Will otolaryngologists someday use biologics to manage allergic rhinitis (AR)? Perhaps. Monoclonal antibodies have already expanded the list of available treatment options for patients with allergic asthma and chronic rhinosinusitis (CRS) with nasal polyps, offering relief and hope.
Explore This IssueSeptember 2022
“Biologics have been game changing for patients with recalcitrant polyps and severe asthma,” said Sandra Lin, MD, professor and chair of the department of surgery division of otolaryngology–head and neck surgery at the University of Wisconsin–Madison. “But there are a lot of patients who have nasal polyps and asthma who don’t need these medications. When looking at new therapies, we need to be cognizant of how they compare to older treatments. How much do they add therapeutically, and who should we use them for?”
These questions are of particular importance as researchers and otolaryngologists consider the use of biologic agents to manage AR, a common, non-life-threatening condition.
Can Biologics Fulfill an Unmet Need?
Although there are dozens of available treatment options for AR, including immunotherapy and over-the-counter and prescription antihistamines and corticosteroids, many people with the condition still report reduced quality of life due to AR symptoms and treatment side effects. Successful management of symptoms with medication requires strict compliance with medication regimens and immunotherapy is time consuming, requires significant patient commitment, and includes a risk of potentially severe adverse reactions. As noted by the authors of a 2019 article published in Pediatric Investigation, “The use of biologics could overcome the limitations of other therapeutic modalities” (Pediatr Investig. 2019;3:165-172).
“Asthma, chronic rhinosinusitis, and allergic rhinitis all share a similar inflammatory immune profile,” said Amber Luong, MD, PhD, a professor of otorhinolaryngology with the McGovern Medical School at UTHealth Houston, so it’s reasonable to assume that biologics that effectively target elevated cytokines associated with allergic asthma and CRS may also decrease AR symptoms.
If we are going to prescribe something that is very expensive, we need to consider, how does it compare to other accepted therapies for allergic rhinitis. —Sandra Lin, MD
In fact, there’s a fair amount of evidence showing that biologic medications improve allergic rhinitis symptoms, said Christopher Brook, MD, assistant professor of otolaryngology– head and neck surgery at Harvard Medical School in Cambridge, Mass. “They suppress Th-2 inflammation, which is the driver for allergic rhinitis,” he added.
Omalizumab, a biologic that’s currently FDA approved to treat AR and CRS with polyps, is a monoclonal anti- IgE antibody that inhibits IgE binding and cross-linking. Mepolizumab (also FDA approved to treat allergic asthma and CRS with polyps) binds to IL-5 and decreases eosinophil levels. Reslizumab and benralizumab also both target IL-5 and are approved to treat allergic asthma. Dupilumab inhibits IL-4 and is FDA-approved to treat both allergic asthma and CRS with polyps (Otolaryngol Head Neck Surg. 2021;164(1suppl):S1-S21).