Adding a second biologic therapy to dupilumab for patients with refractory chronic rhinosinusitis with nasal polyps (CRSwNP) appears feasible, effective, and safe for most severe and complex inflammatory airway disease patients, according to a new study presented at the 2023 American Rhinologic Society, Combined Otolaryngology Spring Meeting (ARS-COSM) held in Boston, Massachusetts, May 3-5.
A team of researchers led by Zachary Warren, MD, from the University of Chicago, investigated the use of dual biologic therapy, dupilumab in a combination of benralizumab and mepolizumab, to manage severe persistent asthma and CRSwNP.
The study presented cases of three adult women (aged 44, 66, and 81) with refractory CRSwNP. All of them were allergic and asthmatic, with one having additional aspirin sensitivity. After failed attempts to improve both symptom control and disease burden based on the nasal endoscopy, the three patients were prescribed an additional biologic therapy with a combination of (1) dupilumab/benralizumab (2) and dupilumab/mepolizumab.
Following the initiation of dual therapy, significant improvements were seen in all three patients regarding congestion symptoms, rhinorrhea, postnasal drip, headaches, and facial pressure. “We found improved symptom control of both upper and lower airway disease, no additional or synergistic side effects, and improved objective clinical metrics (polyp size, decreased use of rescue medications, reduced healthcare utilization),” the authors wrote.
CRSwNP is a chronic inflammatory disease characterized by polyps in the nose and sinuses, leading to nasal congestion, loss of smell, and other symptoms. Current treatment options include surgery and medications such as intranasal steroids, oral steroids, antibiotics, and biologics.
While biologics target specific pathways involved in type II inflammation, a considerable (~30%) number of patients do not respond well to initial biologic monotherapy. There have been no studies on using multiple concurrent biologics for patients with refractory disease on monotherapy.
A recent systematic review of biologics for CRSwNP has also revealed that dupilumab and other biologics were associated with significant reduction in SNOT-22 scores. “However, these agents target difference components of the immune system, and some patients do not respond to monotherapy”, the further added.
According to the authors, further research is needed to better understand this approach’s safety and efficacy in larger patient populations and identify optimal treatment regimens and patient selection criteria. Nevertheless, dual biologic therapy may be a promising new avenue for managing severe persistent asthma and CRSwNP.
Reference:
Warren Z, Rotolo SM, Pinto M. J. Use of Dual Biologics in Patients with Chronic Rhinosinusitis with Nasal Polyposis. ARS-COSM, May 4-5, 2023.