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Towards a comprehensive management of upper and lower airways diseases

Published: May 11, 2022

Respiratory diseases affecting upper and lower airways, such as asthma and chronic rhinosinusitis with nasal polyps (CRSwNP), have been traditionally managed as independent entities. However, it is currently known that some respiratory diseases share common pathophysiological characteristics due to their anatomical and immunological relationship (e.g., type 2 inflammation). In this context, the United Airways Disease (UAD) concept refers to the coexistence of upper and lower airway diseases as a single entity, in the same patient and with a unified therapeutic approach. Among the several types of UAD that have been described, the multimorbidity of asthma and CRSwNP is one of the most frequent. Unfortunately, clinical trials and real-world studies have often evaluated the treatment of those diseases independently rather than as UAD, hence the management of these patients remains challenging for involved health care professionals, including allergists, ENT specialists, and pulmonologists.

In a new systematic review published in The Journal of Allergy and Clinical Immunology: In Practice, Mullol et al. summarized the most recent evidence on the management of patients with asthma and CRSwNP from a UAD perspective. Based on nine pre-defined clinical questions, the authors systematically searched for studies published since 2015 across three international scientific databases. Studies reporting interventions to control type 2 inflammation including medical (i.e., biologics, corticosteroids) and surgical treatment were considered. In total, more than a thousand articles related to the topic were retrieved, of which 32 were finally selected - based on specific inclusion/exclusion criteria - for analysis and data synthesis.

According to the scientific evidence analyzed in this review, biologic therapies play a key role in the management of patients with UAD. Type 2 inflammation can be effectively controlled by biologics, with a positive impact on both asthma and sinonasal outcomes. These agents have enabled a reduction in the dose of systemic corticosteroids that patients may require to control their disease. Moreover, a reduction in the need for endoscopic sinus surgery (ESS) has been consistently reported among the benefits of biologics. On the other hand, ESS has been shown to improve asthma in addition to sinonasal outcomes. Given the lack of publications on certain topics, Mullol et al. reported several gaps and unmet needs that would require further research. For instance, there was a lack of scientific evidence on clinical and/or biochemical markers associated with the response to biologics in patients with UAD and on how the reduction of corticosteroids should be performed in responders to biologics. These findings led authors to conclude that, whereas most current treatment algorithms and criteria for the indication of biologics consider asthma and CRSwNP as separate entities, a paradigm change towards a common algorithm and a more integrative approach for the management of UAD is warranted.  

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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