British Rhinological Society Consensus Guidance on the use of biological therapies for chronic rhinosinusitis with nasal polyps

Impact of dupilumab prescribing on utilization of medical and surgical therapies for chronic rhinosinusitis with nasal polyps

KEY POINTS

Increased dupilumab utilization coincided with decreased ESS in patients with CRSwNP between 2019 and 2021. One potential confounder was the concurrent COVID-19 pandemic, which may have negatively impacted surgery utilization rates.

Antibody-based therapeutics for chronic rhinosinusitis with nasal polyps

INTRODUCTION

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a prevalent inflammatory condition with heterogenous underlying endotypes, the most common being type 2 mediated inflammation. Several biologics have been developed to target specific pro-inflammatory cytokines and their receptors with proven efficacy in both quantitative and qualitative outcomes in patients with severe uncontrolled disease. However, there is an ongoing debate on the role of biologics relative to conventional therapies for CRSwNP and their efficacy in patient subgroups with non-polyp type 2 disease.

AREAS COVERED

This review examines the evidence on the efficacy and safety of biologics in CRSwNP, recommendations for their use, and discusses the broader economic factors influencing their application in clinical practice.

EXPERT OPINION

Emerging real-life data demonstrating the variable efficacy of the available biologics for patients with CRSwNP, coupled with the high cost compared to conventional therapies such as surgery, renders biologics to be considered as an add-on therapy in the majority of cases. However, ongoing research into increasing biologic dose intervals and novel therapies targeting alternative pathways may offer a more cost-effective and sustainable option in future.

Biologics: The Good, the Bad and the Future of Ear, Nose and Throat

Sensorineural hearing loss and chronic rhinosinusitis with nasal polyps affect a large proportion of the UK population. However, treatment with high efficacy to manage these pathologies remains to be found. With the development of biologic drug treatments, there is hope that this will improve quality of life for patients affected by these conditions. A literature review was carried out using PubMed. Studies that investigated the use of biologic drug treatment in chronic rhinosinusitis with nasal polyps, head and neck squamous cell carcinoma and sensorineural hearing loss were included in this paper. Studies have demonstrated that cost is quite possibly the greatest limiting factor for the licencing of these novel drugs by the National Institute for Health and Care Excellence. Biologics are currently approved in the management of squamous cell carcinoma of the head and neck for curative and palliative management. Although sensorineural hearing loss and chronic rhinosinusitis with nasal polyps are not life-threatening conditions, they do have a great effect upon a patients' quality of life. Current literature has identified several drug targets for biologics to be developed. Biologics, used off-licence, have been demonstrated to be effective in the management of the ear, nose and throat pathologies described. Although the off-licence use of biologics have been found to be beneficial, larger randomised control trials will be required to demonstrate the true efficacy of these drugs and allow for approval by the National Institute for Health and Care Excellence. Cost will become less of a limiting factor as time progresses as biosimilars will be able to be produced once drug patents expire, thus making the market more competitive, driving prices down.

Is generative pre-trained transformer artificial intelligence (Chat-GPT) a reliable tool for guidelines synthesis? A preliminary evaluation for biologic CRSwNP therapy

INTRODUCTION

Biologic therapies for Chronic Rhinosinusitis with Nasal Polyps (CRSwNP) have emerged as an auspicious treatment alternative. However, the ideal patient population, dosage, and treatment duration are yet to be well-defined. Moreover, biologic therapy has disadvantages, such as high costs and limited access. The proposal of a novel Artificial Intelligence (AI) algorithm offers an intriguing solution for optimizing decision-making protocols.

METHODS

The AI algorithm was initially programmed to conduct a systematic literature review searching for the current primary guidelines on biologics' clinical efficacy and safety in treating CRSwNP. The review included a total of 12 studies: 6 systematic reviews, 4 expert consensus guidelines, and 2 surveys. Simultaneously, two independent human researchers conducted a literature search to compare the results. Subsequently, the AI was tasked to critically analyze the identified papers, highlighting strengths and weaknesses, thereby creating a decision-making algorithm and pyramid flow chart.

