Remission: does it already exist in chronic rhinosinusitis with nasal polyposis?

Chronic spontaneous urticaria remission definition and therapy stepping down: World Allergy Organization position paper

BACKGROUND

There is no global agreement on the definition of chronic spontaneous urticaria (CSU) remission.

OBJECTIVE

Our aim was to generate a consensus for clinical definitions of CSU-related terms focused on remission.

METHODS

The World Allergy Organization Urticaria Committee systematically reviewed current available longitudinal articles. On the basis of this review, a consensus agreement was reached for the definition of the term CSU remission. In addition, a scheme specifying when and how therapeutic de-escalation should be performed was constructed.

RESULTS

Almost all of the groups that have carried out longitudinal studies to evaluate the frequency of CSU remission agreed to use the term CSU remission if the patient remains without urticaria signs and symptoms without pharmacologic treatment (omalizumab, cyclosporine, antihistamines, or systemic corticosteroids). According to our systematic review, the available evidence does not specify the best time to consider CSU remission. However, current evidence suggests that there is no significant difference in CSU relapse between 6- and 12-month periods of remission. So far, no evidence exists to propose any biomarkers for defining inflammatory or mechanistic remission in CSU or identifying patients with a high probability of cure. It can be reasonable to consider a reduction of treatment after 6 months of CSU control, with evaluation 2 to 6 months after stepping down treatment.

CONCLUSION

The World Allergy Organization Urticaria Committee proposes defining CSU clinical remission based on the total resolution of urticaria signs and symptoms without pharmacotherapy for at least 6 months. The implications of this definition in clinical practice must be evaluated and validated in future studies.

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.

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.

Brazilian guideline for the use of immunobiologicals in chronic rhinosinusitis with nasal polyps ‒ 2024 update

INTRODUCTION

Biologics targeting type 2 inflammation have revolutionized the way we treat patients with Chronic Rhinosinusitis with Nasal Polyps (CRSwNP). Particularly in severe and difficult-to-control cases, these drugs have provided a new reality for these patients, allowing for the effective and safe treatment of extensive diseases that were not completely managed with the typical strategy of surgery and topical medications.

OBJECTIVES

The experience achieved with the approval of these medications by ANVISA for use in CRSwNP and the knowledge obtained regarding outcomes, adverse effects, and the ideal patient profile prompted the update of the previously published guideline, with a detailed review of the most recent scientific literature, the personal experiences of experts, and the adaptation to the reality of the Brazilian healthcare system, both public and private.

RESULTS

We proposed a new eligibility criterion for biologics in patients with CRSwNP based on four pillars of indication: the impact of the disease on the patient's life, whether in the presence of specific symptoms or in overall quality of life; the extent of sinonasal disease; the presence of type 2 comorbidities, considering other associated diseases that may also benefit from anti-T2 biologics, and the presence of biomarkers to define type 2 inflammation, especially those associated with worse disease prognoses.

CONCLUSIONS

This innovative and pioneering method has two major advantages. First, it ensures a comprehensive evaluation of patients; second, it is flexible, as advancements in our understanding of the disease and changes in cost-effectiveness can be addressed by simply adjusting the required score for indication, without the need to modify the entire evaluation scheme.

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.

Pulmonology for the rhinologist

PURPOSE OF REVIEW

The upper and lower airways are inter-related despite serving different functions and can no longer be considered separately. Rhinologists are becoming increasingly aware of the role the lower airway plays in optimizing outcomes for their patients. This review highlights recent developments in pulmonology that impact rhinologic conditions.

RECENT FINDINGS

The unified airway concept now supports the multidisciplinary management of respiratory and rhinologic pathologies. Biomarkers, biologics and the concept of treatable traits have permitted the development of personalized and precise treatment of the entire respiratory tract. The concept of corticosteroid stewardship, the introduction of steroid sparing agents for the treatment of respiratory diseases and the development of biomarkers, now forces us to be more considerate and precise with oral corticosteroid (OCS) prescribing and to consider reduction regimens. Finally, current research on climate change and vaping will allow us to better educate and prepare our patients to improve adherence and avoid exacerbations to maintain optimal global respiratory health.

SUMMARY

The inter-relatedness of the upper and lower airway has encouraged a multidisciplinary focus in respiratory medicine. More research is required to improve the precision respiratory medicine model, particularly in the realm of biomarkers and endotyping. These developments must also consider the impact of climate change, pollution and toxins for us to provide optimum care for our patients.