of allergic fungal rhinosinusitis (AFRS).

METHODS

A review article on the pathophysiology, diagnosis, and treatment of AFRS was performed.

RESULTS

AFRS is a subtype of chronic rhinosinusitis with nasal polyps characterized by noninvasive fungal hyphae, eosinophilic mucin, and a type 2 inflammatory response, resulting in significant clinical and radiographic presentations. Although a diagnostic criterion has been used since the 1990s, advances in the pathophysiology and treatment of AFRS question the specificity and applicability of such criteria. Furthermore, the development and progression of AFRS are closely associated with the social determinants of health (SDOH) with a possible genetic component that limits sinonasal antifungal activity. Surgery followed by topical corticosteroids and nasal saline irrigations remains the mainstay of treatment with immunotherapy, antifungals, and biologics having a potential role.

CONCLUSIONS

AFRS is a complex sinonasal inflammatory disease influenced by socioeconomic, genetic, and environmental factors. Future research is needed to investigate the influence of the SDOH on AFRS, advance diagnostic methods to optimize utility in everyday clinical practice and research, and elucidate the role of potential novel medical therapies in the current treatment pathway.

Multi-omics integration and machine learning identify and validate neutrophil extracellular trap-associated gene signatures in chronic rhinosinusitis with nasal polyps

This study aimed to explore the molecular characteristics of neutrophil extracellular traps (NETs) in chronic rhinosinusitis with nasal polyps (CRSwNP). Differentially expressed gene analysis, weighted gene co-expression network analysis, and machine learning algorithms identified three core NETs-associated genes: CXCR4, CYBB, and PTAFR, which were significantly upregulated in CRSwNP patients. The diagnostic performance of these genes was evaluated using receiver operating characteristic (ROC) curves, and their clinical relevance was validated using multicenter data. Immune infiltration analysis showed strong correlations between these genes and neutrophil and immune cell infiltration. Single-cell RNA sequencing demonstrated that these genes were predominantly expressed in myeloid and immune cells and exhibited dynamic changes during disease progression. These genes may contribute to CRSwNP pathogenesis through IL-17 signaling and metabolism-related pathways. This study identifies novel biomarkers and therapeutic targets for precise diagnosis and personalized treatment of CRSwNP.

Biyuantong decoction improves chronic rhinosinusitis by inhibiting inflammatory cell adhesion via NF-кB pathway modulation

ETHNOPHARMACOLOGICAL RELEVANCE

Biyuantong decoction (BYT), a traditional Chinese medicinal formulation, has been used for years to treat chronic rhinosinusitis (CRS) with good clinical results. However, the underlying mechanisms of its treatment for CRS remain to be fully elucidated.

STUDY AIM

This research investigates the molecular mechanism by which BYT ameliorates CRS and provide new perspectives for CRS treatment research.

MATERIALS AND METHODS

Clinical research is conducted on CRS patients who underwent surgery, and post-operative treatments and observations were performed. The pathological alterations of CRS were inspected by H&E staining and nasal endoscopy. Flow cytometry and ELISA were employed to measure the levels of inflammatory cells and cytokines in the peripheral blood of CRS patients. The cytotoxic impacts of BYT were assessed by cell viability, cell cycle and apoptosis assays. The effects of BYT on the adhesion and invasion of inflammatory cells to endothelial cells were evaluated by hetero-adhesion and transwell assay. Flow cytometry was employed to analyze the expression of cell adhesion molecules (CAMs) on HUVECs. The effects of BYT on NF-κB signaling pathway was analyzed by Western blot and immunofluorescence staining. The chemical components of BYT was determined by UPLC-HRMS, and network pharmacology analysis was adopted to predict potential targets in the NF-κB pathway.

RESULTS

Clinical samples demonstrated that BYT treatment could effectively alleviate sinus mucosal edema and significantly decreased the recurrence rate after surgery. H&E staining disclosed obvious inflammatory cell infiltration in the sinus mucosa of CRS patients. Flow cytometry and ELISA results indicated that BYT treatment reduced the levels of eosinophils (median decrease 16.21 %) and cytokines in peripheral blood. Cell adhesion and transwell assays manifested that BYT inhibited the adhesion and invasion of U937 cells to TNF-α-induced HUVECs. Moreover, BYT counteracted the TNF-α-induced upregulation of CAMs on endothelial cells. Western blot and immunofluorescence analyses confirmed that BYT reduced the expression of NF-κB-related proteins and hindered the nuclear translocation of NF-κB. Network pharmacology analysis and component identification of BYT further supported the function of its compounds in synergistically modulating NF-κB signaling.

CONCLUSION

BYT enhances the clinical efficacy of CRS by suppressing inflammatory cell adhesion and infiltration into the nasal mucosa via NF-кB pathway regulation. These findings provide a robust foundation for the clinical application of BYT in CRS treatment and suggest interrupting inflammatory cell adhesion as a potential new approach.

Effects of Different Types of Medications on Olfactory Dysfunction in CRSwNP: A Systematic Review and Network Meta-Analysis

OBJECTIVE

To evaluate the efficacy of various pharmacological treatments for olfactory disorders in patients with chronic rhinosinusitis with nasal polyps (CRSwNP).

DATA SOURCES

PubMed, Embase, Cochrane Library, and Web of Science.

METHODS

We searched the related literature in PubMed, Embase, Cochrane Library, and Web of Science up to Aug 2024 to appraise the effects of pharmacotherapy on olfactory sensation. After that, two reviewers independently screened the retrieved articles, extracted the pertinent data, and assessed the risk of bias in the included studies. Then we used Stata 14.2 to perform a network meta-analysis.

RESULTS

Ninteen randomized controlled trials (RCTs) and 2354 participants were included. Compared with placebo, biologics demonstrated the most significant improvement in subjective olfactory dysfunction (OD) [standardized mean difference (SMD) = -0.75, 95% confidence intervals (CI) (-1.08, -0.41)]. In terms of objective olfactory function improvement, biologics also exhibited the greatest effect (SMD = 0.93, 95% CI [0.56, 1.31]). Among various biologics, dupilumab was the most effective in alleviating both subjective OD (SMD = -1.30, 95% CI [-1.51, -1.09]) and objective OD (mean difference [MD] = 11.13, 95% CI [9.91, 12.35]).

CONCLUSIONS

Our research results indicated that biologics might show better performance in terms of improving the olfactory sensation of patients with CRSwNP, particularly dupilumab. However, given the limitations of this study, future research should employ more standardized olfactory assessment methods and conduct more large-scale RCTs, ultimately guiding clinicians and patients in making informed and optimal treatment choices.

LEVEL OF EVIDENCE

NA.

Rhinosinusitis: Evidence and experience - 2024

It has been 10-years since the publication of Rhinosinusitis: evidence and experience, and since then a lot has changed in our understanding of the disease. Advances in pathophysiology, endotyping and new treatments such as biologics brought a new era in the management of our patients. This new guideline, developed jointly by ABR and ABORL-CCF, with the help of ASBAI presents an updated, evidence-based approach to the different forms of rhinosinusitis that aims to improve the diagnosis and treatment of this complex disease. The document covers a wide range of topics, including clear definitions of the different stages of acute sinusitis. It also introduces a new term called Prolonged Acute Viral Rhinosinusitis. Reviews phenotypes and endotypes of chronic rhinosinusitis, recommending methods for clinical and laboratory investigation, clinical and surgical treatment. We also discuss in detail fungal sinusitis and pediatric sinusitis. The objective of this updated Consensus is to clarify some already established and recent concepts, highlighting the importance of an accurate diagnosis to promote treatment approaches that reflect the best practices based on solid evidence. Therefore, we seek not only to improve the results of patients care, but also to guide thealth professionals through a clinical panorama that is in constant transformation.

Depemokimab in chronic rhinosinusitis with nasal polyps: A turning point or a missed opportunity?

The ANCHOR-1 and ANCHOR-2 trials of the long-acting anti-interleukin (IL)-5 monoclonal antibody depemokibab in chronic rhinosinusitis with nasal polyposis demonstrated the safety and statistical efficacy of the drug compared to placebo.1 However, its clinical benefits appear limited compared to other biologic therapies. The reduced dosing interval may improve adherence, but further research is needed to identify the most responsive patients.

Reappraisal of Biologic Efficacy from Phase 3 Trials in Refractory Chronic Rhinosinusitis and Nasal Polyps

Chronic rhinosinusitis with nasal polyps (CRSwNP) is commonly associated with type 2 inflammation and may be punctuated by exacerbations requiring systemic corticosteroids and eventually a need for surgery. The use of biologics to target type 2 inflammation has greatly ameliorated the management of refractory CRSwNP. Currently available biologics act upstream by blocking the epithelial cytokine thymic stromal lymphopoietin (TSLP) or downstream blocking type 2 cytokines including Interleukin (IL4), IL5, and IL13, or Immunoglogulin E (IgE). Synthesizing the data from phase 3 randomized control trials using Forest plots to compare crude 95% confidence intervals permits an indirect comparison of different biologics in terms of their relative efficacy. Anti-TSLP (tezepelumab) or anti-IL4Rα (dupilumab) provide the best improvements in coprimary end points of nasal polyp and congestion score compared with other biologics including anti-IL5/5Rα (mepolizumab, depemokimab, and benralizumab) and anti-IgE (omalizumab). Greater improvements were also seen with tezepelumab and dupilumab in regard to olfaction as loss of smell score and University of Pennsylvania Smell Identification Test, computerized tomography sinus imaging as Lund Mackay score, and also the need for surgery or rescue use of systemic corticosteroid. Prospective pragmatic studies are required to directly compare different biologics in type 2 high and low CRSwNP, including effects on the unified airway in patients with severe asthma and CRSwNP, in particular to look at quality of life as well as clinical remission for upper and lower airway outcomes.

