xRead - Nasal Obstruction (September 2024) Full Articles

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Orlandi et al.

studies appeared to have evidence of improvement on CT 1163 or polyp scores, 1165 neither study found evidence of symptomatic improvement and thus the clinical signifi cance of these findings is likely to be negligible. There were variable delivery methods used in the studies, but this did not result in any major differences in the outcomes. On the basis of the available studies, there is no evidence to sup port the use of topical antifungal treatment in the routine management of CRSsNP or CRSwNP. No further studies should be conducted without strict eligibility criteria and use of the Core Outcome set for RS. 1173 Topical Antifungals for CRSsNP Aggregate Grade of Evidence: A (Level 1: 1 study; level 2: 11 studies; Table IX-35). Benefit: No apparent benefit from using topical antifungals. Harm: Treatment generally well tolerated with potential for local irritation; possible epistaxis and headache less common. Cost: 50 mg of Amphotericin B is £ 3.88 or USD$4.86 – given maximum daily dose seen in these studies was 20 mg/d, 4 weeks of treatment would cost USD$54.43. Benefits-Harm Assessment: Minimal risk of harm but no apparent potential for benefit. Value Judgments: The role in selected cases of AFRS is not considered here. Policy Level: Strong Recommendation Against. Intervention: Topical antifungal agents are not rec ommended for CRSsNP or CRSwNP. IX.D.6 Management of CRSsNP: Biologic Therapy Following an extensive literature search, only 1 study of biologic therapy included CRSsNP subjects. Pinto et al. conducted a randomized, double-blind, placebo controlled trial of omalizumab, an anti-IgE biologic for 6 months, in 14 patients with severe, refractory CRS. 1174 Only 2 subjects had CRSsNP, and both were in the placebo arm. Based on a lack of data, omalizumab is not recommended for standard treatment of CRSsNP. While some CRSsNP patients may also have eosinophilic inflammation, 1175,1176 biologics such as dupilumab may have a role in some CRSsNP but given that current evidence is lacking, further study in the CRSsNP population is needed in this specific subgroup.

The current literature demonstrates an absence of a well-designed investigation that has examined the role of biologics in the management and treatment of CRSsNP. No recommendation can be given based on currently available data.

Biologics for CRSsNP Aggregate Grade of Evidence: Not applicable.

IX.D.7 Management of CRSsNP: Anti-Leukotriene Therapy

There have been few studies examining the therapeutic efficacy of anti-leukotriene (LT) therapy in CRSsNP, and no systemic reviews or meta-analyses. Furthermore, the existing studies often group CRS and AR together into the same study group, making it difficult to determine which subgroup of patients might derive the most bene fit. An early case series of patients with allergic and non allergic uncontrolled CRS suggested that the addition of montelukast to INCS may improve subjective symptom scores. 1177 There has been 1 RCT of 128 patients with severe allergic CRS that compared montelukast plus INCS to placebo plus INCS, 1178 and assessed outcomes with a QoL questionnaire and symptom scales. After 1 and 2 months of treatment, both the symptom and QoL scores were signifi cantly more improved in the montelukast group compared with the placebo group, with additional improvements noted in allergy symptoms as patients in the montelukast group required significantly fewer rescue antihistamines to control allergic symptoms during the study period. Two additional randomized open-label studies of 30 patients 1179 and 100 patients 1180 with AR compared montelukast alone to INCS alone to montelukast plus INCS, for either a 1 month or a two-week study period, respectively. The Dalgic study specifically investigated the effects of the interven tions on olfactory function in patients with AR and found that INCS alone or with montelukast improved olfaction as measured with Sniffin’ Sticks, but montelukast alone did not, and the addition of montelukast to INCS offered no further benefit. The Chen study evaluated the effects of the interventions on symptom scores, fractional exhaled NO (FeNO), and nasal cavity volume, and found that all 3 treat ment arms improved symptoms from baseline, and that the combination of montelukast plus INCS produced greater improvements in nasal congestion than either drug alone. One prospective open-label study of 75 AR patients 1181 compared the efficacy of montelukast to the antihistamine