AROMA: real-world global registry of dupilumab for chronic rhinosinusitis with nasal polyps

[Diagnosis and drug therapy of chronic rhinosinusitis]

Chronic rhinosinusitis is one of the most common chronic diseases of the upper respiratory tract and is associated with a significant reduction in quality of life. Precise diagnostic workup is therefore necessary to provide patients with adequate treatment. The introduction of biologics has opened up new options for the treatment of severely affected patients with chronic rhinosinusitis with nasal polyps in the sense of precision medicine that goes beyond the mere control of symptoms. This has been accompanied by a certain degree of standardization with regard to diagnostic procedures and the assessment of disease-specific quality of life. Against the background of the 2025 congress theme "Individualization vs. standardization in otorhinolaryngology," this paper examines and summarizes the diagnosis and drug therapy of chronic rhinosinusitis, with a focus on biologic therapy.

Baseline disease characteristics by surgery history among patients with chronic rhinosinusitis with nasal polyps (CRSwNP) in the global AROMA registry

PURPOSE

The global Assessing long-teRm Outcomes in dupiluMAb (AROMA) registry study aims to characterize the long-term, real-world use of dupilumab in patients with chronic rhinosinusitis with nasal polyps (CRSwNP). This paper reports interim analysis of the baseline characteristics for the first 303 patients enrolled in AROMA.

METHODS AND MATERIALS

AROMA is currently ongoing in adult patients with CRSwNP who initiated dupilumab for up to 36 months. This interim analysis describes baseline demographics; systemic/oral corticosteroid (SCS/OCS) and antibiotic use; disease burden; healthcare resource utilization; and medical history. All outcomes are summarized descriptively.

RESULTS

As of February 2023, AROMA had enrolled 303 patients; 61.7 % had ≥1 prior surgery and 38.3 % were surgery naive. Disease burden at baseline was greatest among patients with prior surgery vs the surgery-naive group: 72.2 % vs 62.9 % had used SCS/OCS, mean University of Pennsylvania Smell Identification Test scores were 10.9 vs 19.2, 31.0 % vs 27.6 % of patients reported severe symptoms, and 47.6 %/16.6 % vs 39.7 %/16.4 % of patients were classified as having severe/very severe disease according to global physician assessment scores. Otolaryngologist/ear, nose, throat and allergist/immunologist were the most common specialties seen regularly by CRSwNP patients (52.8 % and 48.2 %, respectively) and surgery-naive patients were more likely to have visited an allergist than those with prior surgery (66.4 % vs 36.9 %).

CONCLUSIONS

Patients with CRSwNP in AROMA show considerable disease burden at baseline prior to treatment. Those with prior surgery had worse olfaction and an overall worse burden of disease.

PLAIN LANGUAGE SUMMARY

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a condition characterized by at least 12 weeks of symptoms such as nasal congestion and loss of smell, along with the presence of nasal polyps. Treatment for CRSwNP includes intranasal steroids, but if these cannot control disease, systemic steroids or sinus surgery may be required. Systemic steroids have known side effects and only provide temporary symptom improvement. Following surgery, patients may experience both symptom and polyp recurrence. Dupilumab is a monoclonal antibody that is approved for the treatment of inadequately controlled CRSwNP and can improve disease symptoms such as nasal congestion and loss of smell. This article presents the initial findings from a large global study called AROMA, which observes patients in real-world medical practice for 3 years after initiating dupilumab for CRSwNP. This analysis compares the characteristics of those in the registry who had and had not undergone prior sinonasal surgery for CRSwNP. In this analysis, patients who had previously undergone surgery to remove nasal polyps were more likely to have used steroids for CRSwNP treatment and were in worse health because of their CRSwNP condition despite having similar severity of symptoms at baseline.

Brazilian guideline for the use of immunobiologicals in chronic rhinosinusitis with nasal polyps ‒ 2024 update

INTRODUCTION

Biologics targeting type 2 inflammation have revolutionized the way we treat patients with Chronic Rhinosinusitis with Nasal Polyps (CRSwNP). Particularly in severe and difficult-to-control cases, these drugs have provided a new reality for these patients, allowing for the effective and safe treatment of extensive diseases that were not completely managed with the typical strategy of surgery and topical medications.

OBJECTIVES

The experience achieved with the approval of these medications by ANVISA for use in CRSwNP and the knowledge obtained regarding outcomes, adverse effects, and the ideal patient profile prompted the update of the previously published guideline, with a detailed review of the most recent scientific literature, the personal experiences of experts, and the adaptation to the reality of the Brazilian healthcare system, both public and private.

