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Bobolea I, Hagemann J, Sanak M, Klimek L, Mullol J. Current Goals of NSAID-ERD Management: Patient-Centered Approaches Involving NSAID Desensitization With and Without Biologics. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024:S2213-2198(24)00938-3. [PMID: 39306329 DOI: 10.1016/j.jaip.2024.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/15/2024] [Revised: 09/02/2024] [Accepted: 09/16/2024] [Indexed: 10/11/2024]
Abstract
The classic approach of nonsteroidal anti-inflammatory drug (NSAID)-exacerbated respiratory disease (NSAID-ERD) includes pharmaceutical and surgical treatments, as well as avoidance of cyclooxygenase 1-inhibitor NSAIDs. The introduction of biologics in the treatment of severe asthma and chronic rhinosinusitis with nasal polyps represents an alternative therapeutic approach to the classical aspirin therapy after desensitization (ATAD) in some regions, and with convincing results. However, their use is limited due to approval and/or high-cost restrictions. NSAID-ERD is a mainly type 2 and highly eosinophilic disease, and mAbs targeting IgE or IL-5, IL-4, and IL-13 have been shown to be effective for both severe asthma and severe chronic rhinosinusitis with nasal polyps. So far, dupilumab demonstrated greater efficacy in patients with NSAID-ERD than in aspirin-tolerant patients with regard to several clinical outcomes. Patients with NSAID-ERD respond very rapidly to omalizumab also, with reduction in the release of prostaglandin D2 and cysteinyl leukotrienes. Patients favored biologic treatment over ATAD in multiple retrospective analyses, which must be acknowledged when choosing one or the other option. Although this review will summarize ATAD in general, it will more prominently focus on when ATAD should be considered, even when type 2 biologics are available. In addition, there are conflicting studies as to whether patients on a type 2 biologic become desensitized to NSAIDs, because omalizumab proved to restore tolerance to aspirin in only two-third of patients. This goal of NSAID tolerance should be considered as part of disease control future approaches, representing one of many aspects in a patient-centered care approach.
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Affiliation(s)
- Irina Bobolea
- Severe Asthma Unit, Allergy Department, Hospital Clinic Barcelona, FRCB-IDIBAPS, Barcelona, Catalonia, Spain; CIBER of Respiratory Diseases (CIBERES), Madrid, Spain.
| | - Jan Hagemann
- Center for Rhinology and Allergology, Wiesbaden, Germany; Department of Otolaryngoloy, Head and Neck Surgery, Universitätsmedizin Mainz, Mainz, Germany.
| | - Marek Sanak
- Department of Internal Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Ludger Klimek
- Center for Rhinology and Allergology, Wiesbaden, Germany
| | - Joaquim Mullol
- CIBER of Respiratory Diseases (CIBERES), Madrid, Spain; Rhinology Unit & Smell Clinic Unit, ENT Department, Hospital Clinic Barcelona, FRCB-IDIBAPS, Universitat de Barcelona, Barcelona, Catalonia, Spain
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Klimek F, Förster-Ruhrmann U, Hagemann J, Cuevas M, Gröger M, Klimek L. [Does aspirin therapy after desensitization still have a role in treatment of chronic rhinosinusitis with nasal polyposis in the era of biologics?]. HNO 2024; 72:484-493. [PMID: 38409556 DOI: 10.1007/s00106-024-01431-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2024] [Indexed: 02/28/2024]
Abstract
The prevalence of analgesic intolerance syndrome (AIS), internationally known as NSAID-exacerbated respiratory disease (NERD), is reported to be 0.5-5.7% in the general population. The disease often begins with nasal symptoms, which are later joined by chronic rhinosinusitis with nasal polyposis (CRSwNP), asthma, and respiratory hypersensitivity reactions following use of nonsteroidal anti-inflammatory drugs (NSAIDs). In the setting of chronic respiratory disease, the type 2 inflammatory endotype is predominant in approximately 80% of patients with CRSwNP, rendering biologics directed against interleukin (IL)-4, IL‑5, IL-13, and IgE of high clinical interest, particularly in patients with severe CRSwNP and NERD. NERD is often associated with CRSwNP and asthma. Patients with CRSwNP and NERD have been treated, among other therapies, with aspirin therapy after desensitization (ATAD). With the approval of monoclonal antibodies for CRSwNP and asthma, the question arises as to what extent ATAD, which is associated with undesirable side effects, is still useful in the treatment of CRSwNP. In this manuscript, the use of ATAD in CRSwNP patients is discussed from different medical and socioeconomic points of view, both alternatively to or in combination with monoclonal antibodies. Accordingly, both ATAD and biologics continue to play a supporting role in modern treatment of CRSwNP in NERD patients, and should be used judiciously to complement each other.
