The pros of these drugs include that they help people avoid the use of long-term steroids. But the cons are that they’re very expensive and require lifelong injections every two to four weeks. —Rodney J. Schlosser, MD
Explore This IssueNovember 2019
Biologics like dupilumab, which suppress the immune system, have potential side effects, Dr. Laidlaw added. Dupilumab’s possible adverse effects include allergic reactions, conjunctivitis, keratitis, injection site reactions, eye and eyelid inflammation, eosinophilia, insomnia, toothache, arthralgia, and gastritis. Patients must not receive live vaccines while taking the drug. However, she has seen only mild reactions from her patients on dupilumab.
“So far, we have not come up against an infection issue with this drug. Local rashes in some patients, and I had a couple of eosinophil counts go up, so we follow these patients. But patients have begged me not to go off their drug. For patients who have failed other treatments, this drug has been incredibly life-altering for them,” she said. “Right now, in part because of knowledge of short- and long-term side effects and costs, if a single surgery gives you five to 10 years of relief, it may be worthwhile to have surgery every five to 10 years. My approach to this is that in patients who have already had one surgery, and either have polyp recurrence after surgery or if the surgery didn’t improve their symptoms enough, then I think dupilumab is a good choice.”
Better for Severe Polyps
Biologics may be more appropriate in patients with severe polyps than in those with mild to moderate polyps, said Rodney J. Schlosser, MD, director of the Nose and Sinus Center at the Medical University of South Carolina in Charleston. He finds dupilumab’s clinical trial results encouraging, and feels the new drug has good outcomes for quality of life and polyp score reduction.
“Biologics have been studied primarily in patients with severe polyps based on grading scores, but they have not been studied in patients with mild to moderate polyps,” said Dr. Schlosser. “The pros of these drugs include that they help people avoid the use of long-term steroids. But the cons are that they’re very expensive and require lifelong injections every two to four weeks. Injections would be required indefinitely. Biologics should be reserved for patients who have failed comprehensive sinus surgery followed by postoperative steroid rinses. That treatment controls the vast majority of polyp patients. Most don’t need a revision surgery. In the past, surgeons did repeated polypectomy. Now, we know that comprehensive polyp surgery is required to really open the sinuses, and then we deliver the steroid rinse.”
How expensive are biologics? While out-of-pocket costs vary considerably depending on a patient’s individual insurance coverage, dupilumab’s average wholesale price for one box of two prefilled 300 mg/2 mL syringes is $3,517.85, and its wholesale acquisition cost (WAC) is $37,000 per year (P.T. 2018;43:532–535). Endoscopic sinus surgery costs also vary widely depending on location, center, and insurance coverage, but one estimate of the mean cost for surgery is around $10,000 (Value Health. 2018;21(suppl 1):S13).