Biologics “Switching” Common among Canadian Rhinology Patients with CRSwNP

CLINICAL QUESTION

Within Canadian rhinology practices, what is the incidence of, and what are the patterns and reasons for, switching biologics in the treatment of patients with chronic rhinosinusitis with nasal polyps (CRSwNP)?

BOTTOM LINE

Switching biologics for CRSwNP is frequent in Canadian rhinology; the most common switch is from mepolizumab to dupilumab, with inadequate CRSwNP control driving the switch.

BACKGROUND: Type 2 biologics are increasingly used for the treatment of CRSwNP; however, not all patients respond equally to biologics, and sequential or simultaneous use of another biologic (“switching”) may be necessary to achieve optimal outcomes in these patients. There are currently no established guidelines for switching, and few studies.

STUDY DESIGN: Retrospective study

SETTING: Division of Otolaryngology–Head and Neck Surgery, University of British Columbia, Vancouver, Canada

SYNOPSIS: Researchers identified 225 rhinology patients from four tertiary care centers across three Canadian cities who had a confirmed diagnosis of CRSwNP, had undergone at least one endoscopic sinus surgery, had recurrent symptoms despite maximal medical and surgical management, and had received at least one dose of any type 2 biologic between July 1, 2019, and June 1, 2024. Patients who remained on their initial biologic comprised the continuous group (n=183); patients with sequential or simultaneous use of more than one biologic for any reason were considered the switched group (n=42; 16%). Among the switched group, six (3%) patients switched twice. The most common switch was from mepolizumab to dupilumab (11/91; 12%), with poor control of CRSwNP symptoms as the leading cause. Mepolizumab patients were more likely to switch biologics late in their treatment (after 18 months), while dupilumab patients rarely switched (11/121; 9%) after 12 months of therapy. All four patients initially on omalizumab changed biologics. Switching between biologics with the same mechanism did not appear to improve symptom control. The authors note that these findings may help guide sequential or simultaneous use of biologics in CRSwNP patients.

CITATION: Dorling M, et al. Switching biologics in chronic rhinosinusitis with nasal polyps: A multicenter Canadian experience. Int Forum Allergy Rhinol. 2025;15:166–173.

COMMENT: Biologic medication utilization has become increasingly prevalent for the management of CRSwNP, which is largely driven by type 2 inflammation. While the decision on a particular biologic is often a team endeavor with involvement of allergy, pulmonology, and ENT, otolaryngologists play a key role in determining candidacy and response with regards to symptom management and the status of nasal polyps, and for many patients are the prescribers of the medications. Given this, it’s important to understand the reasons behind switching these often effective but very expensive medications. This study finds that the most common reason for switching away from mepolizumab is lack of efficacy, with far fewer patients switching due to an adverse event. Dupilumab, on the other hand, is most frequently discontinued in favor of another agent due to adverse events, followed by lack of coverage, with lack of efficacy falling in a distant third. These findings can be incredibly helpful when counseling patients on biologic options in a shared decision-making conversation and determining each individual’s preference for an initial agent selection. —Ashoke Khanwalkar, MD