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Affiliation(s)
- F Klimek
- Zentrum für Rhinologie und Allergologie, Wiesbaden, Deutschland
| | - U Förster-Ruhrmann
- Klinik für Hals‑, Nasen- und Ohrenheilkunde, Universitätsmedizin Charité, Berlin, Deutschland
| | - J Hagemann
- Klinik für Hals‑, Nasen- und Ohrenheilkunde, Universitätsmedizin Mainz, Mainz, Deutschland
| | - M Cuevas
- Klinik und Poliklinik für HNO-Heilkunde, Universitätsklinikum Carl Gustav Carus, TU Dresden, Dresden, Deutschland
| | - M Gröger
- Klinik für Hals‑, Nasen- und Ohrenheilkunde, Universitätsklinikum der Ludwig-Maximilians-Universität, Marchioninistr. 15, 81377, München, Deutschland.
| | - L Klimek
- Zentrum für Rhinologie und Allergologie, Wiesbaden, Deutschland
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Strauss J, Lochbaum R, Hoffmann TK, Mayer B, Appel H, Hahn J. [Chronic rhinosinusitis with nasal polyposis : A retrospective analysis of therapeutic approaches in 463 patients]. HNO 2024; 72:464-472. [PMID: 38700581 PMCID: PMC11192687 DOI: 10.1007/s00106-024-01479-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/04/2024] [Indexed: 06/22/2024]
Abstract
BACKGROUND Chronic rhinosinusitis with nasal polyps (CRSwNP) is a multifactorial inflammatory disease, the treatment of which has undergone significant changes in recent years. In addition to surgical approaches, topical and systemic steroids, and adaptive acetylsalicylic acid (ASA) desensitization, three specific antibodies have complemented the therapeutic portfolio since 2019. METHODS A retrospective evaluation of all patients who presented as outpatients for the first time due to CRSwNP in 2007 and 2008 (collective A) and 2017 and 2018 (collective B) was performed, up to and including June 2023. RESULTS The clinical courses of 463 patients (mean age 49.1 years, range 5-82 years; 65.9% male) were included in the analysis. Conservative treatment with nasal corticosteroids started before initial presentation was more frequent in collective B (collective A 43.9% vs. collective B 72.2%). In 278 of the 463 patients (60%; A: 62%, B: 58%), at least one operation on the nasal sinuses had been performed after initial presentation; in 101 of these patients (36.3%) recurrent polyposis (within mean follow-up of 2.4 years) required further treatment. The indication for ASA provocation/desensitization was applied less frequently in collective B, also due to a high discontinuation rate (at least 38%) of the maintenance therapy. Of the total cohort, 16 patients (3.5%; A: n = 8, B: n = 8) were meanwhile switched to antibody therapy at recurrence. CONCLUSION A step-by-step guideline-orientated approach is recommended in the treatment of CRSwNP. Systemic antibodies as an add-on to nasal corticosteroids are a relatively new therapeutic option for treatment-refractory CRSwNP, which reduces the indication for ASA desensitization, which is associated with a relatively high incidence of side effects and poor compliance.
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Affiliation(s)
- J Strauss
- Klinik für Hals-Nasen-Ohrenheilkunde, Kopf- und Halschirurgie, Universitätsklinik Ulm, Frauensteige 12, 89075, Ulm, Deutschland
| | - R Lochbaum
- Klinik für Hals-Nasen-Ohrenheilkunde, Kopf- und Halschirurgie, Universitätsklinik Ulm, Frauensteige 12, 89075, Ulm, Deutschland
| | - T K Hoffmann
- Klinik für Hals-Nasen-Ohrenheilkunde, Kopf- und Halschirurgie, Universitätsklinik Ulm, Frauensteige 12, 89075, Ulm, Deutschland
| | - B Mayer
- Institut für Epidemiologie und Medizinische Biometrie, Universität Ulm, Ulm, Deutschland
| | - H Appel
- Klinik für Hals-Nasen-Ohrenheilkunde, Kopf- und Halschirurgie, Universitätsklinik Ulm, Frauensteige 12, 89075, Ulm, Deutschland
| | - J Hahn
- Klinik für Hals-Nasen-Ohrenheilkunde, Kopf- und Halschirurgie, Universitätsklinik Ulm, Frauensteige 12, 89075, Ulm, Deutschland.
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Förster-Ruhrmann U, Olze H. [Importance of aspirin challenges in patients with NSAID-exacerbated respiratory disease]. HNO 2024; 72:494-498. [PMID: 38597968 DOI: 10.1007/s00106-024-01460-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/02/2024] [Indexed: 04/11/2024]
Abstract
BACKGROUND Nonsteroidal anti-inflammatory drug-exacerbated respiratory disease (N-ERD) is often characterized by a severe course of chronic rhinosinusitis with nasal polyps (CRSwNP), comorbid asthma, and NSAID hypersensitivity. The gold standard for N-ERD diagnosis is challenge with acetylsalicylic acid (ASA). In expert recommendations, the diagnosis of N-ERD is established based on a plausible positive history of NSAID hypersensitivity and CRSwNP with asthma. OBJECTIVE The following review describes the performance of ASA challenges and their sensitivity and specificity. It also examines the extent to which a positive history of NSAID hypersensitivity correlates with ASA challenge results in clinical trials and when ASA challenges should be performed. RESULTS AND CONCLUSION ASA challenges have high sensitivity and specificity. In clinical ASA challenge studies, there is a high concordance between a positive history of NSAID hypersensitivity obtained by rhinologists and the measured data of ASA challenge in patients with CRSwNP and comorbid asthma. Therefore, ASA challenge is primarily indicated in patients with an unclear history of NSAID hypersensitivity.
