Chronic Rhinosinusitis With Nasal Polyposis Treated With Dupilumab: Real-World Use and Outcomes

Sustained Efficacy and Low Rate of Adverse Events of Dupilumab in Type-2 CRSwNP Over 48 Months

OBJECTIVE

Dupilumab is a fully humanized monoclonal antibody that interferes with the inflammatory cascade in type-2 Chronic Rhinosinusitis with Nasal Polyps (CRSwNP). Studies evaluating its safety and efficacy in the long term are still few. Our study analyzed outcomes and adverse events after 1, 3, 6, 12, 24, 36, and 48 months of dupilumab administration in patients affected by CRSwNP.

MATERIALS AND METHODS

A monocentric, retrospective study assessing blood eosinophil (BEC) and total IgE count, Sinonasal Outcome Test-22 (SNOT-22), Nasal Polyps Score (NPS), sniffin' sticks identification test (SSIT-16), and Lund-Mackay score (LMS) in patients receiving subcutaneous Dupilumab 300 mg/2 weeks for at least 1 year and up to 4 years.

RESULTS

Seventy patients were enrolled, of whom 70, 38, 25, and 12 completed a 12, 24-, 36-, and 48-month follow-up period, respectively. Patients showed a very rapid and long-lasting statistically significant improvement in their SNOT-22, NPS, and SSIT after 1 month, and this trend was kept in the following 48 months. The total IgE count has been constantly reducing over the study period. BEC increased in the first 6 months and then gradually decreased over time, reaching an even smaller value than baseline at 36 and 48 months. Four patients (5.9%) complained of severe adverse events within 6 months, with two interrupting treatment due to hypereosinophilia.

CONCLUSION

Dupilumab was safe and effective in extinguishing the symptomatologic burden of CRSwNP as early as 1 month and up to 48 months, with side events limited to the first 6 months of administration.

LEVEL OF EVIDENCE: 4

Real-world predictors of dupilumab prescription in patients with chronic rhinosinusitis with nasal polyps

BACKGROUND

Despite increasing dupilumab use for chronic rhinosinusitis with nasal polyps (CRSwNP), little is known about the factors influencing its use in real-world practice. We aimed to identify factors that may predict dupilumab prescription in CRSwNP patients who have undergone endoscopic sinus surgery (ESS).

METHODS

A single-institution, retrospective cohort study of patients who underwent ESS for CRSwNP between 2015 and 2023 was conducted. Demographics, comorbidities, 22-item sinonasal outcome test (SNOT-22) scores, and dupilumab prescription date were extracted from patient records. Intraoperative nasal mucus cytokine levels were measured using a multiplex bead assay. Univariate logistic regression analysis was performed to identify factors associated with dupilumab prescription, and multivariate logistic regression was used to adjust for surgery date.

RESULTS

A total of 299 CRSwNP patients were included, including seventy (23.4%) who were prescribed dupilumab postoperatively. Patients were more likely to be prescribed dupilumab if they had asthma (odds ratio [OR] 2.304), aspirin-exacerbated respiratory disease (AERD, OR 3.375), elevated tissue eosinophils (OR 1.005), and higher 3-month postoperative SNOT-22 scores (OR 1.027). Patients prescribed dupilumab also had greater odds of having elevated mucus interleukin (IL)-5 (OR 1.128) and IL-13 (OR 1.213). When adjusting for surgery date, associated factors included: asthma (OR 2.444), AERD (OR 3.750), allergic rhinitis (OR 1.833), higher tissue eosinophils (OR 1.005), elevated 3-month SNOT-22 scores (OR 1.028), and higher IL-5 (OR 1.123) and IL-13 (OR 1.202) levels.

CONCLUSION

Asthma, AERD, allergic rhinitis, and elevated tissue eosinophil, IL-5, and IL-13 levels are predictive of dupilumab prescription in CRSwNP patients. These may serve as clinical and inflammatory biomarkers and can aid in counseling patients about expected disease trajectory.

Eosinophil-Driven vs. Eosinophil-Associated Severe Asthma: Practical Implications for Target Treatment

Severe asthma (SA) is a chronic inflammatory condition affecting approximately 10% of asthmatic patients, and eosinophils are considered key pathogenetic actors in a significant number of patients. Biological therapies have been demonstrated to improve asthma control by decreasing exacerbation rates and reducing the use of oral corticosteroids. In this context, phenotyping and endotyping patients with SA is essential for selecting the most effective therapeutic approach. For this purpose, biomarkers such as IgE, absolute blood eosinophil count, and fractional exhaled nitric oxide (FeNO) are crucial in defining a patient's inflammatory profile. Their integration provides a framework for classifying asthma into T2-high, T2-mild, or T2-low categories, guiding personalized treatment strategies. By incorporating multiple biomarkers into a unified model, it is possible to better stratify patients and optimize biologic therapy selection, paving the way for improved outcomes in SA management. This review aims to evaluate the role of phenotyping and endotyping SA patients, with particular attention to the impact of eosinophilic inflammation and combinatory biomarkers on decision-making processes for the selection of biological therapies.

