Biologics is a growing area of interest and research for CRS.
There is a risk of bias assessment in studies, and some question the clinical relevance of study outcomes.
Some uncommon potential effects have been reported; autoantibodies and allergy to the antibodies have also been reported.
Biologics are costly and may not be cost-effective when compared with other treatments.
There is no set algorithm for patients with chronic sinusitis and nasal polyposis.
Case Presentation: How Should We Use Biologics?
A 28-year-old female presents experiencing recurrent sinusitis. For her asthma, she has received inhaled steroids and the occasional rescue beta agonist. For her environmental allergies, she has been treated with SCIT immunotherapy. Both aspirin and NSAIDs cause an asthma flare. She has worsening nasal obstruction, loss of sense of smell, and has received intermittent intranasal steroids. There is increased dyspnea on exertion. She has bilateral nasal polyposis extending past the middle meatus. Her allergist has advised treatment with a biologic.
What are the panel’s recommendations?
Dr. Han: A biologic is probably not indicated at this time because there are other treatment options. You first give an antibiotic and steroids. If they fail, then you should discuss surgery. If the polyps recur quickly and she becomes steroid-dependent and fails aspirin desensitization, then consider biologics.
Dr. Smith: They are absolutely not indicated in this patient. I’m concerned that clinicians will treat all NP patients with these systemic, lifelong medications—that would be completely inappropriate and would in essence be overutilization.
Dr. Thaler: I agree. There is still a lot of work to be done with this patient. It would be absurd to start her on a biologic.
Dr. Stewart: Biologics are not indicated. Down the line this patient might be a candidate for a biologic, so when we have better data and if she is farther along in the process of trying and failing traditional therapy, maybe.
The patient underwent functional endoscopic sinus surgery with polypectomy. She was managed postoperatively with topical steroid irrigation. Her asthma improved, as well as her QOL. Six months later, she presented with recurrence of polyps and reduced olfaction.
Dr. Stewart: You could go back to remove the NP, but that is expensive. We have to ask, ‘Is the difference large enough to be worth it?’ At this time and in this patient, biologics might be indicated.