Treatment of Nasal Polyposis with Biologics

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a type 2 inflammatory disorder characterized mucosal polyclonal IgE formation and eosinophilic infiltration. A substantial proportion of severe CRSwNP patients, typically with a high degree of type 2 inflammation, continues to have bothersome symptoms, despite currently available medical treatment and/or sinus surgery. For these difficult-to-treat patients, biologics targeting key mediators of the type 2 immune reaction may represent a solution. In recent years, monoclonal antibodies targeting IgE and type 2 cytokines such as IL-4, IL-5, and IL-13 have been developed and successfully tested in CRSwNP. This resulted in the approval of dupilumab (anti-IL4Rα) in 2019, followed by omalizumab (anti-IgE) in 2020. As these novel biotherapeutics are relatively expensive, it is important to select patients that are most likely to benefit from a specific biological. Future research should therefore focus on head-to-head comparisons of biologics and endotyping of responders and nonresponders to develop endotype-driven care pathways for CRSwNP.