Effect of Dupilumab in CRSwNP Sinonasal Outcomes from Real Life Studies: A Systematic Review with Meta-analysis

PURPOSE OF REVIEW

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a debilitating inflammatory condition that significantly impacts quality of life. Despite treatment advances, recurrence is common, prompting the exploration of novel therapies such as monoclonal antibodies targeting the type 2 immune response, notably dupilumab. This research aims to evaluate the real-world evidence (RWE) of dupilumab in treating severe CRSwNP, comparing sinonasal outcomes to those observed in randomized clinical trials.

RECENT FINDINGS

Significant improvements were noted, with the average SNOT-22 score reduction being 37.2 points post-dupilumab treatment. The nasal polyp size (NPS) showed an average decrease of 3.6 points. The analysis highlighted the practical effectiveness of dupilumab, emphasizing its benefit over conventional therapies in reducing NPS and improving nasal symptoms. The findings advocate for the integration of dupilumab into standard treatment protocols for severe CRSwNP, providing a robust alternative that could potentially reduce the high recurrence rates associated with current management strategies. This study underscores the utility of RWE in assessing the effectiveness of new medical treatments, suggesting that dupilumab offers substantial real-world benefits for patients suffering from this challenging condition.

Dupilumab Use in Patients With Hypereosinophilic Syndromes: A Multicenter Case Series and Review of the Literature

BACKGROUND

Hypereosinophilic syndromes (HES) are defined as hypereosinophilia with eosinophil-related clinical manifestations, some of which overlap in presentation with asthma, atopic dermatitis, eosinophilic esophagitis, and/or chronic rhinosinusitis with nasal polyps. Dupilumab is approved to treat these conditions but can induce a transient rise in the absolute eosinophil count and rare eosinophil-related complications.

OBJECTIVE

To determine whether eosinophil-related complications of dupilumab are increased in HES.

METHODS

Retrospective chart review of patients with HES treated with dupilumab enrolled on an institutional review board-approved research protocol at the National Institutes of Health (NCT00001406) or receiving care at Walter Reed National Military Medical Center. Clinical response and treatment-emergent adverse events were recorded. Serum mediators were assessed in a subset of patients before and after dupilumab using stored samples.

RESULTS

Among the 28 patients (15 male, 13 female; median age 41.5 y), the most common prescribing indication for dupilumab was chronic rhinosinusitis with nasal polyps (n = 11). Twenty-three patients (82%) showed significant clinical improvement on dupilumab. Hypereosinophilia (absolute eosinophil count > 1.5 × 109/L) recurred or worsened in 9 of 20 patients on dupilumab monotherapy. Moreover, 4 of 20 (20%) patients developed an eosinophil-related complication with dupilumab discontinuation and/or addition of eosinophil-lowering therapy. None of the 8 patients who received dupilumab while in hematological remission on an eosinophil-lowering biologic developed hypereosinophilia or an eosinophil-related complication. Serum immunoglobulin E and eotaxin levels decreased on dupilumab therapy.

CONCLUSIONS

These data suggest that dupilumab is effective in treating residual symptoms in HES patients but that the incidence of eosinophil-related complications is increased. Concomitant eosinophil-lowering therapy may reduce the risk of eosinophil-related complications during dupilumab therapy in patients with HES.

Association between Hidradenitis Suppurativa and Gout: A Propensity Score-Matched Cohort Study

INTRODUCTION

While an association between hidradenitis suppurativa (HS) and inflammatory arthritis has been reported in clinical studies, the potential link between HS and gout remains uncertain. As HS and gout share common immunological pathways, we conducted a retrospective cohort study to determine whether HS patients are at an increased risk of developing gout in the future.

METHODS

This retrospective multicenter cohort study obtained information through the US collaborative network, a subset of the TriNetX research network. Patients diagnosed with HS between January 01, 2005, and December 31, 2017, were recruited, and a 1:1 propensity score matching was conducted to identify appropriate controls. The hazard ratio (HR) for the new-onset gout in HS patients was subsequently calculated.

RESULTS

Compared to individuals without HS, those with HS were associated with a 1.39-fold higher risk (95% confidence interval [CI], 1.20, 1.62) of developing new-onset gout within 5 years after the index date. This association remained significant in shorter follow-up times and sensitivity analyses utilizing different matching models. For both male and female HS patients, the risk of developing new-onset gout within 5 years after the index date was statistically significant, with respective HRs of 1.61 (95% CI, 1.28, 2.02) for males and 1.41 (95% CI, 1.11,1.78) for females.

CONCLUSION

HS patients are at a high risk of developing gout within 5 years after an HS diagnosis while comparing with non-HS controls.