Long-Term Effectiveness of Dupilumab in Severe Uncontrolled Chronic Rhinosinusitis with Nasal Polyps: A Multicenter Retrospective Study

BackgroundChronic rhinosinusitis with nasal polyps (CRSwNP) is a complex immunological disease associated with significant morbidity and reduced health-related quality of life. Dupilumab is an anti-T2-inflammatory biological drug registered for chronic rhinosinusitis with nasal polyps, indicated by integrated care pathways when optimal medico-surgical treatment yields insufficient control of sinonasal symptoms.ObjectiveThe purpose of this study was to confirm the long-term efficacy of dupilumab in the treatment of severe uncontrolled CRSwNP.MethodsMulticentric data collection of patients with severe uncontrolled CRSwNP treated with Dupilumab was retrospectively performed. Mixed Model Anova test was used to evaluate the effect of the biological therapy in the improvement of nasal polyp score and quality of life measured with Sinonasal Outcome Test-22 (SNOT-22) and visual analog scale (VAS) scores.ResultsThe study showed a statistically significant and progressive improvement in the Nasal Polyp Score with a decrease from a median baseline value of 6 (IQR 5-6) to 0 (IQR 0-2) at 24 months. Furtherly, optimal results were found for SNOT-22 scores from baseline (62 ± 19) to 6 months (15± 11), with further variations on each successive timepoint remaining below the minimal clinically important difference. VAS scores of nasal obstruction, rhinorrhea, sleep disorders, and craniofacial pain, demonstrated consistent and significant improvements over time until one year of treatment, confirming substantial relief for the most pertinent symptoms of the conditionConclusionsThe results of this study show high therapeutic efficacy and safety of dupilumab for severe CRswNP particularly in the first 6-12 months, with sustained benefits up to 24 months.

Clinical and mechanistic advancements in aspirin exacerbated respiratory disease

Aspirin-exacerbated respiratory disease (AERD) is characterized by the clinical triad of chronic rhinosinusitis with nasal polyps, asthma, and a hypersensitivity to nonsteroidal anti-inflammatory drugs (NSAIDs). AERD is estimated to occur in as many as 15% of patients with chronic rhinosinusitis with nasal polyps and/or asthma. Uniquely, patients with AERD develop respiratory symptoms within 30 to 180 minutes after ingesting NSAIDs such as aspirin or ibuprofen. However, even in the absence of NSAIDs, patients tend to have more severe upper and lower respiratory disease. The underlying pathogenic mechanisms contributing to AERD are complex and intertwined; they include a systemic dysregulation in arachidonic acid metabolism, an aberrant inflammatory response, a disruption in the respiratory epithelial barrier, and an imbalance between the formation and degradation of fibrin locally in nasal polyps. This review will highlight novel mechanistic findings contributing to the pathogenesis of AERD. In addition, recent advancements in the clinical understanding and management of patients with AERD will be discussed.

Clinical Effects and Response Time of Biological Drugs in Chronic Rhinosinusitis with Nasal Polyps Patients: Real-life Experience

OBJECTIVE

Chronic Rhinosinusitis with Nasal Polyps (CRSwNP) is a challenging condition often managed with biologic therapies. This study compares the clinical effects and response times of dupilumab, omalizumab, and mepolizumab in Italian patients with severe uncontrolled CRSwNP.

METHODS

This bicentric, retrospective study included 33 patients treated at two Italian hospitals between April and December 2023. Inclusion criteria followed EPOS 2020 guidelines, focusing on adults with bilateral polyposis, history of endoscopic sinus surgery, and evidence of type 2 inflammation. Patients self-administered biologics according to AIFA protocols. Outcomes were assessed using SNOT-22 for quality of life, Nasal Polyp Score (NPS) for polyp size, and Sniffin' Sticks-12 for olfactory function at baseline, 4 weeks, 3, 6, and 9 months.

RESULTS

All three treatment groups (dupilumab, omalizumab, mepolizumab) showed significant improvements in SNOT-22 scores from baseline to 9 months, with no significant differences between groups. Dupilumab showed the most rapid and sustained improvement in NPS, with significant reductions observed from 4 weeks onward. Both omalizumab and mepolizumab showed significant NPS reductions by 6 months. Olfactory function improved significantly in the dupilumab group, with a notable decrease in anosmic patients from 64.3% to 28.6% at 9 months. Asthma control, measured by Asthma Control Test (ACT) scores, improved across all groups.

CONCLUSION

Dupilumab, omalizumab, and mepolizumab significantly improve quality of life and reduce nasal polyp size in CRSwNP patients, with dupilumab showing the fastest response. These findings support the effectiveness of biologics in real-world settings for managing severe CRSwNP.

LEVEL OF EVIDENCE

3 Laryngoscope, 135:1628-1635, 2025.

Improving patient outcomes: Mepolizumab's impact in IL-5-mediated diseases

ABSTRACT

The Interleukin-5 (IL-5)-mediated pathogenic role of eosinophils in airway disorders including severe eosinophilic asthma (SEA), chronic rhinosinusitis with nasal polyps (CRSwNP), eosinophilic granulomatosis with polyangiitis (EGPA), and rare hyper-eosinophilic syndrome (HES) is well established. Mepolizumab, an IL-5-targeting humanised antibody, is approved as an add-on maintenance therapy for SEA, EGPA, CRSwNP, and HES. Here, we review the safety and efficacy findings of mepolizumab in clinical trials and real-world evidence studies in patients with SEA, CRSwNP, EGPA, and HES. We specifically explore the data on mepolizumab that support early initiation of IL-5-targeted therapy to maximise its corticosteroid-sparing effect. This review consolidates the clinical data on mepolizumab, highlights other promising IL-5-targeting agents, and supports the IL-5 pathway as the key therapeutic target across eosinophilic indications.

Investigation of PDE5 effect on NOS in nasal polyp pathophysiology

PURPOSE

Nasal polyps are masses resulting from chronic mucosal inflammation. Nitric oxide (NO) has recently attracted attention in nasal polyps as it plays an important role in both acute and chronic inflammation. One of the important mechanisms controlling NO production is phosphodiesterase (PDE) enzymes. The enzyme phosphodiesterase type 5 (PDE5) is an important regulator of cyclic guanosine 3'-5'-monophosphate (cGMP) signalling. PDE5 inhibitors increase intracellular cGMP concentration by inhibiting cGMP degradation and prolong NO signalling. NO is thought to cause nasal congestion because it increases microvascular permeability and causes mucosal oedema. The aim of our study was to investigate the role of PDE5, inducible nitric oxide synthase (iNOS), and endothelial nitric oxide synthase (eNOS) in the pathophysiology of nasal polyps with mucosal oedema in histopathology.

METHODS

Nasal mucosal tissues were obtained from 25 patients with nasal polyps who underwent endoscopic sinus surgery as the study group and 25 patients who underwent rhinoplasty as the control group. eNOS, iNOS and PDE5 levels were measured in nasal mucosal tissues.

RESULTS

The mean age was 47.40 ± 16.33 years in the nasal polyp group and 35.44 ± 12.47 years in the normal group, and 64.0% (n = 16) of both groups were male. ELISA measurements showed that PDE5 levels were significantly decreased and iNOS and eNOS levels were significantly increased in the nasal polyp group compared with the control group. CONCLUSıON: This study suggest that iNOS, eNOS, and PDE5 may play important roles in the pathophysiology of nasal polyps.

Allergic Fungal Rhinosinusitis Diagnosis, Management, Associated Conditions, Pathophysiology, and Future Directions: Summary of a Multidisciplinary Workshop

Allergic fungal rhinosinusitis (AFRS) is a unique endotype of chronic rhinosinusitis with nasal polyps (CRSwNP). Despite high recurrence rates and often more severe presenting signs compared with other subtypes of CRSwNP, research dedicated to AFRS has been lacking. Diagnostic criteria are outdated, the mechanistic relationship of AFRS to other associated diseases is unclear, and the pathophysiology of disease and risk factors for recurrence have not been well studied. In December 2023, a multidisciplinary group of rhinologists, otolaryngologists, pulmonologists, allergists, immunologists, scientists, and infectious disease experts met at the National Institute of Health to discuss unmet needs for future AFRS research and care, including patient management, diagnostic criteria, severity, pathophysiology, and related conditions. A summary of these clinical and associated research discussions is included below.

Comorbidities and multimorbidity in asthma

PURPOSE OF REVIEW

To describe the associations between asthma and relevant comorbidities, and appraise the latest evidence on the management strategies of asthmatics with comorbid conditions.

RECENT FINDINGS

Conditions such as allergic rhinitis, chronic rhinosinusitis with and without nasal polyps, gastroesophageal reflux disease, obesity, chronic obstructive pulmonary disease, bronchiectasis, anxiety and depression have been linked to worse outcomes in asthma. Recognition and treatment of these conditions is important in asthma, particularly in those with uncontrolled or severe asthma. Biologics for asthma have been effective in those with chronic rhinosinusitis with nasal polyps and chronic obstructive pulmonary disease (COPD), with emerging evidence in bronchiectasis. Weight loss programs with diet and exercise improve asthma control. Anxiety and depression are often unrecognized in patients with asthma.

SUMMARY

Comorbid conditions have been recognized as important factors in the diagnosis and treatment of asthma, particularly in patients who have severe disease and remain uncontrolled. Comorbidities in asthma are correlated with poor quality of life and asthma control, increased healthcare utilization and their treatment is associated with improved outcomes.

Obesity: Next game changer of allergic airway diseases?