RESULTS

We proposed a new eligibility criterion for biologics in patients with CRSwNP based on four pillars of indication: the impact of the disease on the patient's life, whether in the presence of specific symptoms or in overall quality of life; the extent of sinonasal disease; the presence of type 2 comorbidities, considering other associated diseases that may also benefit from anti-T2 biologics, and the presence of biomarkers to define type 2 inflammation, especially those associated with worse disease prognoses.

CONCLUSIONS

This innovative and pioneering method has two major advantages. First, it ensures a comprehensive evaluation of patients; second, it is flexible, as advancements in our understanding of the disease and changes in cost-effectiveness can be addressed by simply adjusting the required score for indication, without the need to modify the entire evaluation scheme.

Visual and bibliometric analysis of chronic rhinosinusitis and nasal polyps

Background

Chronic rhinosinusitis (CRS) is a heterogeneous disease characterized by persistent sinonasal inflammation and sinus microbiome dysbiosis. Nasal polyps (NPs) are one of the main manifestations that cause diverse clinical symptoms of CRS.

Objective

We sought to conduct a bibliometric and visual analysis of articles on CRS and NPs published between 2003 and 2022 to provide researchers with the current state of research and potential directions.

Methods

We searched relevant articles from 2003 to 2022 in the Web of Science database. VOSviewer and the Bibliometrix R package were used to perform the bibliometric analysis.

Results

A total of 3907 publications were retrieved. The United States made the highest contributions to global research, followed by China. Northwestern University had the most publications. The most published author was C. Bachert, followed by R. P. Schleimer and R. J. Schlosser. The authors with the most co-citations were C. Bachert, W. J. Fokkens, and P. Gevaert. Moreover, the journal with the most publications was the International Forum of Allergy & Rhinology, and the Journal of Allergy and Clinical Immunology was the most cited. "Covid-19," "biologics," and "type 2 inflammation" were the top current research hotspots.

Conclusions

The United States and Northwestern University were the leading country and institution in researching CRS and NPs. C. Bachert was the most influential expert. The International Forum of Allergy & Rhinology and the Journal of Allergy and Clinical Immunology were leading journals. "Covid-19," "biologics," and "type 2 inflammation" were the trending topics.

Prevalence of type 2 inflammatory signatures and efficacy of dupilumab in patients with chronic rhinosinusitis with nasal polyps from two phase 3 clinical trials: SINUS-24 and SINUS-52

BACKGROUND

This post hoc analysis of the international SINUS-24/-52 trials (NCT02912468/NCT02898454) aimed to assess dupilumab efficacy in patients with severe chronic rhinosinusitis with nasal polyps (CRSwNP) according to different definitions of type 2 inflammatory signature.

METHODS

Six definitions of type 2 inflammation were used: ≥150 eosinophils/μL or total immunoglobulin E (IgE) ≥100 IU/mL with a coexisting type 2 condition; ≥150 eosinophils/μL or total IgE ≥100 IU/mL; ≥150 eosinophils/μL; ≥250 eosinophils/μL or total IgE ≥100 IU/mL; coexisting asthma or ≥300 eosinophils/μL; presence of a coexisting type 2 condition. Odds ratios (ORs; dupilumab vs. placebo) for achieving clinically meaningful improvement (≥1 point) from baseline to week 24 (pooled SINUS-24/-52) and week 52 (SINUS-52) were calculated for nasal polyp score (NPS; range 0-8), nasal congestion/obstruction score (NC; 0-3), and loss of smell score (LoS; 0-3).

RESULTS

At baseline (n = 724), most patients displayed a type 2 inflammatory signature across definitions (64.2%-95.3%). At week 24, ORs for clinically meaningful improvement ranged from 11.9 to 14.9 for NPS across type 2 definitions, 6.5-9.6 for NC, and 12.2-17.8 for LoS (all p < 0.0001). OR ranges were similar or greater at week 52: 19.0-36.6, 7.6-12.1, and 9.2-33.5, respectively (all p < 0.0001).

CONCLUSION

Most patients with CRSwNP in the SINUS study had type 2 inflammation. Dupilumab demonstrated robust efficacy across definitions of type 2 inflammation, consistent with its profile as an inhibitor of Interleukin-4 and Interleukin-13 signaling, key and central drivers of type 2 inflammation in CRSwNP.

KEY POINTS

This study assessed type 2 inflammation prevalence and dupilumab efficacy in chronic rhinosinusitis with nasal polyps according to algorithm-defined type 2 inflammation Dupilumab efficacy was similar across all type 2 definitions.