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Affiliation(s)
- Ulrike Förster-Ruhrmann
- HNO-Klinik, Charité - Universitätsmedizin Berlin (CCM/CVK), Charitéplatz 1, 10117, Berlin, Deutschland.
| | - Heidi Olze
- HNO-Klinik, Charité - Universitätsmedizin Berlin (CCM/CVK), Charitéplatz 1, 10117, Berlin, Deutschland
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Staufenberg AR, Frankenberger HK, Förster-Ruhrmann U, Spahn FC, Klimek L, Fruth K, Stihl C, Matthias C, Gröger M, Hagemann J. [Biologic therapy in patients with severe NSAID-exacerbated respiratory disease and previous aspirin desensitization : Results of a multicentric study]. HNO 2024; 72:473-483. [PMID: 38466409 PMCID: PMC11192825 DOI: 10.1007/s00106-024-01433-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/22/2024] [Indexed: 03/13/2024]
Abstract
BACKGROUND Chronic rhinosinusitis with nasal polyps (CRSwNP) is a type‑2 inflammatory disease of the upper airways, with severe impairment of quality of life. Persons affected by NSAID-exacerbated respiratory disease (NERD) usually present with highly dynamic recurrence of polyps and disease despite prior treatment with sinus surgeries, oral corticosteroids, and aspirin desensitization (ATAD). Biologic therapy has fundamentally changed the choice of therapeutic concept; however, limited data exist on subgroups such as NERD patients. The aim of the current article is to report on a multicenter retrospective study on add-on therapy with dupilumab, omalizumab, and mepolizumab in patients with NERD. METHODS This is a retrospective cohort study of patients (NERD+, status after ATAD) in three reference centers in Germany (Munich, Mainz, Berlin). Subjective and objective parameters were collected at 4, 8, and 12 months after biologic therapy initiation in accordance with current EPOS/EUFOREA (European Position Paper on Rhinosinusitis and Nasal Polyps/European Forum for Research and Education in Allergy and Airway Diseases) guidelines. Biologic agents were chosen depending on availability and patient characteristics. RESULTS Treatment was commenced in 122 patients meeting the criteria for CRSwNP and NERD. The endoscopic polyp score, SNOT-22 questionnaire score, visual analogue scoring of total symptoms/severity of disease, and sense of smell (psychophysical testing with Sniffin'Sticks/Brief Smell Identification Test, B‑SIT; Sensonics, Inc., Haddon Heights, NJ, USA) improved significantly after 4 and 12 months of add-on therapy (p < 0.0001). All three biologic agents significantly improved one or more disease parameter. Adverse events were not life threatening but led to change of biologic agent in 4 cases. Patients rated biologic therapy significantly better than ATAD, with improved long-term disease control. CONCLUSION Add-on biologic therapy is effective, safe, and widely accepted among CRSwNP + NERD patients. Future studies might allow for personalized algorithms with sequential surgery, ATAD, and/or biologic therapy.
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Affiliation(s)
- Anna-Rebekka Staufenberg
- Hals‑, Nasen‑, Ohrenklinik und Poliklinik, Universitätsmedizin Mainz, Langenbeckstr. 1, 55131, Mainz, Deutschland
| | - Hanna K Frankenberger
- Klinik und Poliklinik für Hals-Nasen-Ohrenheilkunde, Klinikum der Ludwig-Maximilians-Universität München, Campus Großhadern, München, Deutschland
| | - Ulrike Förster-Ruhrmann
- Klinik für Hals‑, Nasen‑, Ohrenheilkunde, Charité - Universitätsmedizin Berlin, Berlin, Deutschland
| | - Franziska C Spahn
- Hals‑, Nasen‑, Ohrenklinik und Poliklinik, Universitätsmedizin Mainz, Langenbeckstr. 1, 55131, Mainz, Deutschland
| | - Ludger Klimek
- Hals‑, Nasen‑, Ohrenklinik und Poliklinik, Universitätsmedizin Mainz, Langenbeckstr. 1, 55131, Mainz, Deutschland
- Zentrum für Rhinologie und Allergologie, An den Quellen 10, Wiesbaden, Deutschland
| | - Kai Fruth
- HNO Zentrum Mainz, Emmeransstr. 9, 55161, Mainz, Deutschland
| | - Clemens Stihl
- Klinik und Poliklinik für Hals-Nasen-Ohrenheilkunde, Klinikum der Ludwig-Maximilians-Universität München, Campus Großhadern, München, Deutschland
| | - Christoph Matthias
- Hals‑, Nasen‑, Ohrenklinik und Poliklinik, Universitätsmedizin Mainz, Langenbeckstr. 1, 55131, Mainz, Deutschland
| | - Moritz Gröger
- Klinik und Poliklinik für Hals-Nasen-Ohrenheilkunde, Klinikum der Ludwig-Maximilians-Universität München, Campus Großhadern, München, Deutschland
| | - Jan Hagemann
- Hals‑, Nasen‑, Ohrenklinik und Poliklinik, Universitätsmedizin Mainz, Langenbeckstr. 1, 55131, Mainz, Deutschland.
