The medical management of chronic rhinosinusitis with nasal polyps and aspirin-exacerbated respiratory in the biologic age

The advent of biologic therapy for the treatment of chronic rhinosinusitis with nasal polyps (CRSwNP) has allowed for substantial improvement in symptom control and reduction in medical resource utilization for patients with CRSwNP. CRSwNP is characterized by chronic symptoms (>12 weeks), including nasal congestion, hyposmia or anosmia, anterior or posterior mucopurulent drainage, and, in some patients, facial pain or pressure, with patients also having objective evidence of CRSwNP on nasal endoscopy or imaging. In Western countries, CRSwNP is most frequently marked by type 2 inflammatory cells and mediators, including tissue eosinophilia, T helper type 2 cells, group 2 innate lymphoid cells, locally produced immunoglobulin E, type 2 cytokines, and mast cell activation. Both CRSwNP and aspirin-exacerbated respiratory disease (AERD), an important, severe phenotype of CRSwNP, are associated with impairments in quality of life, medical resource consumption, and recurrent CRSwNP after functional endoscopic sinus surgery (FESS), with some patients requiring revision FESS. There are now four U.S. Food and Drug Administration approved biologics for treatment of CRSwNP, including dupilumab, omalizumab, mepolizumab, and tezepelumab, and more under investigation for the treatment of CRSwNP. Biologics have been shown to decrease nasal polyp size, improve sense of smell, reduce the need for systemic corticosteroids and FESS, and improve quality of life for patients with CRSwNP. In this review, I discuss guidelines for the treatment of CRSwNP and AERD in the biologic era, efficacy of biologic medications, and emerging real-world evidence for the use of biologic therapy for CRSwNP and AERD.