Obesity and allergic diseases are global health concerns, both of which are seeing an increase in prevalence in recent years. Obesity has been recognised as an important comorbidity in subpopulations with allergic airway diseases, which represents a unique phenotype and endotype. Obesity-related allergic airway diseases are associated with exacerbated clinical symptom burden, altered immune response, increased disease severity and compromised predictive capability of conventional biomarkers for evaluating endotype and prognosis. Moreover, treatment of obesity-related allergic airway diseases is challenging because this unique endotype and phenotype is associated with poor response to standard therapeutic strategies. Therapeutic regimen that involves weight loss by non-surgical and surgical interventions, gut microbiome-targeted treatment, glucagon-like peptide-1 receptor agonist and other agents should be considered in this population. In this review, we outline the current knowledge of the impact of obesity on prevalence, endotypes, clinical symptom and management of allergic airway diseases. Increased understanding of the implications of obesity may contribute to better treatment options for the obesity-related refractory airway inflammation, particularly in precision medicine. KEY POINTS: Obesity can increase the prevalence of allergic airway diseases such as asthma, AR, and CRSwNP. Obesity alters the immune endotype and exacerbates clinical symptoms of respiratory allergic diseases. Obesity-related allergic airway diseases exhibit therapeutic resistance to standard treatment. Obesity-related allergic airway diseases constitute a distinct category of endotypes and phenotypes, requiring further in-depth research and novel therapeutic approaches.

Efficacy and Safety of Biologics for Chronic Rhinosinusitis With Nasal Polyps: A Meta-Analysis of Real-World Evidence

Dupilumab, omalizumab, mepolizumab, and benralizumab have demonstrated good efficacy and safety in the treatment of severe uncontrolled chronic rhinosinusitis with nasal polyps (CRSwNP) in phase 3 randomised controlled trials (RCTs). With recent regulatory approvals, there has been a surge in real-world studies (RWSs). This systematic review and meta-analysis aimed to summarise the efficacy and safety of these four biologics in real-world settings. Primary outcomes were nasal polyp score and sino-nasal outcome test-22 score. Secondary outcomes included smell identification test score, loss of smell score, nasal congestion score, overall nasal symptom score, treatment response, and adverse events (AEs) prompting discontinuation. Efficacy outcomes at 4, 6, 12, and over 12 months were summarised, and meta-analyses of mean changes from baseline were conducted. Sixty-four RWSs involving 3921 patients were included. Significant improvements in clinical outcomes were observed at most follow-up time points, with dupilumab showing particularly notable effects. The efficacy observed in these RWSs was superior to that demonstrated in phase 3 RCTs. All biologics exhibited low discontinuation rates due to AEs. Overall, biologic treatments for CRSwNP in real-world settings demonstrate strong efficacy and good safety. However, the limitations in current RWSs highlight the need for long-term, high-quality multicentre prospective studies and comprehensive healthcare database analyses.

Efficacy and safety of GR1802 in uncontrolled chronic rhinosinusitis with nasal polyps: Placebo-controlled phase 2 trial

BACKGROUND

Anti-IL-4 receptor subunit alpha (IL-4Rα) treatments can effectively treat eosinophilic chronic rhinosinusitis with nasal polyps (ECRSwNP). However, their impact on the overall population of patients with uncontrolled CRSwNP remains unclear.

OBJECTIVES

We evaluated the safety and efficacy of GR1802, a novel anti-IL-4Rα monoclonal antibody, in patients with uncontrolled CRSwNP.

METHODS

Seventy patients with uncontrolled CRSwNP were randomized (1:1) to receive either GR1802 (300 mg with an initial doubled dose) or placebo every 2 weeks. Primary end points were the changes from baseline in nasal polyp score and nasal congestion score at week 16. Secondary end points mainly included change from baseline in Total Nasal Symptom Score (TNSS), 22-item Sino-Nasal Outcome Test (SNOT-22) score, and Lund-Mackay score. Efficacy (exploratory) was also analyzed in ECRSwNP and non-ECRSwNP subgroups. Safety was evaluated throughout the study.

RESULTS

In uncontrolled CRSwNP participants, GR1802 significantly improved nasal polyp score and nasal congestion score compared with placebo, with least squares mean differences of -2.1 (95% confidence interval, -2.6, -1.5) and -0.8 (95% confidence interval, -1.1, -0.4), respectively. Participants treated with GR1802 had significantly decreased TNSS, SNOT-22 score, and Lund-Mackay score. The subgroup analysis demonstrated that GR1802 improved the symptoms and quality of life in both ECRSwNP and non-ECRSwNP participants, as evidenced by changes in nasal polyp score, University of Pennsylvania Smell Identification Test score, and Lund-Mackay score. Treatment-related adverse events occurred in 19.4% of the GR1802 group and 17.6% of the placebo group.

CONCLUSION

GR1802 is well tolerated and effective in treating the overall population with uncontrolled CRSwNP.

Chinese Position Paper on Biologic Therapy for Chronic Rhinosinusitis With Nasal Polyps

Emerging biologics that selectively target key cytokines present a promising therapeutic alternative for patients suffering from severe, uncontrollable chronic rhinosinusitis with nasal polyps (CRSwNP). Despite the limited availability of registered biologics for CRSwNP treatment in China, the country is experiencing rapid development in this field. It is imperative to standardize the application of biologic agents in CRSwNP management in preparation for their future integration into the CRSwNP care pathway. The Rhinology Group, Chinese Society of Otorhinolaryngology-Head and Neck Surgery; the Rhinology Group, Chinese Medical Doctor Association of Otorhinolaryngology-Head and Neck Surgery; and the Nasal and Ocular Allergy Group, Chinese Society of Allergy have convened an expert panel consisting of principal investigators experienced in clinical trials of biologic treatment for CRSwNP. This expert panel was assembled to discuss the application of biologic agents in patients with CRSwNP in China. Additionally, the latest findings on the pathogenesis of CRSwNP, mechanisms of biologic agents, and efficacy and safety of biologic treatment in patients with CRSwNP were reviewed, with a special emphasis on research evidence from China. The expert panel reached a consensus on several critical issues, including criteria for the prescription, treatment course, and efficacy evaluation from a Chinese perspective. This position paper aims to guide Chinese physicians in the use of biologic agents for patients with CRSwNP. As our experience with biologic treatment continues to grow, this position paper will be further updated.

Guidance for type 2 inflammatory biomarkers

Type 2 inflammation in the airways and lungs is inflammation induced by type 2 cytokines such as IL-4, IL-5, and IL-13, produced primarily by type 2 helper T cells and type 2 innate lymphoid cells, and causes changes in the physiology and structure of the airways. Type 2 inflammation is currently in the spotlight because of its direct link to the treatment of several airway and lung diseases. Abundant evidences have accumulated that inflammatory biomarkers such as blood eosinophils, fractional exhaled nitric oxide, and IgE are essential clinical tools in the diagnosis and management of asthma and COPD. It is well known that asthma and COPD have diverse inflammatory phenotypes even when clinical features are similar, and it has been demonstrated that assessment of airway inflammation with biomarkers can improve diagnostic accuracy, determine safer and more effective treatment strategies, and predict future risks such as exacerbations and lung function decline. The Japanese Respiratory Society has published clinical practice guidelines for the evaluation of type 2 inflammation in the airways and lungs. In addition to asthma and COPD, the guide covers a wide range of airway and lung diseases, including interstitial lung disease, allergic bronchopulmonary mycosis, allergic rhinitis, and eosinophilic chronic rhinosinusitis. It also provides comprehensive guidelines covering a variety of clinical biomarkers. The purpose of this guidance is to provide evidences for the interpretation of type 2 inflammation measurements and to promote the widespread use of inflammation assessment to further improve the efficiency of airway and respiratory disease management.

Clinical efficacy and mechanisms of biologics for chronic rhinosinusitis with nasal polyps

The management of chronic rhinosinusitis with nasal polyps (CRSwNP) can be challenging, particularly when standard treatments including intranasal corticosteroids and endoscopic sinus surgery do not result in adequate symptom control. CRSwNP is frequently characterized by a type 2 immune signature, and many patients have other comorbid type 2 conditions, including asthma. There are currently 3 biologic therapies approved for the treatment of CRSwNP-omalizumab, mepolizumab, and dupilumab-and there are promising therapies in development. Biologic therapies allow for improved patient quality of life in CRSwNP, reduction in need for systemic corticosteroid treatment and endoscopic sinus surgery, and improvement in treatment of comorbidities. Translational studies assessing how biologic therapies can modify inflammation in CRSwNP have allowed for a greater understanding of CRSwNP pathogenesis. We review CRSwNP clinical trial and real-world data on the effectiveness and safety of biologics, discuss their therapeutic mechanisms, assess outcomes of biologic therapy versus endoscopic sinus surgery, and discuss therapies in development and future directions.

Long-term efficacy and safety of different biologics in treatment of chronic rhinosinusitis with nasal polyps: A network meta-analysis

OBJECTIVES

Direct comparison of the long-term effectiveness and safety of biologics for Chronic Rhinosinusitis with Nasal Polyps (CRSwNP) is lacking. The study aimed to compare the long-term efficacy and safety of various biologics in the management of CRSwNP.

METHODS

The PubMed, Embase, Cochrane Library, and Web of Science databases were searched from database inception to March 2024, to identify all relevant literature on the use of biologics for CRSwNP. The research protocol was registered on PROSPERO.Two independent reviewers screened the studies, extracted the data, and performed a quality assessment using the Cochrane Risk of Bias tool. Network meta-analysis was conducted using STATA 17.0 and Review Manager (Version 5.3).

RESULTS

Six studies with a minimum follow-up period of 52-weeks were analyzed, demonstrating the superior long-term efficacy of dupilumab compared to the other three biologics. The surface under the cumulative ranking curve were 100% for Nasal Polyp Score (NPS), 72.7% for Sino-Nasal Outcome Test-22 (SNOT-22), 94.6% for Visual Analogue Scale (VAS), and 100% for Nasal Congestion Score (NCS). In the comparison of NPS, dupilumab showed improvements of 1.84 (95% Confidence Interval [95% CI 0.78, 2.91]) over mepolizumab and 2.31 (95% CI 0.99, 3.63) over benralizumab. Among the symptom scores evaluated, only dupilumab achieved a significant improvement in NCS compared to benralizumab, with an improvement of 0.74 (95% CI 0.86, 1.19). No significant differences in adverse events was observed between biologics treatment or versus placebo.