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Foerster-Ruhrmann U, Jurkov M, Szczepek AJ, Bergmann KC, Fluhr JW, Olze H. Biologics Reduce Symptoms of Alcohol Intolerance Better than Aspirin Desensitization in Patients with N-ERD and Nasal Polyps. Biomedicines 2024; 12:1025. [PMID: 38790987 PMCID: PMC11118606 DOI: 10.3390/biomedicines12051025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Revised: 04/18/2024] [Accepted: 04/30/2024] [Indexed: 05/26/2024] Open
Abstract
BACKGROUND Non-steroidal anti-inflammatory drugs (NSAIDs) exacerbated respiratory disease (N-ERD) is associated with chronic rhinosinusitis with nasal polyps (CRSwNP), asthma, and NSAID hypersensitivity. An overproduction of leukotrienes characterizes the pathomechanism of the disease. N-ERD patients often report breathing difficulties after consuming alcohol. These symptoms have been observed in patients receiving either aspirin therapy after desensitization (ATAD), therapy with the biologics dupilumab (anti-IL-4Ra antibody) and omalizumab (anti-IgE antibody), or intranasal corticosteroid treatment (INCS). METHODS This retrospective, real-world study assessed the severity of alcohol-related and non-alcohol-related respiratory symptoms in CRSwNP/N-ERD patients 3-6 months after ATAD, biologic (dupilumab or omalizumab), or INCS therapy. A total of 171 patients (98 women and 73 men) were enrolled in the study. All groups received standard INCS therapy. Sixty-three patients were treated with ATAD; 48 received biologics (dupilumab n = 31; omalizumab n = 17); and 60 received INCS only and served as a control group. Alcohol-dependent symptoms and typical CRS symptoms (alcohol-independent) were quantified using visual analog scales (VAS). RESULTS ATAD and biological therapy significantly reduced VAS scores for alcohol dependence and CRS symptoms. In the control group receiving INCS, only non-alcohol dependent CRS symptoms improved significantly (p < 0.05). The most significant differences in pre/post scores were observed in patients receiving dupilumab, with the most significant improvement in alcohol-dependent and CRS symptoms (dupilumab > omalizumab > ATAD). CONCLUSIONS This real-world study shows that alcohol-related respiratory symptoms are a relevant parameter in CRSwNP/N-ERD patients. Patients benefit more from biologic therapy than from ATAD in terms of their alcohol-related symptoms and other CRS symptoms. Future studies should include placebo-controlled oral alcohol challenge.
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Affiliation(s)
- Ulrike Foerster-Ruhrmann
- Department of Otorhinolaryngology, Head and Neck Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität and Berlin Humboldt Universität zu Berlin, Charitéplatz 1, 10117 Berlin, Germany; (U.F.-R.); (M.J.); (A.J.S.)
| | - Miroslav Jurkov
- Department of Otorhinolaryngology, Head and Neck Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität and Berlin Humboldt Universität zu Berlin, Charitéplatz 1, 10117 Berlin, Germany; (U.F.-R.); (M.J.); (A.J.S.)
| | - Agnieszka J. Szczepek
- Department of Otorhinolaryngology, Head and Neck Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität and Berlin Humboldt Universität zu Berlin, Charitéplatz 1, 10117 Berlin, Germany; (U.F.-R.); (M.J.); (A.J.S.)
| | - Karl-Christian Bergmann
- Institute of Allergology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 12203 Berlin, Germany; (K.-C.B.); (J.W.F.)
- Fraunhofer Institute for Translational Medicine and Pharmacology, Immunology and Allergology, 12203 Berlin, Germany
| | - Joachim W. Fluhr
- Institute of Allergology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 12203 Berlin, Germany; (K.-C.B.); (J.W.F.)
- Fraunhofer Institute for Translational Medicine and Pharmacology, Immunology and Allergology, 12203 Berlin, Germany
| | - Heidi Olze
- Department of Otorhinolaryngology, Head and Neck Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität and Berlin Humboldt Universität zu Berlin, Charitéplatz 1, 10117 Berlin, Germany; (U.F.-R.); (M.J.); (A.J.S.)
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Domínguez-Ortega J, Mullol J, Álvarez Gutiérrez FJ, Miguel-Blanco C, Castillo JA, Olaguibel JM, Blanco-Aparicio M. The effect of biologics in lung function and quality of life of patients with united airways disease: A systematic review. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. GLOBAL 2024; 3:100174. [PMID: 37915724 PMCID: PMC10616425 DOI: 10.1016/j.jacig.2023.100174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 08/08/2023] [Accepted: 08/16/2023] [Indexed: 11/03/2023]
Abstract
Background Increasing evidence supports the united airway disease concept for the management of upper and lower respiratory tract diseases, particularly in patients with asthma and chronic rhinosinusitis with nasal polyps (CRSwNP). However, evidence for a combined approach in asthma and CRSwNP is scarce. Objective In this systematic review, we focused on the role of biologics in the lung function and quality of life in patients with severe asthma and CRSwNP. Methods We conducted a systematic search of 3 electronic databases using 2 search strategies to identify studies published from January 2010 to March 2022. Quality assessment was performed with the Critical Appraisal Skills Programme. Results Of 1030 studies identified, 48 original studies reporting data of benralizumab (12), dupilumab (14), mepolizumab (10), omalizumab (13), and reslizumab (2) were analyzed. Primary diagnosis was mostly asthma or CRSwNP, with only 15 studies, mainly observational, performed in populations with united airway disease. In total, 18 studies reported data on quality of life (mostly 22-item Sino-Nasal Outcome Test score), 8 on lung function (mostly FEV1), and 22 on both outcomes. Significant FEV1 and 22-item Sino-Nasal Outcome Test score improvements were consistently observed after 24-week treatment, and thereafter, mostly in real-world studies that included variable proportions of patients with asthma/CRSwNP. Conclusions The use of biologics in patients with severe asthma and CRSwNP was overall associated with significant improvements in lung function and quality of life. However, we observed a high heterogeneity of populations and outcome measurements across studies. Notwithstanding the need of larger studies, our results reinforce the joint management of asthma and CRSwNP as united airway disease in clinical practice.
