Parameters guide treatment for chronic rhinosinusitis with nasal polyps

Key takeaways:

• Stents, sprays and exhalation delivery systems had the best results among intranasal corticosteroids.
• Dupilumab and omalizumab had the most benefits among biologics.

The Allergy-Immunology Joint Task Force on Practice Parameters has issued guidelines for the medical management of chronic rhinosinusitis with nasal polyps, according to a review published in Annals of Allergy, Asthma & Immunology.

These guidelines also address aspirin-exacerbated respiratory disease, So Lim Kim, MD, assistant professor of pediatrics in the department of medicine, division of allergy and immunology at Northwestern University Feinberg School of Medicine, and colleagues wrote.

The task force developed the 2022 Chronic Rhinosinusitis with Nasal Polyps Practice Parameters after a systematic review of the literature, with a focus on intranasal corticosteroids (INCS), biologics and aspirin therapy after desensitization (ATAD) and how these therapies affect the two critical outcomes of disease-specific quality of life and nasal obstruction symptom score.

Intranasal corticosteroids

First, the task force recommended the use of INCS over not using INCS to treat CRSwNP, which they described as a conditional recommendation due to the small to moderate effect size across the critical outcomes and the low certainty of the evidence, especially regarding quality of life and harm, the authors wrote.

Delivery modalities had different impacts on the outcomes that were important to patients. For example, exhalation delivery systems (EDS) and rinses were the most beneficial for quality of life. Sprays, EDS, stents and high-dose sprays had the most benefits for symptoms.

Also, stents were most beneficial for smell, followed by EDS, sprays and drops. Stents and sprays were most beneficial in reducing the need for rescue surgery, followed by EDS. Finally, sprays and EDS had the most benefit for polyp sizes.

There did not appear to be any differences in adverse events for the various delivery methods compared with placebo, although this was mostly based on low or very low certainty of evidence.

Physicians should consider corticosteroid delivery methods based on these varied

outcomes, the authors wrote. Costs, insurance coverage, patient preference, availability and practical implications should be part of the shared decision-making process too.

Biologics

Next, the authors conditionally recommended the use of biologics over not using them based on moderately certain evidence. Physicians should consider options such as INCS, surgery and ATAD before or concurrently with biologics, the authors wrote.

Patients whose symptoms improve without biologics may prefer to continue that course to avoid systemic therapy, cost and insurance issues, the authors wrote. But patients who do not see sufficient benefit with those other therapies may value the higher certainty and magnitude of the benefits that biologics provide, the authors continued.

Also, patients with a baseline of severe disease and patients who value improvements in disease-specific quality of life and nasal symptoms over risks for adverse events with biologics may prefer biologics before trying alternative therapies, the authors wrote, due to the higher certainty of the magnitude of benefits.

Although the overall balance of effects favored the use of biologics over not using biologics, the authors wrote, their use depends on the values of the patients and their givers as well as on improvements with alternative treatments.

The task force did not consider insurance issues, costs or other economics relevant to treatment with biologics, but they added that physicians should discuss these factors in their shared decision-making with patients.

Dupilumab (Dupixent; Sanofi Genzyme/Regeneron) and omalizumab (Xolair; Genentech, Novartis) had the most benefits for disease-specific quality of life. Also, dupilumab, omalizumab and mepolizumab (Nucala, GSK) were most effective for nasal symptom scores.

Dupilumab improved sense of smell the most, followed by mepolizumab, omalizumab and benralizumab (Fasenra, AstraZeneca). Dupilumab also decreased the need for oral corticosteroids and rescue polyp surgery the most, followed by mepolizumab and benralizumab.

Biologics were safe and more effective than ATAD too, the task force added, with rates of adverse events that were not significantly different from placebo, although the authors called the certainty of this evidence low or very low.

ATAD for AERD

Without subsequent continued daily aspirin therapy, the authors wrote that aspirin desensitization by itself was believed to be ineffective. Further, patients with aspirin-exacerbated respiratory disease (AERD) and CRSwNP would benefit from ATAD compared with no ATAD, although this recommendation was conditional due to moderate certainty of evidence and a close balance between patient-important outcomes and harms.

Quality of life and nasal symptoms improved with aspirin desensitization compared with placebo, the authors wrote, but there was no difference in smell, nor was there any decrease in the need for oral corticosteroids or rescue surgery.

Risks for bleeding and gastrointestinal adverse effects also increased with ATAD compared with placebo, the authors continued, so physicians should discuss them in shared decision-making with patients as well.

INCS, surgery, biologics and antileukotrienes are options for patients with CRSwNP and AERD who want to avoid these adverse events, the authors wrote, but patients who have conditions that require nonsteroidal anti-inflammatory drugs may prefer ATAD.

Physicians also should discuss risks for desensitization and risks in long-term aspirin use with patients, in addition to monitoring these patients for long-term adverse events, the authors wrote.

Despite these recommendations, the authors wrote, active treatments should be compared directly and in combination with each other via randomized controlled trials, along with further investigation into which outcomes patients value the most.