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CRSwNP: Unclear Origins and Developing Treatments

Innovations in Treatment of Chronic Rhinosinusitis with Nasal Polyposis: from Bench Research to Clinical Practice

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“CRSwNP can be a challenging and frustrating disease to control, even with intense medical and surgical therapy,” said Andrew P. Lane, MD, director of the Division of Rhinology, Sinus, and Skull Base Surgery at Johns Hopkins School of Medicine in Baltimore, Maryland.

Dr. Lane began this Panel Presentation on Tuesday, September 15, by describing the heterogeneity of CRSwNP. The disease covers a spectrum, and it’s not strictly genetic or allergic, nor is it necessarily caused by eosinophils, a fact we now know because research has shown that eliminating eosinophils does not eliminate polyps.

“Eosinophils are like fans in major league baseball,” Dr. Lane said. “They’re associated but not necessary, as we have learned from this year.”

Different endotypes of CRSwNP mean different manifestations as response to treatment. What is the common denominator? Where is the best place to intervene? The research still isn’t clear.

Future directions in the management of CRSwNP, said Dr. Lane, will require linking different endotypes with their respective responses to biologics and finding upstream targets of polyps so that physicians can target those triggers.

The biologics part of that equation, though, is also still developing.

Biologics may help to improve symptoms of nasal polyps when proper sinus surgery, which involves having an extensive opening of all the sinus cavities, is not adequate, according to Joseph K. Han, MD, chief of the Division of Allergy and the Division of Rhinology and Endoscopic Sinus and Skull Base Surgery at Eastern Virginia Medical School in Norfolk, Virginia, and president of the American Rhinologic Society.

Studies have shown statistically significant improvement for both nasal polyps and congestion in patients who received Dupilumab, Omalizumab, or Mepolizumab. Dupilumab is currently the only biologic approved for treatment of CRSwNP, but the other two options—and possibly more biologic treatment options—may soon come down the pipeline.

Dr. Han said that, while the research is promising, there are still questions regarding the use of biologics to treat CRSwNP. For example, which biologic is best? Is one better for a specific type of nasal polyp patient, and are these therapies better than what physicians are currently using?

For Dr. Han, the treatment of CRSwNP is still a mixed bag. He incorporates a shared decision-making process with his patients and noted that the advent of biologics doesn’t necessarily mean the death of endoscopic sinus surgery.

“I usually do surgery, then topical steroids, and then biologics if the polyps seem to come back,” said Dr. Han.