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Affiliation(s)
- Javier Domínguez-Ortega
- Department of Allergy, La Paz University Hospital, Institute for Health Research (IdiPAZ), CIBER of Respiratory Diseases (CIBERES), Madrid, Spain
| | - Joaquim Mullol
- Rhinology Unit & Smell Clinic, ENT Department, Hospital Clinic, Universitat de Barcelona, IDIBAPS, CIBERES, Barcelona, Spain
| | | | | | | | - Jose María Olaguibel
- Department of Allergy, Hospital Universitario de Navarra, CIBER of Respiratory Diseases (CIBERES), Navarra, Spain
| | - Marina Blanco-Aparicio
- Department of Respiratory Medicine, Complexo Hospitalario Universitario de A Coruña A Coruña Spain
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De Corso E, Pipolo C, Cantone E, Ottaviano G, Gallo S, Trimarchi M, Torretta S, Cavaliere C, Lucidi D, Seccia V, Settimi S, Canevari FRM, Pasquini E, La Mantia I, Garzaro M, Bellocchi G, De Benedetto M, Lombardo N, Macchi A, Malvezzi L, Motta G, Vicini C, Maselli A, Dell’Era V, Dragonetti A, Asprea F, Lupato V, Ghidini A, Masieri S, Mattavelli D, Salzano FA, Passali D, Galli J, Pagella F. Practical recommendations for managing severe chronic rhinosinusitis with nasal polyps in the era of biologics. ACTA OTORHINOLARYNGOLOGICA ITALICA : ORGANO UFFICIALE DELLA SOCIETA ITALIANA DI OTORINOLARINGOLOGIA E CHIRURGIA CERVICO-FACCIALE 2023; 43:324-340. [PMID: 37224173 PMCID: PMC10551726 DOI: 10.14639/0392-100x-n2422] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 03/09/2023] [Indexed: 05/26/2023]
Abstract
Objective We conducted a national survey to understand how rhinology practice has changed with the advent of biologics and how this affected patients with uncontrolled, severe chronic rhinosinusitis with nasal polyps (CRSwNP). We aimed to analyse the results of the survey and infer practical recommendations for clinical practice. Methods A group of ear, nose, and throat specialists (ENTs) experienced in the management of CRSwNP developed a 74-question survey. ENTs from rhinology centres authorised to prescribe biologics in the context of the national health system were invited to answer it between 01/05/2022 and 31/07/2022. The responses underwent descriptive analyses, and the authors discussed the results and derived practical recommendations for clinical practice. Results ENTs working in rhinology centres changed their practices coinciding with the advent of biologics. CRSwNP evaluations have become more complex because they involve diagnostic confirmation, determining the patients' immunologic profile, and other factors. We observed heterogenous behaviours in practice that may be conditioned by the novelty of the topic. The results of the survey were used to develop practical recommendations for ENTs and are summarised herein. Conclusions Clinical practice in rhinology outpatient clinics has changed profoundly in the era of biologics. Our practical recommendations for clinicians working in rhinology centres are expected to help standardise practice and improve care.
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Affiliation(s)
- Eugenio De Corso
- Otorhinolaryngology Unit, Head and Neck Department, A. Gemelli Universitary Hospital Foundation IRCCS, Rome, Italy
| | - Carlotta Pipolo
- Otorhinolaryngology Unit, Head and Neck Department, Dipartimento di Scienze della Salute, Università degli Studi di Milano, ASST Santi Paolo e Carlo Hospital, Milan, Italy
| | - Elena Cantone
- Department of Neurosciences, Reproductive and Odontostomatologic Sciences, Unit of Ear, Nose and Throat, “Federico II” University, Naples, Italy
| | - Giancarlo Ottaviano
- Department of Neuroscience DNS, Otolaryngology Section, University of Padua, Padua, Italy
| | - Stefania Gallo
- Otorhinolaryngology Unit, Head and Neck Department, ASST Sette Laghi and UPLOAD Research Center, University of Insubria, Varese, Italy
| | - Matteo Trimarchi
- Division of Head and Neck Department, Otorhinolaryngology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Sara Torretta
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Carlo Cavaliere
- Dipartimento di scienze odontostomatologiche e maxillo facciali. Sapienza University of Rome, Rome, Italy
| | - Daniela Lucidi
- Department of Otolaryngology – Head and Neck Surgery, University Hospital of Modena, Modena, Italy
| | - Veronica Seccia
- Otolaryngology, Audiology, and Phoniatric Operative Unit, Department of Surgical, Medical, Molecular Pathology, and Critical Care Medicine, Pisa University Hospital, Pisa, Italy
