An Overview of Recent Advances in Management of Chronic Rhinosinusitis With Nasal Polyps

Citing major progress in the understanding and clinical practice of chronic rhinosinusitis (CRS) with and without nasal polyps, authors of a review published in the Journal of Allergy and Clinical Immunology explored research advances in pathophysiology, therapeutics, and management of the condition published in the past 2 years.

In researching key recent findings and trends since 2020 for CRS with nasal polyps (CRSwNP) and without (CRSsNP), they first discussed the clinical implications of phenotyping and endotyping.

“Endotypical classification is crucial in predicting the natural course of the disease and should be integrated in care pathways to determine adequate treatments including pharmacotherapy, surgery, and biologicals,” they noted.

Regarding cytokines, 3 main inflammatory patterns have been distinguished to characterize CRS inflammation: types 1 and 3, which are inversely correlated with recurrence and associated with a milder clinical picture; and the more severe type 2 that serves as the main target of most currently available biologicals.

In predicting type 2 and non–type 2 inflammation, several biomarkers have emerged that have provided prognostic and pharmacologic value, including eosinophil, mast cell, and basophil microparticles, as well as cystatin SN levels in nasal secretions and allergic sensitization.

“B cells are also pivotal in type 2 inflammation of CRSwNP, which is usually characterized by the upregulation of polyclonal, functional immunoglobulin E (IgE),” they added.

Regarding the evolution of therapeutic approaches, CRS has historically been treated with nasal saline rinses, intranasal corticosteroids, and oral corticosteroids for severe cases, in which endoscopic sinus surgery is implemented if treatment response is inadequate.

However, there are several emerging therapeutics that have shown efficacy for the treatment of CRSwNP in recent years. In particular, monoclonal antibody therapies directed against the cytokines interleukin (IL)-4, IL-5, and IL-13, as well as IgE, have provided insight into the role of single mediators.

For the clinical care pathways of CRS, biologics currently serve as an option for those with uncontrolled severe CRSwNP, either as a monotherapy or in combination with other available treatments. The criteria for the selection of specific biologic drugs still have to be developed, they noted, because several drugs for uncontrolled severe CRSwNP will be available within the near future in many countries.

“Monitoring the drug effects is crucial to recognize clinical response and consecutively adapt the decision to continue or discontinue the biologic and possibly add other interventions, including surgery.”

Researchers concluded that further research is warranted to better understand the regulation of type 2 inflammation and for biologics, including development of non-type 2-targeted biologics, drug selection strategies, and comprehensive evaluation of a patient’s responsiveness.

Reference

Xu Z, Huang Y, Delemarre T, Cavaliere C, Zhang N, Bachert C. Advances in chronic rhinosinusitis in 2020 and 2021. J Allergy Clin Immunol. Published online December 29, 2021. doi:10.1016/j.jaci.2021.12.782