Biologics for the treatment of chronic rhinosinusitis with nasal polyps - state of the art.

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a complex upper airway disease affecting up to 11% of the population of Western Europe. In these western countries, 85% of the CRSwNP disease reveals a type 2 inflammatory pattern. In the last 15 years, several randomized double-blind studies on monoclonal antibodies in CRSwNP were performed. These studies demonstrated for the first time that biologics targeting type 2 immune reactions might be successful in nasal polyps. The target proteins, interleukin (IL)-4, IL-5, IL-13, and IgE were previously identified as key mediators in studies using nasal polyp tissues to measure and to interact in ex-vivo settings. No biomarkers have been identified to predict response to a specific biologic or to monitor treatment success. These studies were characterized by small numbers of patients and heterogeneous populations. They did, however, pave the way for currently performed and analyzed phase 3 studies, which will possibly lead to the registration of the first biologic drug with the indication CRSwNP. The studies already provide indications on the effects to be expected from those biologics; the results of phase-3 studies in larger populations will be decisive for the indications, patient selection, and finally the stopping rules for those drugs in subjects with severe nasal polyps, in whom the current standard of care including topical and oral glucocorticosteroids, antibiotics and surgical procedures failed to control the disease. We may expect that those biologics will open new perspectives for those patients with severe polyposis with, but also independent of asthma, allowing to avoid the possible adverse events resulting from systemic glucocorticosteroids and surgery.