| | | | - Frank Rikki Mauritz Canevari
- UOC di Otorinolaringoiatria IRCCS Policlinico San Martino Genova, Dipartimento DISC Università di Genova, Genoa, Italy
| | - Ernesto Pasquini
- ENT Unit “Bellaria” Hospital – Specialized Dep AUSL Bologna, Italy
| | | | | | | | | | - Nicola Lombardo
- ENT Unit Department of Medical and Surgical Sciences, University Magna Græcia Catanzaro, Italy
| | - Alberto Macchi
- ENT University of Insubria, ASST Settelaghi, Varese, Italy
| | - Luca Malvezzi
- IRCCS Humanitas Research Hospital, Department of Otorhinolaryngology and Head and Neck Surgery, Rozzano (MI), Italy
| | - Gaetano Motta
- Otorhinolaryngology – Head and Neck Surgery, University of Campania “L. Vanvitelli”, Naples, Italy
| | - Claudio Vicini
- Department of Head-Neck Surgery, Otolaryngology, Head-Neck and Oral Surgery Unit, Morgagni Pierantoni Hospital, Forlì, Italy
| | - Alessandro Maselli
- Department Otorhinolaryngology, Hospital of Barletta, Barletta (BT), Italy
| | - Valeria Dell’Era
- ENT Division, Maggiore Hospital, Eastern Piedmont University – Novara, Italy
| | | | - Francesco Asprea
- Otorinolaringoiatria e audiologia. Università degli studi di Messina, Messina, Italy
| | - Valentina Lupato
- Division of Otolaryngology, Ospedale Civile di Pordenone, Azienda Sanitaria Friuli Occidentale (ASFO), Pordenone, Italy
| | - Angelo Ghidini
- Otorinolaringoiatria Azienda USL di Reggio Emilia/IRCCS, Italy
| | - Simonetta Masieri
- Dipartimento di scienze odontostomatologiche e maxillo facciali. Sapienza University of Rome, Rome, Italy
| | - Davide Mattavelli
- Unit of Otorhinolaryngology – Head and Neck Surgery, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, ASST Spedali Civili di Brescia – University of Brescia, Brescia, Italy
| | | | | | - Jacopo Galli
- Otorhinolaryngology Unit, Head and Neck Department, A. Gemelli Universitary Hospital Foundation IRCCS, Rome, Italy
- Catholic University of The Sacred Heart, Rome, Italy
| | - Fabio Pagella
- Department of Clinical, Surgical, Diagnostic, and Pediatric Sciences, University of Pavia, Pavia, Italy
- Otorhinolaryngology Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
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9
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Sánchez J, García E, Lopez JF, Calle A, Buendia JA. Nonsteroidal Anti-inflammatory Drug (NSAID) Tolerance After Biological Therapy in Patients With NSAID-Exacerbated Respiratory Disease: A Randomized Comparative Trial. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:2172-2179. [PMID: 37146885 DOI: 10.1016/j.jaip.2023.04.033] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 04/12/2023] [Accepted: 04/13/2023] [Indexed: 05/07/2023]
Abstract
BACKGROUND There are no prospective studies comparing how biological therapies affect nonsteroidal anti-inflammatory drug (NSAID) tolerance in NSAID-exacerbated respiratory disease. OBJECTIVE To study the induction of NSAID tolerance after biological therapy in patients with NSAID-exacerbated respiratory disease. METHODS A prospective pilot study in a real-world clinic setting was conducted among subjects with severe asthma and type 2 inflammation. A random allocation of therapy was carried out: benralizumab, dupilumab, mepolizumab, or omalizumab. NSAID intolerance was confirmed by an oral challenge test (OCT) using acetyl-salicylic acid (ASA-OCT). The principal outcome was NSAID tolerance according to OCT before and after 6 months of each biological therapy (intragroup comparisons). As exploratory outcomes, we compared NSAID tolerance between biological therapies (intergroup comparisons). RESULTS A total of 38 subjects were included; 9 received benralizumab, 10 dupilumab, 9 mepolizumab, and 10 omalizumab. There was an increase in the concentration needed to produce a reaction during ASA-OCT with omalizumab (P < .001) and dupilumab (P = .004) but not with mepolizumab and benralizumab. Omalizumab and dupilumab achieved the highest frequency of NSAID tolerance (omalizumab 60%, dupilumab 40%, mepolizumab 22%, and benralizumab 22%). CONCLUSIONS Biological therapies for asthma are useful for inducing NSAID tolerance; however, in patients with type 2 inflammation and high levels of total IgE, atopy, and eosinophils, anti-IgE or anti-IL4/13 seem to be more effective than antieosinophilic therapies. Omalizumab and dupilumab increased ASA tolerance, whereas mepolizumab and benralizumab did not. Future trials will be able to clarify this finding.
