Biologics for Chronic Rhinosinusitis and Polyps: When and Which One?

PROGRAM DESCRIPTION: The recent approval of three biologic therapy for recalcitrant chronic rhinosinusitis with nasal polyposis (CRSwNP) has opened up a new paradigm of treatment. Biologic agents can be very effective in some patients, but not all patients. Many patients with recurrent nasal polyposis have severe biologically recalcitrant disease, whereas in others inadequate surgery may contribute to early recurrence of nasal polyps. The duration of therapy with biologic agent, long-term adverse effects and total costs are currently not understood. Given these considerations, diligence must be exercised in selecting patients for biologic therapy versus “standard of care” (surgery and conventional maintenance medical therapy). In addition, CRS patients without nasal polyps on office nasal endoscopy (CRSsNP) also may show intra-operative polyps/ polypoid changes; histopathology and pathophysiologic mechanisms similar to CRSwNP patients may be at work in these patients. Therefore, some recalcitrant CRS patients without polyps may be candidates for biologic therapy. While patients with severe biological recalcitrance may be optimally served by the use of a biologic, other patients may be well or better served by standard of care utilizing meticulous revision surgery and postoperative maintenance medical therapy. Multidisciplinary management of these patients with an allergy-immunologist is optimal.
This panel of seasoned Otolaryngology and Allergy Immunology experts will discuss optimal use of biological therapy for CRS, focusing data on CRSwNP and also discussing potential use for CRSsNP. We will outline how to identify which patients are best suited for potential biological therapy. Considerations in selection of the “right” biologic through interpretation of postoperative sinus CT, serum assays and histopathology, lower airway and immunologic testing will be discussed.

OUTCOME OBJECTIVE 1: Evaluate candidature of CRS and nasal polyp patients for biologic therapy vs. standard of care

OUTCOME OBJECTIVE 2: Implement a personalized plan for each patient on choice of the biologic agent based on disease subtype, histopathology, presence of and clinically accessible testing

OUTCOME OBJECTIVE 3: Explain advantages and adverse effects of each biologic approved for CRSwNP

BACKGROUND STATEMENT: Three biologic agents are FDA approved in the last two years for use in CRSwNP, targeting Type II inflammation. Competence in evaluating and deploying these therapies is a gap that needs to be met for otolaryngologist in practice, as mechanism of action and efficacy of each biologic differs.