RESULTS

The studies evaluated various biologics, including monoclonal antibodies targeting Interleukin-5 (IL-5), IL-4, IL-13, and Immunoglobulin E (IgE), assessing their effectiveness in different patient populations, such as those with comorbid asthma or refractory CRSwNP. Dupilumab, a monoclonal antibody targeting the IL-4 receptor alpha subunit, demonstrated significant improvement in nasal symptoms and quality of life in patients with CRSwNP in several randomized controlled trials and systematic reviews. Similarly, mepolizumab and reslizumab, which target IL-5, have also shown efficacy in reducing nasal polyp burden and improving symptoms in patients with CRSwNP, particularly those with comorbid asthma. However, additional studies are required to confirm the long-term efficacy and safety of these biologics in treating CRSwNP.

CONCLUSIONS

Biologic therapies have surfaced as a promising treatment option for patients with severe or refractory CRSwNP; however, the optimal patient population, dosage, and treatment duration are yet to be defined. The application of AI in decision-making protocols and the creation of therapeutic algorithms for biologic drug selection, could offer fascinating future prospects in the management of CRSwNP.

Multidisciplinary Decision-Making-ITAlian Consensus After Two Years of Real Practice on the Management of Severe Uncontrolled CRSwNP by Biologics (ITACA Study)

PURPOSE OF REVIEW

We aimed to reach an Italian multidisciplinary consensus on some crucial aspects of treatment decision making in CRSwNP, following 2 years of clinical experience in order to support specialists in the management of CRSwNP in clinical practice. We addressed issues relating to therapeutic decision-making and shared criteria for the treatment choice, as well as appropriate timing and criteria for evaluating treatment response, and highlighted the need for repeated multidisciplinary assessments.

RECENT FINDINGS

A national survey has been conducted recently to understand how rhinology practice has changed in Italy with the advent of biologics and how this affects patients with uncontrolled, severe CRSwNP. Despite the many published consensus documents, practical recommendations, and protocols on the use of biologics in CRSwNP, heterogenous behaviors in practice are still observed mainly conditioned by the novelty of the topic. The consensus procedure followed a modified Delphi approach. The scientific board included 18 otorhinolaryngologists and 8 allergists, who selected the 4 main topics to be addressed and developed overall 20 statements. Consensus on these statements was sought by a larger group of 48 additional experts, through two rounds of voting, the first web-based, the second in presence with discussion and possible refinement of the statements. The statements reaching an average score ≥ 7 at the second voting round were approved. Five statements were proposed for each of the following topics: baseline evaluation of patients eligible for biologic therapy; choice between different therapeutic options; assessment of the response to biologic treatment; multidisciplinary management. At the first voting round, 19 out of the 20 statements reached a mean score ≥ 7. Following the discussion and a few consequent amendments, at the second round of voting all the 20 statements were approved.

Mepolizumab in chronic rhinosinusitis with nasal polyposis

Chronic rhinosinusitis with nasal polyposis (CRSwNP) is a heterogeneous upper airway disease that is prevalent globally. Recent research into the molecular basis of the disease has led to the development of biologics as a new therapeutic option for severe and recalcitrant forms of CRSwNP. Mepolizumab is a monoclonal antibody targeting IL-5, one of the signature cytokines of the type 2 immune response and which plays an important role in the pathogenesis of CRSwNP. Here we present the latest evidence behind mepolizumab, examining disease pathophysiology and pharmacology, as well as data from clinical trials, real-life studies and meta-analyses. As we welcome this promising step forward into precision medicine, we discuss practical issues and future perspectives on mepolizumab and biologics for CRSwNP.

Practical recommendations for managing severe chronic rhinosinusitis with nasal polyps in the era of biologics

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.

Dupilumab's Impact on Blood Parameters in Nasal Polyposis: 18-Month Follow-Up in Real Life

Background

Dupilumab represents the first approved biological for severe uncontrolled chronic rhinosinusitis with nasal polyps (CRSwNP).

Objective

Aim of this paper is to provide a multicentric real-life study about treatment with dupilumab for CRSwNP with a special focus on blood parameters and IgE, IgG, and IgA.

Method

A retrospective data collection was jointly conducted at the Otolaryngology departments of San Camillo Forlanini Hospital and University of Rome "La Sapienza" from December 2020 to January 2023.

Results

A total of 130 patients were included in the study. Monitoring our patients for 18 months, we observed a reduction in nasal polyposis and an improvement in symptoms and their impact on quality of life. Regarding blood tests, a transient increase in blood eosinophils was found in most cases. Total IgE showed a gradual decrease in values. IgG and IgA also showed a slight reduction of values, while remaining within normal ranges.

