xRead - Nasal Obstruction (September 2024) Full Articles

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International consensus statement on rhinosinusitis

Subsequently, the association of both asthma and CRSwNP have also been related to an impaired QoL and loss of productivity. 1351–1353 Alobid et al. 1354 showed that the QoL in patients with CRSwNP was worse with concomitant asthma mainly on physical functioning, body pain, and vitality. The same group 1344 found that persistent asthma had an accumulative impact on the loss of smell, propos ing the loss of smell as a predictive symptom to identify severe asthma. Other authors have also found lower olfac tory outcomes in patients who have associated CRSwNP andasthma 1355 orAERD. 1356 Considering the strong association between asthma and CRS, the question is raised of whether treatment of 1 con dition may improve outcomes in the other. Some studies have shown that treatment of CRS decreases the severity of asthma. 170,191,1353 Reflecting this, GINA 2019 guidelines rec ommends the assessment of comorbidities including CRS in every step of the therapeutic approach for asthma. 1357 On the other hand, the American Lung Association–Asthma Clinical Research Centers’ Writing Committee study 1358 concluded that no significant improvement in asthma con trol could be achieved from treatment with nasal corticos teroids. Evidence suggests that the surgical treatment of CRSwNP with concomitant asthma has a positive impact on asthma clinical and biological parameters (Table X-3). Using objective and subjective sinonasal and asthma outcome measures, studies have demonstrated clinical improvement following ESS. 170,191,1359–1361 In patients with asthma and CRSwNP, ESS showed an improvement in asthma severity scores, reduced need of inhaled corti costeroids and reduced the frequency of asthma-related emergency room visits. 1361 A prospective randomized trial showed that patients with CRSwNP had a significant improvement in nasal and lower airway symptoms after ESS. 1355 The same authors followed a cohort of CRSwNP patients after ESS, showing an improvement in asthma symptoms score, daily peak expiratory flow and nasal inspiratory flow. 1362 Zhang et al. 1363 observed a larger QoL improvement measured by SNOT-22 at 1- and 3 months after surgery. In conclusion, data on the impact of surgery for NP on comorbid asthma mostly point toward a beneficial effect of surgery on different parameters of asthma severity. Given monoclonal antibodies (MAbs) target different inflammatory markers involved in the pathophysiology of CRSwNP the questions arise whether they might have an additional influence on patients suffering from CRSwNP and asthma. A preliminary observational study 1364 con ducted on patients suffering from refractory asthma and CRSwNP showed a therapeutic value for both condi tions. A recent systematic review concluded that MAbs alone clinically improved CRSwNP. Omalizumab and

mepolizumab showed improvements in TPS and symp toms score in patients with CRSwNP when compared with placebo. Reslizumab reduced polyp size in patients with high intranasal IL-5 levels. Dupilumab achieved a 70% reduction in TPS compared with 20% in the placebo group ( p < 0.001). 290 Although the 2 most recent randomized controlled stud ies on dupilumab were designed to assess its efficacy on patients with CRSwNP, those patients also suffering from asthma and who were allocated in the control group had more adverse effects, asthma among them. 60 This finding suggests a potential positive “side-effect” of a monoclonal antibody on asthma in patients with both conditions. In fact, the meta-analysis on the effect of monoclonal anti bodies against IL5, anti-IL5R, and anti-IL13 showed that all drugs were superior to placebo groups in preventing rates of asthma exacerbation. 1365 Asthma as a Contributing Factor for CRSwNP Aggregate Grade of Evidence: B (Level 1: 2 studies; level 2: 7 studies; level 3: 7 studies; Table X-3). Benefit: Early diagnosis of asthma in patients with CRSwNP. Harm: Inconvenience of office visit and lab test. Cost: The lab tests for diagnosis of asthma has associated costs. Benefits-Harm Assessment: Preponderance of benefit over harm. Value Judgments: Asthma in nasal polyposis is highly prevalent. Policy Level: Recommendation for asthma screen ing in patients with CRSwNP. Intervention: Screen all patients with CRSwNP for asthma symptoms; consider additional testing as needed. X.C.2 Contributing Factors for CRSwNP: Allergy In order to address the question of what role allergy plays in the pathophysiology of CRSwNP, we must first agree on what we mean by “allergy.” Traditionally, this has been defined as systemic IgE-mediated hypersensitivity in the setting of clinical symptoms attributable to this hypersen sitivity. As our understanding of the complexities of the human immune system deepens, our methods of assess ing biochemical markers suggestive of allergic disease