Different biologics, different outcomes in CRSwNP: dupilumab and omalizumab
Published online: June 1, 2021
Chronic rhinosinusitis with nasal polyps (CRSwNP) is a disease of the nasal passages and sinuses characterized by the presence of nasal polyps (benign growths) inside the nose. Patients experience persistent symptoms including blockage, runny nose, and loss of sense of smell. These symptoms can have a debilitating impact on quality of life. Standard treatments are saline nasal washes and intranasal steroids. In severe cases, patients may need oral steroids and/or nasal surgery to remove the polyps. Unfortunately, patients may have recurrence of nasal polyps and symptoms after receiving oral steroids or surgery, and many patients may need repeated courses of steroids and/or repeated surgeries. Recently, several different monoclonal antibody treatments (biologics) have become available for CRSwNP. These biologics target different components of the immune system’s inflammatory pathways that are thought to drive CRSwNP. There are no clinical trials that directly compare these biologics in CRSwNP. However, a technique called indirect treatment comparison (ITC) can be used to compare treatments from different trials to give an indication of relative efficacy.
In a recent article in The Journal of Allergy and Clinical Immunology: In Practice, Professor Anju Peters et al. conducted an ITC of biologics in patients with severe CRSwNP. They searched for clinical studies with similar design and patient populations, and then compared treatment outcomes across studies using the standard-of-care treatment as a common control arm.
Four clinical trials of biologics in CRSwNP were suitable for ITC: 2 for dupilumab; (724 patients overall) and 2 for omalizumab (265 patients overall). This ITC showed that after 24 weeks of treatment, patients treated with dupilumab had significantly greater reductions in nasal polyp size and significantly greater improvements in nasal congestion, sense of smell, and total symptom score than patients treated with omalizumab. Dupilumab was also associated with greater improvements in health-related quality of life than omalizumab, but this difference did not reach statistical significance. Patients who received dupilumab were 3.6 times more likely to achieve improvement of ≥1 in nasal polyp score (which has a scale of 0–8), and 2.1 times more likely to achieve improvement of ≥1 in nasal congestion score (scale 0–3) than patients who received omalizumab. These results were consistent in several sensitivity analyses conducted to adjust for differences in the inclusion criteria of the clinical trials. In summary, this study showed that among comparable patients with severe CRSwNP, dupilumab was associated with greater improvements than omalizumab. While ITCs have limitations, in the absence of head-to-head clinical trials, this study may provide a better understanding of potential relative efficacy of biologic treatments in CRSwNP.
The Journal of Allergy and Clinical Immunology: In Practice is an official journal of the AAAAI, focusing on practical information for the practicing clinician.