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Chronic rhinosinusitis with nasal polyps: which biologics perform best?

Published: March 8, 2022

Chronic rhinosinusitis with nasal polyps (CRSwNP) affects 1-2.6% of the general population. Patients present with nasal polyps, and experience persistent symptoms including nasal blockage, rhinorrhea / postnasal drip, facial pain / pressure, and loss of smell. Current standard treatments are not sufficient to control type 2 CRSwNP, which is characterized by serious symptoms and high rate of recurrence. Biological therapy is a new direction for the treatment of uncontrolled CRSwNP. Several promising clinical trials have evaluated its efficacy and safety, but there are no direct comparisons between different biologics.

In a recent article published in The Journal of Allergy and Clinical Immunology: In Practice, Cai and colleagues performed an indirect treatment comparison based on existing evidence to examine the differences in the efficacy and safety between biologics targeting type 2 CRSwNP. Efficacy outcomes, including nasal polyp score, nasal congestion severity, and the 22-item Sino-Nasal Outcome Test (SNOT-22) score, were measured after 24 weeks of treatment and at the end of follow-up (EOF, more than 48 weeks). Safety outcomes, including serious and non-serious adverse events, were analyzed at the EOF.

Seven randomized clinical trials (Bachert 2017, OSTRO, POLYP 1, POLYP 2, SINUS-24, SINUS-52, and SYNAPSE) involving 1913 patients and four biologics (benralizumab, dupilumab, mepolizumab, and omalizumab) were included for comparison. Dupilumab presented better effects in decreasing nasal polyp score and nasal congestion severity compared to the other three biologics after 24 weeks of treatment and the EOF. Benralizumab was the least effective in reducing nasal congestion severity and SNOT-22 score at 24 weeks. No significant differences were observed between the effects of the other biologics. Safety outcomes of the above biologics were comparable. These results were consistent in the sensitivity analysis conducted in subjects with previous surgery and the subgroup analysis conducted in CRSwNP patients with or without asthma. Overall, dupilumab may be the best choice among the four biologics when considering biological therapy for CRSwNP with type 2 inflammation. In the future, real-world evidence and head-to-head comparisons with longer follow-up periods will be necessary to confirm these findings.

The Journal of Allergy and Clinical Immunology: In Practice is an official journal of the AAAAI, focusing on practical information for the practicing clinician.

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