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Affiliation(s)
- Jorge Sánchez
- Hospital "Alma Mater de Antioquia, " Group of Clinical and Experimental Allergy (GACE), University of Antioquia, Medellín, Colombia.
| | - Elizabeth García
- Surgical Medical Unit of Otorhinolaryngology (UNIMEQ-ORL), Bogotá, Colombia
| | - Juan-Felipe Lopez
- Hospital "Alma Mater de Antioquia, " Group of Clinical and Experimental Allergy (GACE), University of Antioquia, Medellín, Colombia
| | - Ana Calle
- Hospital "Alma Mater de Antioquia, " Group of Clinical and Experimental Allergy (GACE), University of Antioquia, Medellín, Colombia
| | - Jefferson-Antonio Buendia
- Department of Pharmacology and Toxicology, School of Medicine, Research Group in Pharmacology and Toxicology (INFARTO), University of Antioquia, Medellín, Colombia
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10
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Schneider S, Poglitsch K, Morgenstern C, Quint T, Gangl K, Sinz C, Bartosik T, Campion NJ, Liu DT, Landegger LD, Tu A, Stanek V, Rocha-Hasler M, Bangert C, Eckl-Dorna J. Dupilumab increases aspirin tolerance in NSAID-exacerbated respiratory disease. Eur Respir J 2023; 61:13993003.01335-2022. [PMID: 36549708 PMCID: PMC10017890 DOI: 10.1183/13993003.01335-2022] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 11/14/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Nonsteroidal anti-inflammatory drug (NSAID)-exacerbated respiratory disease (N-ERD) comprises the triad of chronic rhinosinusitis with nasal polyps, asthma and intolerance to NSAIDs. Dupilumab treatment, targeting the interleukin-4 (IL-4) receptor α, significantly reduces polyp burden as well as asthma symptoms. Here we aimed to investigate the effect of dupilumab on aspirin intolerance, burden of disease and nasal cytokine profiles in patients with N-ERD. METHODS In this open-label trial, adult patients with confirmed N-ERD were treated with dupilumab for 6 months. Clinical parameters (e.g. total polyp scores, quality of life questionnaires, smell test, spirometry), oral aspirin provocation testing and blood, nasal and urine sampling were monitored at regular intervals for up to 6 months after starting dupilumab therapy. RESULTS Of the 31 patients included in the study, 30 completed both aspirin provocation tests. After 6 months of treatment with dupilumab, 23% of patients (n=7 of 30) developed complete aspirin tolerance and an additional 33% of patients (n=10 of 30) tolerated higher doses. Polyp burden was significantly reduced (total polyp score: -2.68±1.84, p<0.001), while pulmonary symptoms (asthma control test: +2.34±3.67, p<0.001) and olfactory performance improved (University of Pennsylvania Smell Identification Test: +11.16±9.54, p<0.001) in all patients after therapy. Patients with increased aspirin tolerance showed a significant decrease in urinary leukotriene E4 levels and their improvement in clinical parameters was associated with a reduction of eotaxin-1, C-C motif chemokine ligand 17, IL-5, IL-17A and IL-6. CONCLUSION In this study, 57% of N-ERD patients tolerated higher doses of aspirin under dupilumab therapy.
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Affiliation(s)
- Sven Schneider
- Dept of Otorhinolaryngology, General Hospital and Medical University of Vienna, Vienna, Austria
| | - Katharina Poglitsch
- Dept of Dermatology, General Hospital and Medical University of Vienna, Vienna, Austria
| | | | - Tamara Quint
- Dept of Dermatology, General Hospital and Medical University of Vienna, Vienna, Austria
| | - Katharina Gangl
- Dept of Otorhinolaryngology, General Hospital and Medical University of Vienna, Vienna, Austria
| | - Christoph Sinz
- Dept of Dermatology, General Hospital and Medical University of Vienna, Vienna, Austria
| | - Tina Bartosik
- Dept of Otorhinolaryngology, General Hospital and Medical University of Vienna, Vienna, Austria
| | - Nicholas James Campion
- Dept of Otorhinolaryngology, General Hospital and Medical University of Vienna, Vienna, Austria
| | - David Tianxiang Liu
- Dept of Otorhinolaryngology, General Hospital and Medical University of Vienna, Vienna, Austria
| | - Lukas David Landegger
- Dept of Otorhinolaryngology, General Hospital and Medical University of Vienna, Vienna, Austria
| | - Aldine Tu
- Dept of Otorhinolaryngology, General Hospital and Medical University of Vienna, Vienna, Austria
| | - Victoria Stanek
- Dept of Otorhinolaryngology, General Hospital and Medical University of Vienna, Vienna, Austria
| | - Marianne Rocha-Hasler
- Dept of Otorhinolaryngology, General Hospital and Medical University of Vienna, Vienna, Austria
| | - Christine Bangert
- Dept of Dermatology, General Hospital and Medical University of Vienna, Vienna, Austria
| | - Julia Eckl-Dorna
- Dept of Otorhinolaryngology, General Hospital and Medical University of Vienna, Vienna, Austria
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11
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Schirmer JH, Both M, Müller O. Vaskulitis mimics. AKTUEL RHEUMATOL 2023. [DOI: 10.1055/a-1949-8509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
ZusammenfassungIdiopathische Vaskulitiden sind seltene entzündliche Systemerkrankungen,
die nach der Chapel-Hill Konsensus-Nomenklatur nach der Größe
der prädominant betroffenen Gebiete von Blutgefäßen
(große, mittelgroße, kleine Gefäße und
Gefäße variabler Größe) eingeteilt werden.