CONCLUSION

Treatment with dupilumab in patients with CRSwNP has shown superior long-term efficacy in reducing NPS and various symptom scores compared to other biologics. However, the results should be interpreted with caution due to the heterogeneity of patient characteristics across the included studies (e.g., disease severity, history of surgery, use of oral corticosteroids).

The immunology of asthma and chronic rhinosinusitis

Asthma and chronic rhinosinusitis (CRS) are common chronic inflammatory diseases of the respiratory tract that have increased in prevalence over the past five decades. The clinical relationship between asthma and CRS has been well recognized, suggesting a common pathogenesis between these diseases. Both diseases are driven by complex airway epithelial cell and immune cell interactions that occur in response to environmental triggers such as allergens, microorganisms and irritants. Advances, including a growing understanding of the biology of the cells involved in the disease, the application of multiomics technologies and the performance of large-scale clinical studies, have led to a better understanding of the pathophysiology and heterogeneity of asthma and CRS. This research has promoted the concept that these diseases consist of several endotypes, in which airway epithelial cells, innate lymphoid cells, T cells, B cells, granulocytes and their mediators are distinctly involved in the immunopathology. Identification of the disease heterogeneity and immunological markers has also greatly improved the protocols for biologic therapies and the clinical outcomes in certain subsets of patients. However, many clinical and research questions remain. In this Review, we discuss recent advances in characterizing the immunological mechanisms of asthma and CRS, with a focus on the main cell types and molecules involved in these diseases.

[Diagnosis and drug therapy of chronic rhinosinusitis]

Chronic rhinosinusitis is one of the most common chronic diseases of the upper respiratory tract and is associated with a significant reduction in quality of life. Precise diagnostic workup is therefore necessary to provide patients with adequate treatment. The introduction of biologics has opened up new options for the treatment of severely affected patients with chronic rhinosinusitis with nasal polyps in the sense of precision medicine that goes beyond the mere control of symptoms. This has been accompanied by a certain degree of standardization with regard to diagnostic procedures and the assessment of disease-specific quality of life. Against the background of the 2025 congress theme "Individualization vs. standardization in otorhinolaryngology," this paper examines and summarizes the diagnosis and drug therapy of chronic rhinosinusitis, with a focus on biologic therapy.

Biological therapy in chronic rhinosinusitis with nasal polyps

INTRODUCTION

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a heterogeneous disease. High proportions of patients with CRSwNP characterized by type 2 inflammation fail to gain adequate control with conventional treatment. The application of biologics in clinics and assessments of novel biologics in clinical trials are blooming in expectations to fulfill the unmet medical needs of patients with CRSwNP with type 2 inflammation.

AREAS COVERED

After an extensive search of PubMed, Medline, and EMBASE for the most recent evidence, we thoroughly summarize current advances in biological therapies for treating patients with CRSwNP.

EXPERT OPINION

In recent years, biological therapy has been in the spotlight in clinical studies on CRSwNP. Biologics have proven to be efficacious in reducing nasal polyp size, alleviating CRSwNP-related symptoms, improving quality of life, and reducing the need for systemic corticosteroids or endoscopic sinus surgery for nasal polyps. The considerable efficacy and safety profile of biologics has offered patients with refractory CRSwNP another treatment option. However, some concerns remain to be addressed. Aspects such as the position of biological therapy in the management of CRSwNP, traits of patients suitable for certain biologics, etc. necessitate efforts to elucidate these unknowns in order to provide patients with tailored therapy.

Neuroimmune mechanisms of type 2 inflammation in the skin and lung

Type 2 inflammation has a major role in barrier tissues such as the skin and airways and underlies common conditions including atopic dermatitis (AD) and asthma. Cytokines including interleukin 4 (IL-4), IL-5, and IL-13 are key immune signatures of type 2 inflammation and are the targets of multiple specific therapeutics for allergic diseases. Despite shared core immune mechanisms, the distinct structures and functions of the skin and airways lead to unique therapeutic responses. It is increasingly recognized that the nervous system has a major role in sensing and directing inflammatory processes. Indeed, crosstalk between type 2 immune activation and somatosensory functions mediates tissue-specific signatures such as itching in the skin. However, neuroimmune interactions are shaped by distinct neuronal and immune landscapes, and differ between the skin and airways. In the skin, dorsal root ganglia-derived neurons mediate pruritus via type 2 cytokines and neurogenic inflammation by mast cell or basophil activation. Conversely, vagal ganglia-derived neurons regulate airway immune responses by releasing neuropeptides/neurotransmitters such as calcitonin gene-related peptides, neuromedin U, acetylcholine, and noradrenaline. Sensory neuron-derived vasoactive intestinal peptide forms a feedback loop with IL-5, amplifying eosinophilic inflammation in the airways, a mechanism that is absent in the skin. These differences influence the efficacy of cytokine-targeted therapies. For instance, IL-4/IL-13-targeted therapies like dupilumab demonstrate efficacy in AD and allergic airway diseases, whereas IL-5-targeted therapies are effective in eosinophilic asthma but not AD. Understanding these neuroimmune interactions underscores the need for tailored therapeutic approaches to address allergic diseases where barrier tissues are involved.

How does asthma coexistence affect the strategic selection of biologic therapies in CRSwNP management?

Objectives

We reviewed asthma coexistence and the selection of biologic therapies in CRSwNP Management.

Methods

The literature review utilized Google and Google Scholar, in addition to PubMed, EBSCO, and Proquest Central at Kırıkkale University. We searched for " CRSwNP", "asthma", "biologic therapies", "Anti-IL-4RA", "Dupilumab", "Anti-IgE", "Omalizumab", "Anti-IL-5", "mepolizumab" from 2024 to 2000.

Results

Patients with CRSwNP frequently have co-occurring lower airway illnesses, including asthma and AERD asthma, which have a shared pathogenesis. The inflammatory bases of CRSwNP and asthma might be heterogeneous, with a type 2 or, less frequently, a non-type two inflammatory history. Lower airway inflammation and asthma control are worse in patients with asthma who also have CRSwNP. Patients with CRSwNP can now access targeted biologic medicines, a novel therapy option. The US Food and Drug Administration (FDA) has authorized three medications for CRSwNP: dupilumab, omalizumab, and mepolizumab. To treat chronic rhinosinusitis with a biological agent, the 2020 European position paper on rhinosinusitis established clear indications. A patient is considered a biologic therapy candidate if they have either undergone FESS before or did not meet FESS criteria but met three of the five. A diagnosis of concomitant asthma, necessitating an inhaled glucocorticoid controller regularly, is one of the five requirements.

Conclusion

Biologic treatments have the potential to be used in certain patients where CRSwNP and asthma coexist. The recommended treatments include omalizumab, dupilumab, and mepolizumab.

Tezepelumab in Adults with Severe Chronic Rhinosinusitis with Nasal Polyps

BACKGROUND

Treatment with tezepelumab has been effective for sinonasal symptoms in patients with severe, uncontrolled asthma and a history of chronic rhinosinusitis with nasal polyps, but its efficacy and safety in adults with severe, uncontrolled chronic rhinosinusitis with nasal polyps is unknown.

METHODS

We randomly assigned adults with physician-diagnosed, symptomatic, severe chronic rhinosinusitis with nasal polyps to receive standard care and either tezepelumab (at a dose of 210 mg) or placebo subcutaneously every 4 weeks for 52 weeks. The coprimary end points were the changes from baseline in the total nasal-polyp score (range, 0 to 4 [for each nostril]; higher scores indicate greater severity) and the mean nasal-congestion score (range, 0 to 3; higher scores indicate greater severity) at week 52. Key secondary end points assessed in the overall population were the loss-of-smell score, the total score on the Sinonasal Outcome Test (SNOT-22; range, 0 to 110; higher scores indicate greater severity), the Lund-Mackay score (range, 0 to 24; higher scores indicate greater severity), the total symptom score (range, 0 to 24; higher scores indicate greater severity), and the first decision to treat with nasal-polyp surgery or use of systemic glucocorticoid therapy, or both, assessed in time-to-event analyses (individual and composite).

RESULTS

In total, 203 patients were assigned to receive tezepelumab and 205 to receive placebo. At week 52, the patients who received tezepelumab had significant improvements in the total nasal-polyp score (mean difference vs. placebo, -2.07; 95% confidence interval [CI], -2.39 to -1.74) and the mean nasal-congestion score (-1.03; 95% CI, -1.20 to -0.86) (P<0.001 for both scores). Tezepelumab significantly improved the loss-of-smell score (mean difference vs. placebo, -1.00; 95% CI, -1.18 to -0.83), SNOT-22 total score (-27.26; 95% CI, -32.32 to -22.21), Lund-Mackay score (-5.72; 95% CI, -6.39 to -5.06), and total symptom score (-6.89; 95% CI, -8.02 to -5.76) (P<0.001 for all scores). Surgery for nasal polyps was indicated in significantly fewer patients in the tezepelumab group (0.5%) than in the placebo group (22.1%) (hazard ratio, 0.02; 95% CI, 0.00 to 0.09); there was significantly less use of systemic glucocorticoids with tezepelumab (5.2%) than with placebo (18.3%) (hazard ratio, 0.12; 95% CI, 0.04 to 0.27) (P<0.001 for both time-to-event analyses).

CONCLUSIONS

Tezepelumab therapy led to significantly greater reductions in the size of nasal polyps, the severity of nasal congestion and sinonasal symptoms, and the use of nasal-polyp surgery and systemic glucocorticoids than placebo in adults with severe, uncontrolled chronic rhinosinusitis with nasal polyps. (Funded by AstraZeneca and Amgen; WAYPOINT ClinicalTrials.gov number, NCT04851964.).