Conclusion

To the best of our knowledge, this is the first study to evaluate the impact of dupilumab on several blood parameters in patients receiving treatment for CRswNP. Further studies are needed to confirm our results and to understand the underlying immunological mechanisms.

Prevalence and Associated Factors of Medication Non-Adherence in CRS Patients following Endoscopic Sinus Surgery

This study aimed to evaluate factors that may predispose patients to not adhere to prescribed medication after endoscopic sinus surgery (ESS) and to compare SNOT-22 scores at 0-12 months post-operatively between adherent and non-adherent patients. CRS patients who underwent ESS between 2012 and 2016 were recruited to this retrospective cohort study. Adherence was assessed through a questionnaire and review of medical notes. Ninety-four participants were included (61% male, mean age 60). Of those, 66% did not adhere to their prescribed post-operative CRS medication timing or dosage. The most common reason for non-adherence was improvement of symptoms (17%), followed by deterioration of symptoms (11%) and side effects (10%). Post-operative SNOT-22 scores were lowest for non-intentionally non-adherent (NINA) participants with a mean of 10.5 [95% CI: 7.47-13.5], compared to 25.0 for intentionally non-adherent (INA) [95% CI: 17.6-32.4] and 17.7 for adherent patients [95% CI: 13.7-21.7], p = 0.01. This study identifies that almost two-thirds of patients are not compliant with CRS medications after ESS. NINA participants reported lower post-operative SNOT-22 scores compared to INA and adherent participants. Future studies should focus on educating patients to continue with medications post-operatively despite an initial improvement in symptoms.

Real-world characterisation of patients with chronic rhinosinusitis with nasal polyps with and without surgery in England

OBJECTIVES

To characterise the real-world burden of chronic rhinosinusitis with nasal polyps (CRSwNP) in the UK, stratified by number of surgeries.

DESIGN

Retrospective cohort study.

SETTING

UK Clinical Practice Research Datalink Aurum database with Hospital Episodes Statistics linkage (2007-2019).

PARTICIPANTS

Adults ≥18 years of age with a first NP diagnosis (index) and 365 days of baseline and ≥180 days of follow-up data. Follow-up continued until disenrollment, death or end of data collection.

MAIN OUTCOME MEASURES

Primary: primary care physician prescribed CRSwNP-related treatments, and all-cause healthcare resource utilisation (HCRU) in 90 days post-index, stratified by surgeries during follow-up. Secondary: rate of surgery and CRSwNP point prevalence. Baseline patient demographics, clinical characteristics and comorbidities were also assessed.

RESULTS

Of the 33 107 patients included, 23.5% and 2.2% had ≥1 and ≥2 surgeries during follow-up, respectively (mean follow-up: 5.3 years). Patients with more surgeries (≥2/≥1/0) during follow-up were more likely to be male (67.3%/69.0%/58.0%), have asthma (37.8%/28.2%/20.2%) and have baseline blood eosinophil counts ≥300 cells/μL (68.5%/66.0%/51.5%). During the first 90-days post-index as surgery number increased, the proportion of patients using oral corticosteroids (25.8%/20.7%/14.2%) and mean (SD) number of all-cause healthcare visits (5.9 [4.2]/5.4 [4.0]/4.9 [4.2]) increased. Time between surgeries was shorter among patients with more surgeries. CRSwNP prevalence on 31 December 2018 was 476 cases per 100 000 persons.

CONCLUSION

A small proportion of patients in the UK required multiple surgeries for CRSwNP and this was associated with increasing comorbidity burden, baseline blood eosinophil counts, CRSwNP-related treatment and HCRU use.

Comparison of guidelines for prescription and follow-up of biologics for chronic rhinosinusitis with nasal polyps

PURPOSE

To compare international and regional guidelines for prescription and monitoring of response to biologics in chronic rhinosinusitis with nasal polyps (CRSwNP).

METHODS

A literature review was performed to identify publications reporting indications for biologic therapy in CRSwNP. A full-text reading identified specific issues for comparison: prior surgery, evidence of type 2 inflammation (T2I), smell function, comorbidities, use of systemic corticosteroids, impact on quality of life, and endoscopic and CT findings were compared for the prescription, while the monitoring of the treatment was described in relation to timing, classification of response and criteria for withdrawal.

