EUFOREA consensus on biologics for CRSwNP with or without asthma

Author(s): Wytske J. Fokkens, Valerie Lund, Claus Bachert et al

Allergy 2019; 74: 2312-2319

Airway diseases
General respiratory patient care

Digest Author(s): Stylianos Loukides, e-Learning Director / 15 December, 2019

Type 2 targeting biologics are emerging treatment options for patients with severe asthma. All the currently available biologics have shown positive results in terms of lower number of exacerbations, improvement of quality of life and reducing the daily dose of oral Cs. The majority of patients with chronic rhinosinusitis with nasal polyps (CRSwNP) show a type 2 inflammatory signature in sinonasal mucosa and/or lungs. Type 2‐targeting biologics such as anti‐IgE, anti‐IL4Rα, anti‐IL5, and anti‐IL5Rα have clear indications for severe asthmatics and may soon will reach the market for patients with CRSwNP with or without asthma. The current paper was aimed to discuss the positioning of biologics into the care pathways for CRSwNP patients with and without asthma.

An interesting algorithm is provided. This algorithm provides indications for the initiation of biologics in patients with CRSwNP. The first approach is to identify the presence of bilateral nasal polyps. Then to divide patients into two groups. Those with history of surgery and those without a history of surgery. If the first approach is present we need three of the following criteria, if not we need one more.

Criteria: Evidence of Type 2 related inflammation, presence of asthma, two or more courses of systemic steroids in the previous year, significant impaired quality of life, significant loss of smell. Furthermore, defining the response we have to use the following criteria: Reduced nasal polyp size, reduced need for systemic Cs, improved quality of life, improved sense of smell and reduced impact of co-morbidities. The proposal is to evaluate treatment after 4 months and after 1 year. If we have 5 of the above criteria we define the response as excellent, 3-4 as moderate, 1-2 as poor and 0 as no response.

Comment

We live in the era of biologics. For the above assessment we need a multidisciplinary approach since many ENT departments are lacking experience in terms of biologics. We need to balance the overplay between surgery and biological treatment but more important to further clarify the definition of responders, the duration of treatment and the effect on disease modification particularly in those patients suffering from asthma.