Mechanistic studies on the role of CHI3L1 in eosinophilic inflammation in chronic sinusitis

More than 10% of adults suffer from chronic rhinosinusitis (CRS), a chronic inflammatory condition that lowers quality of life, reduces productivity, and shortens work hours. Every year, more than 1 million surgeries are performed worldwide as a result of CRS. In recent years, targeted therapy for CRS has become a hotspot of research at home and abroad and has made significant progress, but CRS still has a high recurrence rate. Therefore CRS urgently needs precise targeted therapy. In the pathological process of CRS, the involvement of eosinophils is an important inflammatory mechanism. And excessive aggregation of eosinophils often leads to severe inflammatory responses. Studies have shown that chitinase 3-like protein 1 (CHI3L1) plays a key role in the activation and migration of eosinophils. This review will combine the latest research results to analyse in detail the biological properties of CHI3L1, its expression pattern in CRS, and the possible mechanisms by which it affects eosinophil aggregation by regulating immune responses and inflammatory processes, which will provide insights into the key role of CHI3L1 in the pathological process of CRS and offer a new target for the treatment of CRS.

Study protocol for a randomized double-blinded placebo-controlled trial on mepolizumab for patients with chronic rhinosinusitis with nasal polyps, NSAID exacerbated respiratory disease and asthma

Background

Chronic rhinosinusitis with nasal polyps (CRSwNP) is an inflammatory disease of the nose and paranasal sinuses that significantly impactshealth-related quality of life. Nonsteroidal anti-inflammatory drug (NSAID) -exacerbated respiratory disease (N-ERD) affects approximately one fifth of CRSwNP patients. N-ERD and asthma increase the risk of uncontrolled CRSwNP as measured by frequent sinus surgeries and rescue treatment. Compared to non-N-ERD patients, those with N-ERD also have higher risk of asthma exacerbations, severe allergic reactions, and anosmia. Mepolizumab is a humanized monoclonal anti-IL-5 antibody shown to be effective in treating severe eosinophilic asthma and CRSwNP. While evidence suggests that mepolizumab alleviates respiratory symptoms in N-ERD patients, placebo-controlled studies remain limited.

Methods

The aim of this prospective randomized, placebo-controlled, multicenter study is to investigate whether mepolizumab reduces polyp size, symptom scores, and exacerbations more than placebo during the 16-week treatment period in patients with uncontrolled CRSwNP, N-ERD and asthma. Additionally, we will examine the effect of mepolizumab on drug dosage and lung and nasal function and evaluate predictive biomarkers.We will recruit 120 patients with N-ERD, nasal polyposis and asthma in three centers in Finland. Patients will be randomized into two 16-week treatment groups in 1:1 ratio (placebo or mepolizumab 100 mg every 4 weeks). The study lasts for 6 months, including recruitment visit 2-4 weeks before randomization. Participants will attend 6 visits, during four of which they will receive a subcutaneous injection of the study product. At each visit, patient-reported outcome tests, clinical examination, airway function tests, and nasal, blood, urine, and stool samples will be conducted.

Discussion

The efficacy of the 16-week anti-IL-5-treatment in this severe patient group will be analyzed, as well as possible predictive biomarkers.

Clinical Trial registration

ClinicalTrials.gov ID NCT04823585. Registered on 28.3.2021.

Evaluation of LYR-220 Mometasone Sinonasal Implants in Patients With Chronic Rhinosinusitis and Prior Ethmoid Surgery: Results From the Randomized, Blinded, Controlled BEACON Phase 2 Study

BACKGROUND

Endoscopic sinus surgery (ESS) often fails to directly manage the underlying inflammation in chronic rhinosinusitis (CRS), resulting in symptom recurrence in a significant number of patients. LYR-220 is a long-acting (24-week) corticosteroid sinonasal implant being developed for treatment of these patients.

METHODS

Forty-two adults with CRS and prior ESS were enrolled in the multicenter, randomized, controlled Phase 2 (BEACON) study. Patients received LYR-220 or a sham procedure bilaterally. The primary endpoint was occurrence of any treatment-related serious adverse events (SAEs). Efficacy endpoints included change from baseline (CFBL) in Sino-Nasal Outcome Test (SNOT-22); three cardinal symptoms (3CS) of CRS (nasal blockage, nasal discharge, and facial pain/pressure); loss-of-smell; ethmoid percent opacification volume; and need for rescue treatment (systemic corticosteroids [SCS] or sinonasal surgery).

RESULTS

No SAEs were reported in the study. SNOT-22 scores significantly improved with LYR-220 versus sham from week 2 onwards, with a between group difference of -16.8 at Week 24 (p = 0.007). Between group difference at Week 24 for 3CS was -1.50 (p = 0.02) and for ethmoid percent opacification volume was -8.14 (p = 0.035). Five patients from LYR-220 group and seven from sham group used SCS. LYR-220 showed improvement versus sham in the loss-of-smell from Week 8 through the end of treatment at 24 weeks (-0.87, p = 0.026).

CONCLUSIONS

The BEACON study demonstrated safety, efficacy, feasibility, and tolerability of LYR-220 in patients with CRS who have had prior ESS. The primary endpoint was met, with no SAEs reported. LYR-220 demonstrated statistically significant, clinically relevant improvements in key symptomatic and objective efficacy endpoints.

Shared genetic investigation of asthma and blood eosinophils in relation to chronic rhinosinusitis

BACKGROUND

An epidemiological association among asthma, blood eosinophil level and chronic rhinosinusitis (CRS) is well established, but whether consistent genetic relationships exist, and whether this reflects a shared genetic etiology between CRS and asthma or blood eosinophil level remains unclear.

METHODS

Data from CRS patients (N = 1,255) and healthy controls (N = 1,032) were reviewed retrospectively to investigate associations between clinical characteristics and CRS. Data from white blood cells in the UK biobank (N = 173,480), asthma in the Trans-National Asthma Genetic Consortium (127,669) and CRS (N = 272,922) or nasal polyps (N = 264,107) in the FinnGen consortium were used to conduct genetic study, including linkage disequilibrium score regression analysis to detect genetic associations between aforementioned variables, Mendelian randomization (MR) analysis to investigate causal relationships of asthma and blood eosinophil levels on CRS, and Bayesian co-localization to consolidate MR findings and to identify shared genetic signals.

RESULTS

We found that blood eosinophil count, blood eosinophil percentages and asthma shared positive and causal genetic correlations with CRS (all q < 0.0001) and CRS with nasal polyps (CRSwNP) (all q < 0.0001) in both our observational and genetic study. Through colocalization analysis, 4 loci are shared among asthma, CRS and CRSwNP, 7 loci are shared among blood eosinophil count, CRS and CRSwNP, 2 loci are unique to blood eosinophil count and CRS, and 3 loci are unique to blood eosinophil count and CRSwNP.

CONCLUSIONS

These findings contribute to understanding CRS etiology, and provide insights for intervention and treatment target for CRS comorbid with asthma or high blood eosinophil levels.

Efficacy and safety of twice per year depemokimab in chronic rhinosinusitis with nasal polyps (ANCHOR-1 and ANCHOR-2): phase 3, randomised, double-blind, parallel trials

BACKGROUND

Chronic rhinosinusitis with nasal polyps (CRSwNP) symptoms are frequently driven by type 2 inflammation. Depemokimab is the first ultra-long-acting biological drug engineered with enhanced interleukin-5 binding affinity, high potency, and an extended half-life, enabling twice per year dosing and sustained type 2 inflammation inhibition. The ANCHOR-1 and ANCHOR-2 trials investigated the efficacy and safety of depemokimab in people with CRSwNP.

METHODS

ANCHOR-1 and ANCHOR-2 were randomised, double-blind, placebo-controlled, parallel-group, replicate phase 3 trials conducted concurrently at 190 centres (hospitals, specialised clinics, and clinical trial sites) in 16 countries (Argentina, Belgium, Canada, China, France, Germany, Italy, Japan, the Netherlands, Poland, Romania, Spain, Sweden, Türkiye, the UK, and the USA). Individuals aged 18 years or older at the time of consent, with inadequately controlled CRSwNP, an endoscopic bilateral nasal polyps score of 5 or more, previous surgery for CRSwNP or previous treatment with or intolerance to systemic corticosteroids, and severe symptoms were stratified by previous CRSwNP surgery and randomly assigned 1:1 to receive either depemokimab (100 mg subcutaneously) or placebo every 26 weeks (with standard of care). Allocation was computer generated. The trial sponsor, site staff, and participants were masked. The coprimary endpoints were change from baseline in total endoscopic nasal polyps score (0-8) at week 52 and mean nasal obstruction score (verbal response scale [0-3]) over weeks 49-52, assessed in the full analysis set. Integrated analyses were conducted. Adverse events on treatment and after treatment were monitored. The trials are complete and are registered with ClinicalTrials.gov (NCT05274750 and NCT05281523).

FINDINGS

Between April 18, 2022, and Aug 7, 2023, 540 individuals were randomly assigned across ANCHOR-1 and ANCHOR-2; 528 participants comprised the full analysis set (depemokimab, n=272; placebo, n=256). Depemokimab had statistically significant improvements from baseline versus placebo in the coprimary endpoints of total nasal polyps score (treatment difference: ANCHOR-1, -0·7, 95% CI -1·1 to -0·3; p<0·001; ANCHOR-2, -0·6, -1·0 to -0·2; p=0·004; integrated, -0·7, -0·9 to -0·4) and mean nasal obstruction verbal response scale score (ANCHOR-1, -0·23, -0·46 to 0·00; p=0·047; ANCHOR-2, -0·25, -0·46 to -0·03; p=0·025; integrated, -0·24, -0·39 to -0·08). Adverse events were similar between depemokimab and placebo in ANCHOR-1 (74% [n=106] vs 79% [n=101]) and ANCHOR-2 (76% [n=98] vs 80% [n=102]).

INTERPRETATION

Depemokimab significantly improved clinically relevant coprimary endpoints versus placebo and was well tolerated, supporting its use as a twice per year treatment option, with the potential to reduce treatment burden for people with CRSwNP.