Rheumatic adverse events associated with biologic therapy for chronic rhinosinusitis: A systematic review and meta-analysis

BACKGROUND

Biologic therapies approved for treating chronic rhinosinusitis with nasal polyps (CRSwNP) have well-established safety profiles but reports of rheumatic adverse events (AEs) are increasing and not well defined. This review aims to assess the risk and incidence of rheumatic AEs associated with biologic therapy in CRSwNP and summarize current reported management strategies.

METHODS

A protocol was registered in PROSPERO [CRD42024525663]. A search was conducted in four electronic databases: Medline (Ovid), Embase, Scopus, and Cochrane CENTRAL from inception until January 4, 2024. Two reviewers independently screened citations and extracted data. Methodological quality was assessed using the Joanna Briggs Institute's critical appraisal tool. Data were pooled using a random effects model to calculate overall incidence and relative risk.

RESULTS

Twenty-one studies met the final inclusion criteria, totaling 3434 patients of which 2763 (80%) received either dupilumab (n = 2257; 82%), mepolizumab (n = 372; 13%), or omalizumab (n = 134; 5%) for treatment of CRSwNP. The overall incidence rate for any on-treatment rheumatic AE was 0.05 per person-year (95% CI, 0.03-0.09, I2 = 75%). Biologic therapy increased the risk of developing a rheumatic AE (RR = 2.53; 95% CI, 1.29-4.94) compared with placebo. The most frequently reported rheumatic AE was arthralgia or joint pain (n = 94; 95%), followed by lupus-like syndrome or lupus erythematosus-like reaction (n = 2; 2.5%). Discontinuation of treatment was the most common intervention (n = 21, 39%).

CONCLUSION

Biologic therapy increases the risk of rheumatic AEs in CRSwNP patients by over twofold. Healthcare providers should remain vigilant in monitoring rheumatic AEs and apply appropriate management strategies on a case-by-case basis.

Efficacy and safety of dupilumab in the treatment of CRSwNP in the real-life setting: a review of the literature

INTRODUCTION

The recent approval of Dupilumab has profoundly revolutionized the management of patients affected by severe and recalcitrant Chronic Rhinosinusitis with Nasal Polyps (CRSwNP). However, a review that summarizes the results of real-life studies and compares them to phase 3 studies SINUS-24 and 52 is still lacking.

MATERIALS AND METHODS

A search of all real-life studies published from 2019 to 2023 was performed. Patients characteristics at baseline and 6 and 12 months after starting Dupilumab were extracted and compared to those from phase 3 trials: age, sex, smoking habits, comorbid asthma and aspirin-exacerbated respiratory disease (AERD), previous endoscopic sinus surgery (ESS), hematic eosinophils and total IgE, NasalAQ2 Polyps Score (NPS), smell, SNOT-22, adverse events (AEs), and response to treatment.

RESULTS

15 papers were included with an overall number of 1658 patients. A higher rate of comorbidities and previous ESS was found in patients from real-life studies. In addition, they had worse smell and SNOT-22 at baseline compared to patients from SINUS-24 and 52. Comorbid and post-ESS patients tended to have a faster NPS and SNOT-22 improvement, although the absolute values were not clinically relevant. A more extensive surgery and a number of ESS ≥ 2 were related to worse olfactory outcomes, probably due to iatrogenic damage. No correlation was found between hematic eosinophils and outcomes. AEs were reported by 12.4% of patients and 2.2% had to discontinue dupilumab. Weight gain was an emergent AE (0.8%), probably related to the restored sense of smell and taste. Non-responders were 3.5% and they were switched to systemic steroid, ESS, or another biologic.

CONCLUSION

Despite some differences in prescription criteria between countries, dupilumab was demonstrated to be effective even in the real-life scenario. However, emerging AEs and possible unknown long-term AEs of a likely lifelong therapy should be considered.

Risk of osteoarthritis in patients with hidradenitis suppurativa: a global federated health network analysis

BACKGROUND

Osteoarthritis and hidradenitis suppurativa (HS) share a common inflammatory pathway. However, whether patients with HS have higher risk developing osteoarthritis remained unclear.

METHODS

A retrospective cohort design was adopted in this study. Electronic medical records had been retrieved from the US collaborative network in the TriNetX research network. A propensity score matching of 1:1 was performed to match for covariates. In total, 50,931 patients with HS and the same amount of non-HS controls were identified for analyses. Hazard ratio (HR) of osteoarthritis in patient with HS was calculated.

RESULTS

Risk of patients with HS developing osteoarthritis was 1.37-fold higher than that of non-HS controls [95% confidence interval (CI), 1.21-1.55] when followed up for 1 year. The significance remained when the follow-up periods were extended to 3 years and 5 years. When osteoarthritis was stratified on occurring sites, the HR of knee osteoarthritis was 1.19 (95% CI, 1.09-1.29) and the HR of hip osteoarthritis was 1.17 (95% CI, 1.01-1.35) in the 5-year follow-up. The 5-year risk of osteoarthritis remained significant in sensitivity models.

CONCLUSION

Patients with HS were of high risk of developing osteoarthritis compared with people without HS. The clinical association was recommended to be considered while approaching patients with HS.