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Authors Urge Caution with Dupilumab as First-Line Therapy in Patients with Chronic Rhinosinusitis with Nasal Polyposis

by Linda Kossoff •

CLINICAL QUESTION

Should dupilumab be used in patients with limited polyp burden in chronic rhinosinusitis with nasal polyposis (CRSwNP)?

BOTTOM LINE

Caution should be used when considering biologics such as dupilumab as a first-line therapy for recalcitrant CRSwNP when viable revision surgical alternatives exist.

BACKGROUND: Biologics have greatly expanded treatment options for patients with CRSwNP who have recalcitrant nasal polyps, and recent studies have sought to broaden the population of patients who could receive biologics. The biologic dupilumab, approved in the US for use in adult patients with CRSwNP, has been the focus of recent trials.

STUDY DESIGN: Commentary.

SETTING: Department of Otolaryngology–Head and Neck Surgery, The University of North Carolina at Chapel Hill.

SYNOPSIS: The authors present their argument against routine use of dupilumab in patients with limited polyp burden in CRSwNP, stating that legal, practical, and ethical considerations of off-label use of dupilumab must be weighed against aggressive use. They speak to the comparable efficacy of endoscopic sinus surgery (ESS) and cite a multi-center prospective study in which patients displayed greater improvements with ESS versus biologics. They then review data to calculate the relative costs of ESS and biologics and highlight the higher expenses associated with the indefinite use of the drugs over a patient’s lifetime. There follows a discussion of the documented adverse effects seen with the use of dupilumab, including nasopharyngitis, worsening of nasal polyps/asthma, headache, epistaxis, and injection-site reactions, as well as the unavailability of long-term data about the drug’s effect at this early stage. Finally, the authors reference a released multidisciplinary consensus treatment algorithm for the management of CRSwNP that advises against the use of biologics in patients with light polyp burden or minimal symptoms. They state that, while they are optimistic about biologics use, they urge caution when considering them as a first-line therapy or when viable revision surgical alternatives exist.

CITATION: Hardison SA, Senior BA. The argument against the use of dupilumab in patients with limited polyp burden in chronic rhinosinusitis with nasal polyposis (CRSwNP). J Otolaryngol Head Neck Surg. 2023;52:64.