RESULTS

Ten publications were found. Prior surgery was strictly necessary in five guidelines, while in all the remaining it was variably recommended. A confirmation of T2I was considered necessary in one publication, unnecessary in two, and recommended or constituted only one of the factors to consider in seven. All the other issues analyzed were variably considered. Reevaluation was suggested at 4-6 months and 1 year, mostly assessing improvement in the same criteria used for prescription.

CONCLUSIONS

A combination of subjective and objective findings is used for the identification of patients with CRSwNP who are indicated for biologic therapy. Major debate has developed on the need for previous surgery, which is generally recommended, or strictly necessary for some authors. Confirmation of T2I is generally suggested, but compulsory only in a minority of guidelines. Smell function, use of systemic corticosteroids, and the impact on quality of life are the other factors most frequently considered.

Biologicals and Endoscopic Sinus Surgery for Severe Uncontrolled Chronic Rhinosinusitis With Nasal Polyps: An Economic Perspective

Chronic rhinosinusitis (CRS) with nasal polyps (CRSwNP) is a chronic disease with a high prevalence and high disease burden, and the lack of a cure. The socioeconomic burden of the disease is substantial and has been disproportionally increasing over past decades. Treatment is aimed at attaining disease control. Traditionally, topical corticosteroids, endoscopic sinus surgery, and oral corticosteroids are used to treat CRSwNP. The advent of biologics has revolutionized CRSwNP treatment, but these drugs are expensive. From an economic standpoint, it is worth debating whether biologics should be employed in patients with severe uncontrolled CRSwNP who fail to attain disease control with current therapies. This clinical commentary review provides an overview of the socioeconomic burden of chronic rhinosinusitis and treatment modalities, compares endoscopic sinus surgery versus biologics for severe CRSwNP, discusses management recommendations, and highlights future needs in this field. New ways to reduce costs of biologic treatments need to be explored to attain cost-effectiveness and provide patients who have severe CRSwNP with adequate treatment.

Survey on Use of Local and Systemic Corticosteroids in the Management of Chronic Rhinosinusitis with Nasal Polyps: Identification of Unmet Clinical Needs

Background: Local and systemic corticosteroids have long been the workhorse in management of chronic rhinosinusitis with nasal polyps (CRSwNP), although there is no universally accepted modality of prescription. We carried out a survey in Italy to capture current trends in the use of topical and systemic corticosteroids in patients with CRSwNP. Methods: A survey was set up on Survey Monkey^®. Each author distributed the link to the survey in an ad hoc manner and a total of 437 participants filled out the survey. Results: Mometasone furoate (79.3%) was the most frequently prescribed, administered daily by 61.9% of participants; the remaining preferred to discontinue treatment for brief periods to reduce side effects or to modulate the therapy in mild cases. The majority believe that a short cycle of systemic steroids should be prescribed for re-exacerbation of symptoms and that the number of cycles in the previous year should be evaluated to define control of the disease even if international guidelines do not provide clear indications on this topic. A certain degree of divergence emerged from responses regarding how long and the maximal dose of systemic steroids which place patients at high risk for adverse events. Finally, systemic corticosteroids seem to offer only temporary benefit on recovery of smell without guaranteeing long-term control even if the patient is adherent to topical corticosteroids. Conclusions: Our results highlight the need for clear guidelines on oral steroids, which could help supporting the use of a precision medicine approach, including indications for new biological agents.

Developments and Emerging Trends in the Global Treatment of Chronic Rhinosinusitis From 2001 to 2020: A Systematic Bibliometric Analysis

Background

Research on the treatment of chronic rhinosinusitis (CRS) has increased in recent decades. We undertook a bibliometric and visualization analysis of studies on CRS treatment to track research trends and highlight current research “hotspots”.

Methods

Original publications related to CRS treatment were obtained from the Science Citation Index-Expanded (SCI-E) and Social Sciences Citation Index (SSCI) databases in the Web of Science Core Collection (WoSCC) of Clarivate Analytics between 2001 and 2020. The country/region, institution, author, journal, references, and keywords involved in this topic were extracted using CiteSpace and VOSviewer to identify and analyze the research focus and trends in this field.