FUNDING

GSK.

A real-life evaluation of SNOT-22 domains in a cohort of CRSwNP patients treated with biologic therapies for 12 months

BACKGROUND

Chronic rhinosinusitis with nasal polyps (CRSwNP) is an inflammatory disorder associated with rhinorrhea, nasal obstruction, nasal congestion, hyposmia, anosmia, and facial pain or pressure for over 12 weeks. This study examines the Sino-Nasal Outcome Test 22 (SNOT-22) score and its relationship to nasal, otologyc, sleep and emotional domains in CRSwNP patients during the first year of biologics treatment, comparing the pre-biologics score to that at 1, 6, and 12 months in a cohort of 59 patients with CRSwNP.

METHODS

We included 59 patients with CRSwNP (with or without asthma) who received add on therapy with targeted monoclonal antibodies (mAbs). At each visit we administered the SNOT-22 questionnaire and both total score and single domains scores were recorded.

RESULTS

In this real-life, observational study, we found a significant SNOT-22 total score reduction for patients treated with anti-IgE after 1 month, but this significant difference was not maintained at 6 or 12 months compared with the baseline. The use of anti-interleukin 5/5R (IL5/5R) leads to a significant reduction of the SNOT-22 total score after 1 month, which is maintained after 6 months but not at 12 months compared with the baseline. The use of an anti-interleukin 13/4R (IL13/4R) leads to a statistically significant reduction of the SNOT-22 score after 1 month of therapy, which is maintained after 6 and 12 months compared with the baseline. When examining the single domains, we observed that patients who received anti-IL13/4R treatment demonstrated a significant reduction in each domain at each time point (T) compared to the baseline. Patients who received anti-IL5/5R treatment demonstrated an improvement in the nasal domain at each T compared to the baseline. However, the improvement in the otologyc domain was not sustained after 12 months. Similarly, the sleep domain remained unchanged, and the emotional domain only improved significantly after 12 months. Similarly, there was a reduction of the emotional domain in patients treated with anti-IgE.

CONCLUSION

Our real-life study describes the kinetics over the first year of treatment with mAbs in CRSwNP, showing different patterns in reducing symptoms and improving Health Related Quality of Life (HRQoL). SNOT-22 with the factorial division in 4 domains can help distinguish fast responders from low or non-responders to a mAb based on clinical response after 1 month and more accurately assign the right mAb to the right patient.

Dupilumab Treatment for Aspirin-Exacerbated Respiratory Disease in a Real-World Setting: Impact on Quality of Life and Healthcare Utilization

BACKGROUND

Patients with aspirin-exacerbated respiratory disease (AERD) have difficult-to-treat asthma and chronic rhinosinusitis with nasal polyps (CRSwNP) and often require treatment with biologic therapy for asthma or CRSwNP. Healthcare utilization in patients with AERD has not been well described since the advent of respiratory biologics.

OBJECTIVE

To determine real-world healthcare utilization and quality of life among patients with AERD and to understand the impact of dupilumab, a monoclonal antibody targeting the interleukin 4 receptor, on patient-reported health outcomes and healthcare utilization.

METHODS

We conducted a longitudinal survey study of 98 patients with AERD recruited from the Brigham and Women's Hospital AERD registry. Patients completed online questionnaires describing their medication history, healthcare utilization, and quality of life every 3 months for 2 years.

RESULTS

At the end of 24 months, participants who were on dupilumab at the start of the study and those who started dupilumab had a significant reduction in the number of reported poor health days in the preceding month compared to patients not on dupilumab (P < .001 and P < .01, respectively). Participants on dupilumab and those who started dupilumab also had significantly lower overall sinonasal outcome test-22 and asthma control test scores compared to those not on dupilumab over 24 months (P < .05 for both groups).

CONCLUSION

Dupilumab therapy significantly improves health-related quality of life in patients with AERD, specifically as it pertains to patient assessment of days of overall poor health and quality of life related to sinonasal and asthma symptoms.

New insights into the endotypes of chronic rhinosinusitis in the biologic era

Chronic rhinosinusitis (CRS) exhibits significant heterogeneity and has been generally classified as type 1 (T1), T2, and T3 endotypes according to the histopathologic and inflammatory features of the nasal mucosa. T2 inflammation has been regarded as the predominant endotype of CRS linked to disease severity and refractory conditions. The development of biological agents that specifically target key molecules involved in T2 inflammation offers a highly effective and promising therapeutic approach for CRS. Recent findings have expanded the understanding of CRS endotypes by incorporating a range of disease-related molecules for classification, with progress made on the endotyping of CRS without nasal polyps. In addition, there has been an increasing emphasis on the study of mixed inflammatory endotypes. This review examines recent findings on CRS endotyping and the related noninvasive biomarkers, as well as novel mechanisms governing endotype formation, and addresses the efficacy of biologics in targeting T2 inflammation. Further research is warranted to understand if newly identified CRS endotypes show clinical significance for precision medicine and the management and treatment of refractory CRS in the era of biologics.

Clinical Evidence of the Use of Mepolizumab in the Treatment of Chronic Rhinosinusitis with Nasal Polyps: A Prospective Observational Study

Background/Objectives: Chronic rhinosinusitis with nasal polyps (CRSwNP) poses significant therapeutic challenges. The introduction of Mepolizumab, an anti-interleukin-5 monoclonal antibody, offers a new therapeutic option for patients with severe, uncontrolled CRSwNP. This prospective observational study aims to assess the efficacy and safety of Mepolizumab for treating severe CRSwNP in Italy. Methods: A single-center prospective observational study conducted in real-life settings with the patients of our center. Prior to enrollment, each patient underwent an interdisciplinary evaluation involving a pulmonologist and an allergologist if deemed necessary. All patients who were referred for treatment with Mepolizumab in compliance with the AIFA guidelines and the EPOS/EUFOREA update were included in the study population: (1) subjects who were over the age of 18, (2) who had severe CRSwNP, (3) whose condition was not successfully managed with standard therapies alone, and (4) whose blood eosinophil counts were greater than 150 cells/mL. Mepolizumab was administered subcutaneously through a 100 mg injection once every four weeks in addition to the standard-of-care therapy. Results: At the end of the enrollment process, 20 patients with severe CRSwNP were enrolled. Significant improvements were observed in Nasal Polyp Score, quality of life (SNOT-22; p < 0.05), and nasal obstruction and rhinorrhea (p < 0.05), while no significant improvements were seen in olfactory function (p < 0.05). Eosinophil levels also significantly decreased (p < 0.05). Conclusions: Mepolizumab effectively manages severe CRSwNP, showing improvements in symptom control and quality of life with an acceptable safety profile.

New insights into the mechanisms of aspirin-exacerbated respiratory disease

PURPOSE OF REVIEW

Aspirin-exacerbated respiratory disease (AERD), a syndrome characterized clinically by asthma, chronic rhinosinusitis with nasal polyposis, and respiratory reactions to aspirin and other cyclooxygenase-1 inhibitors, is an inflammatory condition of the respiratory tract that is often severe and challenging to treat. There have been several recent advances in our understanding of the underlying pathology of the disease. These have been paralleled by welcome advances in the availability of targeted treatment options for patients with AERD.

RECENT FINDINGS

Spurred in part by results from trials of targeted biologic therapies, along with single cell genomics, there is now clear evidence that the chronic respiratory inflammation in AERD is driven by combination of local tissue factors. These include abnormalities in effector cell populations, with increased accumulation and activation of mast cells and plasma cells in the nasal polyp, along with notable epithelial barrier dysregulation. The key mediators now identified include high levels of both type 2 inflammatory cytokines (IL-4, IL-5, IL-13) and cytokines involved in broader inflammatory pathways (IL-33, TSLP, IL-6, oncostatin M), as well as the overproduction of cysteinyl leukotrienes, and the underproduction of prostaglandin E 2 .

SUMMARY

This review covers the latest insights into the immunopathogenesis of and targeted treatment of AERD, including the roles of lipids, effector cells, and inflammatory cytokines, and discusses unanswered questions regarding its pathogenesis and potential future therapies.

Update on aspirin exacerbated respiratory disease with chronic rhinosinusitis

PURPOSE OF REVIEW

This review provides the current understanding on the mechanism, diagnosis, and treatment of aspirin exacerbated respiratory disease (AERD) with chronic rhinosinusitis (CRS).

RECENT FINDINGS

Updates focus on the current understanding of type 2 inflammation as a disease driver, alterations in gene expression in nasal polyps, and use of biologics in treating aspirin exacerbated respiratory disease. Recent findings include altered expression of GATA binding protein 3 (GATA3), interleukin (IL)-4, IL-5, and IL-17 in nasal polyps supports the current understanding that type 2 inflammation predominantly drives the pathophysiology of AERD with CRS. From a clinical standpoint, biologics offer an effective treatment option to address type 2 inflammation. Biologics should not be favored over endoscopic sinus surgery and aspirin desensitization with daily aspirin therapy (unless contraindication are present) due to high associated cost and failure to achieve remission.

SUMMARY

This review outlines the current approach for diagnosis and treatment of aspirin exacerbated respiratory disease with a focus on desensitization protocols, the importance of endoscopic sinus surgery, the role of biologics, and the use of leukotriene modulators.

