Ep. 46 Biologics for Nasal Polyps — What’s the Role? With Dr. Cecelia Damask and Dr. Matthew Ryan - a podcast by BackTable ENT

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In this episode of BackTable ENT, Dr. Ashley Agan, Dr. Gopi Shah, Dr. Cecelia Damask (Lake Mary ENT and Allergy), and Dr. Matt Ryan (UT Southwestern Otolaryngology) discuss the growing role of biologics for nasal polyps. 
Biologics are monoclonal antibodies that block T2-mediated immune responses (IL-3, IL-4, IL-13, IgE). They are administered subcutaneously and follow various dosing regimens. Biologics are a viable treatment option in patients with recurrent nasal polyps who have failed conventional therapies, such as high doses of antihistamines, topical steroids, and systemic steroids. It is still considered as a last line treatment because of the high cost associated with production of monoclonal antibodies.  
However, not all patients with recurrent nasal polyps are good candidates for biologics. The patient must present with a  specific endotype––the T2-mediated etiology. T2-mediated patients can be identified through their high responsiveness to steroid therapy, positive history for allergic asthma and atopic dermatitis, and high peripheral eosinophil and serum IgE levels on a CBC with differential. In a surgery-naive patient with a temporary steroid response, it is best to perform sinus surgery first in order to widen the nasal mucosal surface area for efficient delivery of topical therapies. However, if post-surgical intranasal steroid sprays and saline irrigations are ineffective, biologics should be considered. It is best to avoid surgery and skip straight to biologics in patients with comorbid conditions that prevent surgery, patients with severe asthma, and patients with high peripheral IgE counts (>1000). 
 Once the decision to start biologic therapy is made, many factors have to be considered, such as insurance pre-authorization, administration methods, and frequency of dosing. Each biologic manufacturer has a “hub” that assists physicians and patients in navigating biologic dosing, delivery, and insurance paperwork. They will often have co-pay assistance programs for patient benefit as well. Common side effects observed in biologic trials are arthralgia, injection site inflammation, oropharyngeal pain, and headaches. However, all the doctors agree that these side effects are more mild than those of long-term systemic steroid use, which include avascular necrosis, cataracts, sepsis, and thromboembolic events. 
 Picking which biologic to prescribe is a clinical decision because they have not been subjected to comparative trials yet. The three biologics currently on the market are: Dupilumab (anti-IL-4 receptor), Omalizumab (anti-IgE), and Mepolizumab (anti-IL-5 receptor). All work to prevent T2 immune signaling by targeting different receptors. Factoring in comorbid conditions, payer systems, and dosing regimens can help a physician choose the best biologic for a nasal polyps patient.

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