Results

In the previous two decades (especially after 2015), the number of publications on CRS treatment has grown markedly. With regard to publications and access to collaborative networks, the leading country was the USA. High-frequency keywords were “CRS,” “endoscopic sinus surgery,” “sinusitis,” “nasal polyps,” “asthma,” “rhinosinusitis,” “management,” “diagnosis,” “outcomes,” and “quality of life.” Inspection of keyword bursts suggested that “clinical practice guideline,” “adult CRS,” “innate lymphoid cell,” “recurrence,” and “mepolizumab” are the emerging research hotspots. The timeline view of the cluster map revealed that biologic agents have become an up-and-coming “hot topic” in CRS treatment in recent years.

Conclusion

Academic understanding of CRS treatment has improved markedly over the past 20 years. We study analyzed the papers objectively, methodically, and comprehensively, and identified hotspots and prospective trends in the field of CRS treatment. These results will aid rhinologists in gaining greater insight into CRS treatment strategies and identifying the changing dynamics of CRS research.

Ethical dilemmas associated with the introduction of biologic treatments in chronic rhinosinusitis with nasal polyps

This review considers ethical dilemmas which may present when introducing the use of biologic treatments alongside existing treatments in the management of chronic rhinosinusitis with nasal polyps. Biologic therapies offer hope to patients with diseases recalcitrant to conventional therapies but are often significantly more expensive. Reducing the need for surgery may act as a disincentive for use within surgical specialities, while reimbursement for administration has the potential to encourage inappropriate use. Any treatment should be used considering the principles of beneficence (offering the most effective treatment to the patient) and non-maleficence (minimising the risk of harm); the challenges of comparing the different available treatment options are considered. Patient autonomy should be involved a process of shared decision making, but when a third-party payor is involved they may seek to place restrictions on access to treatments that limit the choice of both patient and physician. Such decisions are often based on the cost-effectiveness of novel treatments relative to standard of care; published models suggest that at current market prices, biologics are less cost-effective in all groups that standard care. Social justice (fair distribution of limited healthcare resources) therefore may mandate rationing of access. To this end, working as part of professional organisations or research groups, physicians often produce guidelines that help to identify those in greatest need of novel treatments. The challenges in creating and applying these guidelines are also considered.

Outcomes of Dupilumab Treatment versus Endoscopic Sinus Surgery for Chronic Rhinosinusitis with Nasal Polyps

BACKGROUND

Outside of the SINUS-24 and SINUS-52 trials, there is limited data on the efficacy of dupilumab in patients with chronic rhinosinusitis with nasal polyps (CRSwNP). The objective was to compare dupilumab to functional endoscopic sinus surgery (FESS) in CRSwNP patients by assessing the change in nasal polyp and SNOT-22 scores post-intervention.

METHODS

A retrospective matched cohort study compared 54 CRSwNP patients treated with dupilumab to 54 CRSwNP patients who underwent FESS with both cohorts treated with topical corticosteroids. The primary endpoints were change in NPS and change in overall SNOT-22 score. Secondary endpoints were change in SNOT-22 domain scores and change in SNOT-22 olfaction score.

RESULTS

FESS patients had a greater improvement in NPS (5.18 ± 2.01) compared to dupilumab patients (4.27 ± 1.98, p=0.02). There was no significant difference in terms of the change in overall SNOT-22 score. Dupilumab patients had greater improvement in the extra-nasal rhinologic SNOT-22 domain scores (4.87 ± 3.91) compared to FESS patients (2.93 ± 4.32, p=0.02). There was a greater improvement in the SNOT-22 olfaction scores for dupilumab patients (2.35 ± 2.17) compared to FESS patients (1.48 ± 2.24, p=0.04). Dupilumab patients were followed on average for 12.20 months and FESS patients for 17.90 months.

CONCLUSIONS

Overall, both therapies are effective at reducing symptoms in patients with CRSwNP by SNOT-22. Dupilumab patients reported improved olfaction and decreased cough, post-nasal drainage, and thick nasal drainage as compared to FESS patients while FESS patients had a greater reduction in polyp burden. This article is protected by copyright. All rights reserved.