Choosing the Right Biologic for the Right Patient With Severe Asthma

In this installment of the How I Do It series on severe asthma, we tackle the clinical conundrum of choosing the right biologic for the right patient with severe asthma. With six biologics now approved for use in this area comprising four different targeting strategies (anti-Ig E: omalizumab; anti-IL-5 and anti-IL-5-receptor: mepolizumab, reslizumab, and benralizumab; anti-IL-4-receptor: dupilumab; anti-thymic stromal lymphopoietin: tezepelumab), this question is increasingly complex. Recognizing that no head-to-head trial has compared biologics, we based our review on the expected effects of inhibiting different aspects of type 2 airway inflammation, supported whenever possible by clinical trial and real-world data. We use four variations of a case of severe uncontrolled asthma to develop concepts and considerations introduced in the previous installment ("Workup of Severe Asthma") and discuss pregnancy-related, biomarker-related, comorbidity-related, and corticosteroid dependency-related considerations when choosing a biologic. The related questions of deciding when, why, and how to switch from one biologic to another also are discussed. Overall, we consider that the choice of biologics should be based on the available clinical trial data for the desired efficacy outcomes, the biomarker profile of the patient, safety profiles (eg, when pregnancy is considered), and opportunities to target two comorbidities with one biologic. Using systemic and airway biomarkers (blood eosinophils and exhaled nitric oxide [Feno]) and other phenotypic characteristics, we suggest a framework to facilitate therapeutic decision-making. Post hoc studies and new comparative studies are needed urgently to test this framework and to determine whether it allows us to make other clinically useful predictions.

Real-world effectiveness of dupilumab in a European cohort of chronic rhinosinusitis with nasal polyps (CHRINOSOR)

BACKGROUND

Pivotal studies with dupilumab demonstrated clinically relevant improvements in nasal polyp score, symptom score, and quality-of-life score in patients with chronic rhinosinusitis with nasal polyps (CRSwNP).

OBJECTIVE

We evaluated the effectiveness of dupilumab in a large-scale CRSwNP cohort from 6 European tertiary-care centers.

METHODOLOGY

Nasal polyp score, Sinonasal Outcome Test 22 score, visual analog scale for total sinus symptoms, loss of smell, and nasal blockage, and Asthma Control Test (ACT) score were collected from hospital records and assessed at baseline and again at 24 and 52 weeks' treatment with dupilumab in CRSwNP patients. Treatment effectiveness was evaluated in relation to demographic and lifestyle factors, sinus surgery history, presence of comorbidities, and blood eosinophil counts (BEC). Treatment response was evaluated according to European Forum for Research and Education in Allergy and Airway Diseases (EUFOREA) 2021 criteria.

RESULTS

All patient outcomes improved at 24 and 52 weeks' treatment compared to baseline. Dupilumab showed effectiveness independent of age, sex, body mass index, smoking status, prior sinus surgery, presence of asthma, nonsteroidal anti-inflammatory drug-exacerbated respiratory disease, allergy, or baseline BEC. A total of 92.5% and 94.4% showed an improvement in at least 1 EUFOREA criterion at 24 and 52 weeks, respectively; 54.4% and 68.2% met all 4 of the more stringent EUFOREA criteria at 24 and 52 weeks, respectively.

CONCLUSIONS

Real-world evaluation of dupilumab effectiveness demonstrates a robust and sustained response in at least two thirds of patients at 52 weeks' treatment. Favorable treatment response was independent of the number of sinus surgery procedures, major comorbidities, or baseline systemic levels of type 2 inflammation.

Long-term effects of dupilumab on chronic rhinosinusitis with nasal polyps: A step towards clinical remission

Background and objectives

Clinical remission, defined as the absence of disease activity and symptoms, is an emerging goal in the management of chronic rhinosinusitis with nasal polyps (CRSwNP). This study aimed to evaluate the long-term effects of dupilumab on patients with CRSwNP, with or without asthma, and explore the potential for achieving clinical remission.

Methods

A two-year prospective study was conducted on 109 patients with CRSwNP, with or without asthma, who were eligible for dupilumab as an add-on therapy. Comprehensive assessments, including clinical, laboratory, and radiological evaluations, were performed before and after treatment. Clinical remission of CRSwNP was defined as 12 months of dupilumab treatment, no exacerbations requiring oral corticosteroids (OCS), no need for nasal sinus operation, no anosmia or hyposmia, a Sino-Nasal Outcome Test (SNOT-22) score under 20, and a Lund-Mackay score (LMS) below 10. For those with comorbid asthma, clinical remission was defined as an asthma control test (ACT) score of 19 or higher, no asthma exacerbations, and no need for OCS.

Results

Dupilumab significantly improved CRSwNP outcomes in both groups, including SNOT-22 scores, nasal polyp size (LMS), and anosmia/hyposmia. Comorbid asthma was highly prevalent (79.8%), and patients with asthma had significantly larger nasal polyps, both before and after dupilumab therapy, despite similar symptom improvement. Higher fractional exhaled nitric oxide (FeNO) and blood eosinophil count (BEC) levels, along with anosmia/hyposmia, predicted larger polyp size. Dupilumab also significantly improved asthma outcomes, increasing forced expiratory volume in 1 s (FEV1) and decreasing FeNO. Clinical remission was achieved in 11% of patients, with a slightly lower rate in those with asthma (7.3%).

Conclusion

Dupilumab treatment can achieve clinical remission in CRSwNP. However, comorbid asthma appears to reduce the likelihood of remission and is associated with larger nasal polyps, even with similar symptom improvement. Asthma may independently influence polyp development, potentially impacting long-term outcomes in CRSwNP.

Impact of Biologics on Surgery in Chronic Rhinosinusitis with Polyps and Allergic Fungal Sinusitis

OBJECTIVE

To compare the efficacy of th2-targeted biologic medications (dupilumab, omalizumab, and mepolizumab) on absolute risk reduction (ARR) of functional endoscopic sinus surgery (FESS) in patients with chronic rhinosinusitis with nasal polyposis (CRSwNP) and allergic fungal rhinosinusitis (AFRS).

METHODS

The TriNetX Research Network database was queried for each mAb's market lifespan through March 2024. Adults with CRSwNP were propensity score matched against non-mAb controls based on age, sex, race, and asthma diagnosis. The primary outcome was rate of FESS, with secondary outcomes including inpatient admission, emergency department (ED) visit, and incidence of acute sinusitis. Subgroup analysis was performed for patients with AFRS.

RESULTS

All mAbs decreased FESS risk (dupilumab, ARR 11.48%, 95% CI 9.82%-13.15%, p < 0.001; omalizumab, ARR 12.02%, 95% CI 4.36%-19.68%, p = 0.002; mepolizumab, ARR 10.32%, 95% CI 5.24%-15.40%, p < 0.001) in CRSwNP patients. Only dupilumab also reduced risk of inpatient admission (ARR 8.59%, 95% CI 7.04%-10.15%, p < 0.001), ED visit (ARR 5.94%, 95% CI 4.28%-7.61%, p < 0.001), and acute sinusitis (ARR 2.60%, 95% CI 1.09%-4.12%, p = 0.001). In AFRS patients, only dupilumab reduced the risk of all outcomes: FESS (ARR 6.97%, 95 CI 2.86%-11.09%, p = 0.001), inpatient admission (ARR 16.93%, 95% CI 11.30%-22.57%, p < 0.001), ED visit (ARR 13.15%, 95% CI 7.15%-19.14%, p < 0.001), and acute sinusitis (ARR 7.17%, 95% CI 2.18%-12.17%, p = 0.005).

CONCLUSION

Although all mAbs reduced FESS risk in CRSwNP, only dupilumab reduced secondary outcomes as well. Similarly, only dupilumab improved all outcomes in AFRS patients. These data demonstrate the potential of mAbs in reducing disease burden and enhancing patient outcomes in CRSwNP and AFRS.

LEVEL OF EVIDENCE

NA Laryngoscope, 135:593-601, 2025.

A RESPONSE to antiIL-5 therapy in comorbid patients with chronic rhinosinusitis with nasal polyps and severe asthma: Study protocol

Background

Chronic rhinosinusitis with nasal polyps (CRSwNP) and severe asthma (SA) are 2 frequently coexisting conditions that are, in most cases, associated with eosinophilic inflammation. The concurrence of both diseases has a negative synergistic impact on disease severity and patients' health-related quality of life. Thus, a holistic, collaborative management of these patients is a critical unmet need. Mepolizumab, a systemic anti-IL-5 therapy, has been shown to be effective as an add-on treatment in both SA and CRSwNP, with more literature available on asthma outcomes than on CRSwNP.

Objectives

The primary objective of the study is to evaluate the real-world effectiveness of mepolizumab in improving the health-related quality of life of comorbid patients at 12 months using the SNOT-22 questionnaire. Secondary objectives include safety and efficacy outcomes of mepolizumab treatment in the 2 populations, which are expected to have variable severity of the respective comorbid conditions.

Methods

RESPONSE is a European real-world prospective cohort study designed to assess the effectiveness of mepolizumab in 2 cohorts of adult patients: one with SA as primary diagnosis with (secondary diagnosis) comorbid CRSwNP, and another with CRSwNP as primary diagnosis with (secondary diagnosis) comorbid asthma. Up to 350 patients receiving newly prescribed mepolizumab will be followed up for 12 months as per the investigators' standard of care.

Conclusion

This study will report the effects of anti-IL-5 therapy in both diseases investigated and the respective comorbidity, as well as the consequence of treating milder forms of asthma and CRSwNP with mepolizumab, supporting the emerging evidence on early treatment optimization.

Real-world effectiveness of mepolizumab in Japanese asthma patients with diverse backgrounds: Improvements in rhinosinusitis imaging (J-Real-Mepo)

BACKGROUND

Although randomized controlled trials (RCT) have demonstrated the efficacy of mepolizumab for asthma, they have excluded certain patient subgroups. To bridge the gap between RCT and real-world practice, the effectiveness of mepolizumab in a diverse population, including those potentially excluded from RCT, was assessed. Its effects on imaging findings and symptoms of chronic rhinosinusitis (CRS) with asthma were also assessed.

METHODS

This retrospective observational study of patients in Japan (J-Real-Mepo: UMIN000045021) evaluated multiple endpoints and analyzed the relationship between clinical background and treatment outcomes.

