Advances in biologic therapies for chronic rhinosinusitis with nasal polyps

Chronic rhinosinusitis (CRS) is a complex multifactorial inflammatory disease that affects more than ten percent of the adult population globally. CRS represents a large healthcare burden and is associated with significant morbidity. Despite conventional medical and surgical treatments, a subset of patients continue to have poor symptom control due to substantial inflammatory disease persistence. These difficult-to-treat patients represent ideal candidates for biologic therapeutics, which target key inflammatory processes implicated in CRS disease. Biologic agents targeting type 2 inflammation have been shown to reduce disease burden. Phase 3 clinical trials studying the effects of anti-IgE, anti-IL-5/anti-IL-5Rα, and anti-IL-4/IL-13 humanized monoclonal antibodies have shown the efficacy of these therapies to reduce polyp size, the need for revision surgeries, improve daily symptoms, and downregulate inflammatory markers while maintaining an acceptable safety profile. The reductions seen in inflammatory mediators are largely transient following treatment termination and additional investigations are required to discern the long-term effects of biologic use on disease modulation. Specifically, the evidence suggests that these biologics are beneficial for patients with CRSwNPs with comorbid asthma and aspirin exacerbated respiratory disease (AERDBiologics should be used sparingly because of significant cost and accessibility of the treatment. Current guidelines recommend that biologics be reserved for patients with CRSwNP with moderate to severe disease who have failed conventional medical and surgical therapy. Further studies are needed to better endotype patients to optimize biologic use, evaluate long-term effectiveness and compare the relative effectiveness of biologic therapies in these difficult-to-treat patients.