Vaskulitis mimics sind Syndrome, die ein ähnliches klinisches Bild
hervorrufen oder leicht mit einer idiopathischen Vaskulitis verwechselt werden
und teils sogar ein Krankheitsbild, das klinisch und histologisch einer
Vaskulitis gleicht, auslösen können. Die Zahl der Vaskulitis
mimics ist groß, je nach betroffenem Gefäßgebiet kommen
hereditäre Erkrankungen des Bindegewebes, genetisch bedingte
Immundefekt- und Autoinflammationssyndrome, infektiöse Erkrankungen,
seltene entzündliche Systemerkrankungen, Tumorerkrankungen,
medikamenteninduzierte Syndrome und zahlreiche weitere infrage. In diesem Review
wird eine Auswahl klassischer Imitatoren von Vaskulitiden, orientiert an der
Größe der betroffenen Blutgefäße
präsentiert und Konstellationen, die typische
„Fallstricke“ in der klinischen Abklärung darstellen
können, diskutiert.
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Affiliation(s)
- Jan Henrik Schirmer
- Klinik für Innere Medizin I, Sektion Rheumatologie,
Universitätsklinikum Schleswig-Holstein Campus Kiel, Kiel,
Germany
| | - Marcus Both
- Klinik für Radiologie und Neuroradiologie,
Universitätsklinikum Schleswig-Holstein Campus Kiel, Kiel,
Germany
| | - OliverJ Müller
- Klinik für Innere Medizin III (Kardiologie, Angiologie und
internistische Intensivmedizin), Universitätsklinikum Schleswig-Holstein
Campus Kiel, Kiel, Germany
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12
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Bertlich M, Freytag S, Dombrowski T, Jurmeister P, Spiegel JL, Bertlich I, Ihler F, Weiss BG, Haubner F, Gröger M. Subgroups in the treatment of nasal polyposis with dupilumab: A retrospective study. Medicine (Baltimore) 2022; 101:e31031. [PMID: 36397403 PMCID: PMC9666224 DOI: 10.1097/md.0000000000031031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Dupilumab has been shown to be safe and effective in treating chronic rhinosinusitis with polyposis (CRSwNP). There is to this date no published data whether subgroups like patients with aspirin exacerbated respiratory disease (AERD), increased histologic eosinophilia or elevated blood eosinophil or IgE-levels benefit greater from dupilumab therapy. Moreover, there is no data comparing the efficacy of functional endoscopic sinus surgery (FESS) with dupilumab therapy. We conducted a retrospective chart review of all patients that were treated at a tertiary referral center for CRswNP with dupilumab. We also contacted the patients with a questionnaire to evaluate the efficacy of previous surgeries and dupilumab therapy by visual analogue scale (VAS) and the glasgow benefit inventory (GBI) as well as report on side effects. Overall, 75 patients were included in the study at hand that reported back 138 times. While dupilumab treatment was efficient, we found no systematic evidence of greater efficacy of dupilumab in patients with AERD, histologic eosinophilia or increased blood eosinophil or IgE-levels. All patients showed a considerable decrease in subjective burden of disease, objective smell tests and endoscopic findings. From the patients point of view, dupilumab therapy showed greater efficacy both in the VAS and the GBI overall and all subcategories but "social support." Dupilumab is efficient in treating CRSwNP; this effect is independent from disease characteristics like AERD, histologic eosinophilia, serum IgE-levels or eosinophil counts. There seems to be a group of patients that benefit greater from dupilumab therapy compared to FESS.
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Affiliation(s)
- Mattis Bertlich
- Department of Dermatology and Allergy, University Hospital, Ludwig-Maximilians University of Munich, Munich, Federal Republic of Germany
- Department of Otorhinolaryngology, University Hospital, Ludwig-Maximilians University of Munich, Munich, Federal Republic of Germany
- *Correspondence: Mattis Bertlich, Department of Dermatology and Allergology, Ludwig-Maximilians University of Munich, Thalkirchner Str. 48, D-80337 Munich, Germany (e-mail: )
| | - Saskia Freytag
- Department of Epigenetics and Genomics, Harry Perkins Institute of Medical Research, Nedlands, WA, Australia
| | - Tobias Dombrowski
- Department of Otorhinolaryngology, University Medical Center, Georg-August University Göttingen, Göttingen, Federal Republic of Germany
| | - Philipp Jurmeister
- Institute of Pathology, University Hosptial, Ludwig-Maximilians University of Munich, Munich, Federal Republic of Germany
| | - Jennifer Lee Spiegel
- Department of Otorhinolaryngology, University Hospital, Ludwig-Maximilians University of Munich, Munich, Federal Republic of Germany
| | - Ines Bertlich
- Department of Dermatology and Allergy, University Hospital, Ludwig-Maximilians University of Munich, Munich, Federal Republic of Germany
| | - Friedrich Ihler
- Department of Otorhinolaryngology, University Hospital, Ludwig-Maximilians University of Munich, Munich, Federal Republic of Germany
- Department of Otorhinolaryngology, Head and Neck Surgery, Greifswald University Medicine, University of Greifswald, Greifswald, Federal Republic of Germany
| | - Bernhard G. Weiss
- Department of Otorhinolaryngology, University Hospital, Ludwig-Maximilians University of Munich, Munich, Federal Republic of Germany
| | - Frank Haubner
- Department of Otorhinolaryngology, University Hospital, Ludwig-Maximilians University of Munich, Munich, Federal Republic of Germany
| | - Moritz Gröger
- Department of Otorhinolaryngology, University Hospital, Ludwig-Maximilians University of Munich, Munich, Federal Republic of Germany
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