Meta-Analysis Finds Dupilumab Most Effective Biologic for CRS With Nasal Polyps

Dupilumab was identified as the most effective and safe biologic for the treatment of chronic rhinosinusitis with nasal polyps (CRSwNP), according to study findings published in The Journal of Allergy and Clinical Immunology: In Practice.

For patients unresponsive to standard of care topical corticosteriods and nasal saline, several biologics have shown promise in randomized controlled trials (RCT) for CRSwNP, particularly those designed to inhibit type 2 inflammation with a high expression of interleukin (IL)-4, IL-5, IL-13, and immunoglobulin E (IgE).

Dupilumab, omalizumab, and mepolizumab have already been approved by the FDA to enter the market for patients with CRSwNP, with phase 3 findings for benralizumab also demonstrating its potential in treating refractory nasal polyps.

With no head-to-head RCTs having directly compared the efficacy and safety of these type 2 biologics, researchers conducted a network meta-analysis to examine the differences in efficacy and safety outcomes via primary and secondary endpoints.

In their analyses, primary outcomes assessed included nasal polyp score (NPS), nasal congestion severity, and serious adverse events (AEs), with secondary outcomes of the 22-item Sino-Nasal Outcome 48 Test (SNOT-22) score, loss of smell severity, the University of Pennsylvania Smell Identification Test score, and the Lund-Mackay computed tomography score also examined.

Bucher indirect treatment comparison (ITC) was used to compare the outcome parameters. A total of 7 RCTs involving 1913 patients and 4 biologics (benralizumab, dupilumab, mepolizumab, and omalizumab) were included for ITC: Bachert 2017, OSTRO, POLYP 1, POLYP 2, SINUS-24, SINUS-52, and SYNAPSE.

Of the biologics assessed, dupilumab exhibited greater efficacy in reducing NPS compared with omalizumab (mean difference [MD], –1.06; 95% CI, –1.63 to –0.48), mepolizumab (MD, –1.09; 95%CI, –1.68 to –0.51), and benralizumab (MD, –1.64; 95% CI, –2.24 to –1.03]) at 24 weeks. Superior efficacy regarding NPS reduction was also observed at the end of follow-up (EOF; more than 48 weeks).

Furthermore, dupilumab showed greater improvement of nasal congestion severity vs omalizumab at 24 weeks (standardized MD [SMD], –0.37; 95% CI, –0.66 to –0.08), mepolizumab at 24 weeks (SMD, –0.47; 95% CI, –0.71 to –0.24) and at EOF (SMD, –0.59; 95% CI, –0.88 to -0.31), and benralizumab at 24 weeks (SMD, –0.90; 95% CI, –1.15 to –0.65) and at EOF (SMD, –0.82; 95% CI, –1.10 to –0.53).

Benralizumab was found to be the least effective biologic in reducing nasal congestion severity and SNOT-22 score at 24 weeks. No significant differences were observed between the effects of the other biologics.

“Head-to-head comparisons with longer follow-up and real-world evidence are necessary to confirm these findings and determine how these biologics fare in the long run,” concluded the study authors. “Future research on subgroups will further facilitate personalized treatment of patients with CRSwNP.”

Reference

Cai S, Xu S, Lou H, Zhang L. Comparison of different biologics for treating chronic rhinosinusitis with nasal polyps: a network-analysis. J Allergy Clin Immunol Pract. 2022 Mar 7;S2213-2198(22)00235-5. doi:10.1016/j.jaip.2022.02.034