RESULTS

Mepolizumab significantly reduced exacerbations, improved Asthma Control Test (ACT) scores, and forced expiratory volume in 1 s, and reduced oral corticosteroid (OCS) dose, regardless of patient characteristics, including age, body mass index, smoking history, and comorbidities. Regarding RCT exclusion criteria, 29.4 % of patients had no history of exacerbations. Although 25.4 % of these patients required continuous OCS, the OCS dose was reduced similar to those with a history of exacerbations. Disease control and mepolizumab effectiveness in patients with a smoking history ≥10 pack-years was similar to that of never-smokers. Patients with eosinophil counts <150/μL had lower ACT scores and higher OCS use compared with patients with eosinophilia and comparable effectiveness regarding exacerbation and OCS reduction. Significant improvements in Lund-Mackay scores and CRS symptoms were observed.

CONCLUSIONS

Mepolizumab effectiveness was demonstrated in a broad range of patients including those with RCT exclusion criteria, who had significant disease or OCS burden. These findings may explain the consistent results between RCT and real-world studies of mepolizumab.

Efficacy Assessment of Biological Treatments in Severe Asthma

Uncontrolled, severe asthma remains a significant clinical challenge, affecting a small proportion of asthma patients worldwide. Despite advancements in treatment options, a subset of patients continues to experience frequent exacerbations, uncontrolled symptoms, and impaired quality of life. The advent of biological therapies has revolutionized the management of severe asthma, offering targeted treatments that address specific inflammatory pathways. This review provides a comprehensive overview of the efficacy and response criteria of biological treatments in severe asthma, focusing on clinical, functional, and inflammatory markers used to help in the evaluation of the biologic treatment. Key response criteria include symptom control, reduction in exacerbations, improvement in lung function, and a reduction in or the discontinuation of oral corticosteroids. Biomarkers such as blood eosinophils and exhaled nitric oxide (FeNO) are essential tools in guiding treatment adjustments. Real-world studies underscore the importance of personalized treatment strategies, as variability in response to biological therapies can be significant. The emergence of tools such as the FEOS score and EXACTO questionnaire offer quantitative measures for assessing biological response and guiding clinical decisions. Additionally, predictive factors for better or poorer responses, such as pre-treatment lung function and comorbidities, like obesity and rhinosinusitis, are critical in patient selection. This review highlights the need for ongoing reassessments and potential modifications of therapy in cases of suboptimal response. Practical considerations for switching biological therapies are discussed, emphasizing the importance of tailoring treatments to individual patient profiles and disease phenotypes. With the continued development of personalized medicine, the outlook for patients with severe asthma is improving, selecting specific biomarkers to improve the selection of the biologic treatment.

Chronic Rhinosinusitis with Nasal Polyps and Biologics: A Call for Better Data Standardisation and Presentation in Clinical Studies

Chronic rhinosinusitis with nasal polyps (CRSwNP) is often severe, debilitating and difficult to treat. Recent randomised control trials (RCTs) of biologics that target key inflammatory pathways have demonstrated clinical efficacy in treating CRSwNP. Such RCTs must facilitate meta-analysis. Here we report the need for urgent improvement in double-blind randomised controlled trials of biologics in CRSwNP, having previously undertaken a systematic review and meta-analysis of such studies. The RCTs included in that systematic review did not conform to a standard study design. Patient selection criteria was not consistent in studies with several heterogeneous disease subgroups of CRSwNP patients present in each study. Different durations of treatment and variable outcome measures also made the comparative assessment of efficacy between different biologics difficult. Data presentation to allow extraction for meta-analysis was not always clear, such that on occasion selected data sets or even an entire RCT had to be excluded from further evaluation. As such, the high heterogeneity between studies made the overall interpretation of the findings difficult. We make an urgent call to design and conduct future RCTS of biologics in CRSwNP in a more standardised manner, and to present data in a clear way that is easily extractable. This will facilitate more inclusive and thus robust evaluation and interpretation via meta-analysis, which will in turn enable clearer insight into which CRSwNP patient subgroups might benefit from specific biologics and thus achieve better clinical outcomes.

Unveiling and validating biomarkers related to the IL-10 family in chronic sinusitis with nasal polyps: insights from transcriptomics and single-cell RNA sequencing analysis

Introduction

Extensive efforts have been made to explore members of the IL-10 family as potential therapeutic strategies for various diseases; however, their biological role in chronic rhinosinusitis with nasal polyps (CRSwNP) remains underexplored.

Methods

Gene expression datasets GSE136825, GSE179265, and GSE196169 were retrieved from the Gene Expression Omnibus (GEO) for analysis. Candidate genes were identified by intersecting differentially expressed genes (DEGs) between the CRSwNP and control groups (DEGsall) with those between the high- and low-score groups within the CRSwNP cohort (DEGsNP). Biomarker selection was performed using the Least Absolute Shrinkage and Selection Operator (LASSO), Support Vector Machine Recursive Feature Elimination (SVM-RFE), and the Boruta algorithm. Further refinement of biomarkers was carried out using receiver operating characteristic (ROC) analysis, with genes demonstrating an area under the curve (AUC) greater than 0.7 being considered significant. Genes exhibiting consistent expression trends and significant differences across both GSE136825 and GSE179265 were selected as potential biomarkers. Cell-type annotation was performed on GSE196169, and the expression profiles of the biomarkers across various cell types were analyzed. A competing endogenous RNA (ceRNA) network and a biomarker-drug interaction network were also established. Additionally, the mRNALocater database was utilized to determine the cellular localization of the identified biomarkers.

Results

The intersection of 1817 DEGsall and 24 DEGsNP yielded 15 candidate genes. Further filtering through LASSO, SVM-RFE, and Boruta led to the identification of seven candidate biomarkers: PRB3, KRT16, MUC6, SPAG4, FGFBP1, NR4A1, and GSTA2. Six of these genes demonstrated strong diagnostic performance in GSE179265, while four biomarkers, showing both significant differences and consistent expression trends, were validated in both GSE179265 and GSE136825. Single-cell sequencing analysis of GSE196169 revealed seven distinct cell types, including endothelial cells, with the biomarkers predominantly expressed in epithelial cells. The ceRNA network comprised nine nodes and eleven edges, with only FGFBP1 exhibiting a complete lncRNA-miRNA-mRNA interaction.

Discussion

This study identifies several novel biomarkers and their associated drugs for CRSwNP therapy, as well as potential therapeutic targets, such as spiperone and arnenous acid, identified through molecular docking. Ultimately, this work underscores the identification of four IL-10 family-related biomarkers, providing a theoretical foundation for future clinical research in CRSwNP.

Real-world outcomes on quality-of-life improvement in patients with nasal polyposis treated with mepolizumab. RINOSUR study

Chronic rhinosinusitis with nasal polyps (CRSwNP) is characterized by nasal obstruction, reduced sense of smell, rhinorrhea, and facial pain for more than 12 weeks, significantly affecting quality of life (QoL), especially in patients with NSAID-exacerbated respiratory disease (NERD). Initial treatment includes intranasal corticosteroids and nasal irrigations, followed by systemic corticosteroids (SC) in severe cases, as well as endoscopic sinus surgery (ESS) and biological agents. Mepolizumab, a monoclonal antibody against IL-5, has been shown to reduce eosinophilic inflammation in CRSwNP. This study evaluates the improvement in quality of life of patients with CRSwNP treated with mepolizumab before December 2023, recorded by the RINOSUR group. A retrospective observational multicenter cohort study is presented in adult patients with severe asthma and concomitant CRSwNP, treated with mepolizumab 100 mg. Variables such as sex, asthma, allergies, NERD, corticosteroid dependence, and serum eosinophil count were recorded. All patients underwent nasal endoscopy and completed the SNOT22 questionnaire. Therapeutic response was evaluated at 12 months. Out of 143 patients recruited, only 28.6% had the necessary data. 61% were women with a mean age of 55 years. All were corticosteroid-dependent and had required at least one ESS. A 22% reduction in SC cycles was observed, and no patient required revision surgery in the 12 months following treatment. The SNOT22 score was reduced by 53 points, and serum eosinophilia also showed a significant decrease. Mepolizumab is effective in treating severe uncontrolled CRSwNP, improving QoL and reducing dependence on systemic corticosteroids. Its activity is monitored by peripheral blood eosinophilia. Consistency in data collection is crucial to evaluate efficacy and manage the disease.

Postmarketing Analysis of Eosinophilic Adverse Reactions in the use of Biologic Therapies for Type 2 Inflammatory Conditions

BACKGROUND

Temporary eosinophilia is a potential adverse reaction of monoclonal antibody therapies in the treatment of a variety of type 2 inflammatory conditions, including asthma and chronic rhinosinusitis with nasal polyposis (CRSwNP). The pathophysiology, epidemiology, and clinical significance of eosinophilia and eosinophilic adverse reactions following the initiation of biologic therapy are unclear.

OBJECTIVES

To describe the postmarketing, eosinophilic adverse reactions with clinical significance in patients treated with the 3 biologic therapies approved by the U.S. Food and Drug Administration (FDA) for CRSwNP: dupilumab, omalizumab, and mepolizumab.

METHODS

The FDA Adverse Event Reporting System (FAERS) Public Dashboard was searched for eosinophilic adverse reactions related to dupilumab, omalizumab, and mepolizumab treatments from November 2004 to December 2022. Data regarding each of the eosinophilic adverse reactions were extracted and analyzed.

RESULTS

A total of 218, 270, and 134 reports of eosinophilic adverse reactions were reported among patients who were treated with dupilumab, omalizumab, and mepolizumab, respectively. The most common eosinophilic adverse reaction was eosinophilic granulomatosis with polyangiitis (338 patients), followed by eosinophilic respiratory tract reactions (158 patients). The most common indication for biological treatment among the reaction groups was asthma.

CONCLUSIONS

Eosinophilic adverse reactions are rare but consequential complications of biological treatment. They are more common among patients treated for asthma and chronic rhinosinusitis with nasal polyposis. Measuring and monitoring blood eosinophil levels may be appropriate in specific clinical instances when patients are started on different biologic therapies for type 2 inflammatory conditions.