Not Enough Shrinkage
Biologics may also shrink, but not remove, polyps as thoroughly as surgery, Dr. Schlosser said. “On the grading scale of zero to eight, biologics improve them from 5½ to 3½, from severe to moderate. And there are some patients who have no change in polyp score with biologics, so there appear to be some people who do not respond. Physicians have to weigh the options and help the patient make the right decision based on the individual’s needs and comorbidities.”
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November 2019Symptoms, not grading systems, guide physicians’ assessment of polyp severity and help identify who may be a good biologics candidate, said James N. Palmer, MD, a professor of otorhinolaryngology–head and neck surgery at the Hospital of the University of Pennsylvania in Philadelphia.
“Patients usually have chronic sinusitis if they have pressure, pain, headaches, nasal obstruction, nasal drainage, and a decreased sense of smell,” said Dr. Palmer. “Surgical removal and application of a topical steroid works well to remove the polyps or keep them from coming back. A large proportion of patients do really well with this treatment. But they need to have complete, not partial, surgery. They also need to do steroid irrigation washes as a lifelong treatment. But most patients will comply to avoid another surgery.”
Biologics Right for Subset of Patients
After complete surgery and topical steroid application, polyps often do not recur. This treatment provides significant improvement in nasal symptoms and improves the patient’s asthma, but does not cure it, said Dr. Palmer. Patients with polyps who have poorly controlled asthma may be treated with either oral corticosteroids or biologics, he added.
“Dupilumab works in a large percentage of patients, in my opinion, while complete surgery and steroid irrigation will control it in many more. However, biologics may be right for certain subsets of patients. One, patients who want or need to avoid surgery for some reason. Two, patients who have a good surgery and topical steroid treatment, but the asthma is not controlled by topical therapies,” he said. “We are working toward identifying endotypes. All polyps have inflammatory triggers and different underlying genetic conditions that drive the development of the polyps.”
For patients who have failed other treatments, this drug has been incredibly life-altering. —Tanya M. Laidlaw, MD
Biologics may be the right option for patients whose polyps do recur, after eliminating those who may have had either incomplete surgical removal or incomplete post-surgery medical management with steroids, said Timothy L. Smith, MD, MPH, professor of otolaryngology–head and neck surgery in the division of rhinology and sinus surgery at Oregon Health and Science University in Portland.
“It’s in that population that we are particularly interested in newer, better treatments. Enter the biologics. These block the molecules that are possibly involved in the inflammation. We are becoming better at identifying inflammatory mediators, but you still don’t know which specific inflammatory molecule you need to block in each specific patient. Some patients have responded dramatically to these drugs, but some have little or no response,” said Dr. Smith, who added that there may be 100 or more inflammatory pathways involved in polyp development.
Patients with aspirin-exacerbated respiratory disease are one group who would likely benefit from biologics, as they are known for high polyp recurrence rates, said Dr. Palmer. “Their polyps can come back quickly. These patients often require ‘big hole’ surgery to get all the polyps out, followed by strong steroid irrigation. Recurrence of polyps after complete surgery, steroid irrigation, and aspirin desensitization is at best 10% at three years, and in this recalcitrant group, biologics would mostly fit well,” he said.
Dupilumab and other biologics may be more appropriate for patients after surgery and steroid irrigation has failed, but not as a first-line treatment, said Dr. Palmer. While biologics seem relatively safe, they still modulate a patient’s immune system and must be used indefinitely. “Still, surgery is a time-honored treatment with low side effects. If a patient’s symptoms come back, then I would consider biologics. Biologics give us another piece in our armamentarium of treatment.”