Three-dimensional cell culture for the study of nasal polyps

OBJECTIVES

Three-dimensional (3D) cell cultures have many applications such as stem cell biology research, new drug discovery, cancer, and Chronic Rhinosinusitis with Nasal Polyps (CRSwNP). This disease is characterized by a significant impact on quality of life and productivity. The diversity of factors that act in the progression of CRSwNP point to the creation of a cell culture model that allows the integration of different cell types with extracellular matrix. This work aimed to create a cell culture model in 3 dimensions (spheroids) for the study of Nasal Polyposis.

METHODS

Nasal polyp tissue from patients diagnosed with CRSwNP was mechanically dissociated using tweezers and a scalpel and the solution containing cells and small aggregates of nasal polyps was transferred to a Petri dish containing 5 mL of culture medium at the concentration of 10⁶ cells/mL.

RESULTS

The spheroids were cultivated for 20 days, fixed and analyzed using confocal microscopy. In a 3D culture environment, the spheroids were formed both by clustering cells and from small tissue fragments. In the cultures analyzed, the ciliary beat was present from the dissociation of the cells up to 20 days in culture.

CONCLUSION

Our findings also point to these characteristics showing the environment generated in our study, the cells remained differentiated for a longer time and with ciliary beating. Thus, this work shows that nasal polyp-derived cells can be maintained in a 3D environment, enabling better strategies for understanding CRSwNP in situations similar to those found in vivo.

LEVEL OF EVIDENCE

Laboratory studies.

Treatment options for chronic rhinosinusitis with nasal polyps

Background: The management of chronic rhinosinusitis with nasal polyps (CRSwNP) is evolving, with an emphasis on treating the underlying type 2 inflammation. Objective: The objective was to summarize the updated evidence-based medical and surgical treatment recommendations for CRSwNP, including the position of biologics in the treatment algorithm. Methods: This review compared and contrasted the therapeutic recommendations presented by the European Position Paper on Rhinosinusitis and Nasal Polyps 2020 and the International Consensus Statement on Allergy and Rhinology: Rhinosinusitis 2021. Results: The long-term use of intranasal corticosteroids and the short-term use of oral corticosteroids are strongly recommended, whereas corticosteroid-eluting implants are considered an option. Although the use of saline solution rinses is recommended, there is uncertainty as to whether irrigation is more effective than sprays. Oral aspirin (ASA) desensitization, followed by ASA ≥ 300 mg daily for patients with ASA-exacerbated respiratory disease may be considered. In general, the use of antifungal agents offers no benefit and potential harm. Although the use of oral antibiotics for an acute exacerbation is still debated, oral and topical antibiotics are discouraged for subacute or chronic use. Antileukotrienes are inferior to intranasal corticosteroids and are unlikely to provide added benefit when used concomitantly. It is unlikely that the benefit of oral antihistamines and decongestants outweigh the potential harm. Dupilumab is recommended for severe CRSwNP when consensus-determined criteria are met. Omalizumab may be an option with concomitant poorly controlled asthma. Mepolizumab and reslizumab may be used, particularly in patients with concomitant uncontrolled asthma. In allergic fungal rhinosinusitis, oral and topical antifungals, antileukotrienes, allergen immunotherapy, and omalizumab are therapeutic options. Although surgical intervention is recognized to be of benefit for CRSwNP, there are no evidence-based criteria to indicate when maximum medical treatment has failed. Conclusion: An evidence-based CRSwNP treatment algorithm for when to recommend surgery and/or initiate or discontinue biologics to maximize quality of life and cost-effectiveness is still lacking.

Clinical evaluation and diagnosis of aspirin-exacerbated respiratory disease

Aspirin-exacerbated respiratory disease (AERD) is a condition composed of chronic rhinosinusitis with nasal polyposis and asthma that is defined by respiratory hypersensitivity reactions to the cyclooxygenase 1-inhibitory effects of nonsteroidal anti-inflammatory drugs. It is diagnosed in 5% to 15% of patients with asthma and is even more common in those with comorbid nasal polyposis. Diagnosis is confirmed after an aspirin challenge procedure, yet many patients present with all components and can reliably be diagnosed by history. Patients with AERD commonly experience severe uncontrolled nasal polyposis and require multispecialty evaluation to properly stage and treat this condition. The presence of nasal polyposis plays a large component in the diminished quality of life in patients with AERD. In the last decade, multiple new therapeutic areas have been approved for type 2 airway diseases, offering patients with AERD many more options for control. This makes an early and accurate diagnosis of AERD important in the care of the larger population of type 2 airway diseases.