Urgent Need for CRSwNP Treatment Optimization in Finland

In Finland, among patients who have chronic rhinosinusitis with nasal polyps (CRSwNP) and asthma, the use of systemic corticosteroids and chances of undergoing endoscopic sinus surgery (ESS) have increased over the past decade.

Because of this, the investigators of a new study published in Clinical and Translational Allergy are calling for improved treatment optimization, especially among those who have severe comorbid asthma. “A limited number of studies indicate that both medical interventions and functional ESS improve nasal outcomes in patients with CRS and asthma,” they wrote, “but more information is needed about the burden of CRS and how it is affected by concomitant asthma.”

They evaluated the incidence, prevalence, and treatment burden of CRSwNP in Finland, as well as any potential associations with comorbid asthma, dividing their patients into 4 groups based on comorbid asthma severity: no asthma, mild to moderate asthma, severe controlled asthma, and severe uncontrolled asthma. To be included in this analysis, CRSwNP had to be diagnosed between January 1, 2012, and March 31, 2018, by a specialty or a primary care provider.

There was a 42.2% continuous increase in lifetime CRSwNP prevalence for the study period, with this number growing from 602.2 patients per 100,00 population in 2012 to 856.7 patients per 100,000 population in 2019 (P < .001). However, the overall incidence dropped from 50.5 to 43.3 patients per 100,000 between the study years (P < .001).

The overall total was 18,563 patients for the 7 years of the study. Of these patients, 59.9% were male, with the most having mild to moderate asthma (27%) and the fewest having severe uncontrolled asthma (1.5%). The overall incidence of severe asthma was 5.8%.

The highest levels of both systemic corticosteroid use (P < .001) and ESS for a 3-year period following diagnosis were seen in the patients with severe uncontrolled asthma:

• No asthma:
  • Systemic corticosteroid use: 54.1%
  • ESS: 0.49
• Severe controlled asthma:
  • Systemic corticosteroid use: 94.9%
  • ESS: 0.68
• Severe uncontrolled asthma:
  • Systemic corticosteroid use: 99.3%
  • ESS: 0.80

Overall, 62.7% of all patients reported any systemic corticosteroid use, and those with severe uncontrolled asthma had the highest incidence of severe uncontrolled CRSwNP (P < .001).

For this study, the index date was considered the first date of CRSwNP diagnosis, the baseline period was considered the 3 years leading up to the index date, and patients were thought to have severe uncontrolled asthma if they had 2 or more purchases of systemic corticosteroids in a 12-month period and at least 1 revision ESS during the follow-up. Most patients (83.3%) had just 1 ESS, with the remaining having 2 or more ESS (16.6%).

Among the asthma severity groups, the probability of having to repeat ESS within 2 years of the first ESS ranged from 9.5% in patients who had CRSwNP but no asthma to 17.9% in patients with CRSwNP and severe uncontrolled asthma. Further, asthma was the only disease associated with severe uncontrolled CRSwNP, with 3-fold (adjusted odds ratio [aOR], 4.04; 95% CI, 3.44-4.75), 6-fold (aOR, 7.01; 95% CI, 5.50-8.93), and 7.8-fold (aOR, 8.82; 95% CI, 6.25-12.43) higher odds seen in those with nonsevere, severe, and severed uncontrolled asthma.

When data were analyzed by age, older patients (aged 50 to 59 and 60 to 69 years) had a higher mean (SD) annual incidence of CRSwNP, at 96.4 (6.4) and 103.2 (4.6), respectively, per 100,000 population. Male patients also had a higher incidence of CRSwNP starting at age 30. The age groups for this study were 0 to 19, 20 to 29, 30 to 39, 40 to 49, 50 to 59, 60 to 69, 70 to 79, and 80 and older years.

“The management of patients with CRSwNP and severe uncontrolled asthma remains a challenge,” the study authors emphasized. “There is an unmet need in improving the management of CRSwNP to achieve greater patient satisfaction and disease prevention.”

They highlight the great promise seen in several targeted therapies. Among these are dupilumab, mepolizumab, and omalizumab for CRSwNP, as well as benralizumab which has indications for use in patients with CRSwNP who may or may not have asthma.

“As concurrent asthma and especially severe asthma is associated with need for even more intense treatment, these subjects need special attention,” the study investigators concluded. “New treatment modalities, such as monoclonal antibodies, are needed to tackle airway inflammation and decrease the need for systemic corticosteroids and surgical procedures to improve burden of disease in subjects withCRSwNP.”

Reference

Toppila-Salmi S, Hällfors J, Aakko J, et al. The burden of chronic rhinosinusitis with nasal polyps and its relation to asthma in Finland. Clin Transl Allergy. Published online October 9, 2022. doi:10.1002/clt2.12200