Dupilumab for nasal polyposis

The encouraging results of the LIBERTY trials1Bachert C Han JK Desrosiers M et al.Efficacy and safety of dupilumab in patients with severe chronic rhinosinusitis with nasal polyps (LIBERTY NP SINUS-24 and LIBERTY NP SINUS-52): results from two multicentre, randomised, double-blind, placebo-controlled, parallel-group phase 3 trials.Lancet. 2019; 394: 1638-1650Summary Full Text Full Text PDF PubMed Scopus (443) Google Scholar evaluating the effects of dupilumab in patients with severe chronic sinusitis with nasal polyposis that use mometasone furoate nasal spray offer much-needed hope to patients with this condition. However, we believe that these results might not reflect real-life best clinical practice. For example, the standard regimen in the Dundee Rhinology Mega-Clinic to clear polyps is oral prednisolone 25 mg once daily for 2 weeks, then fluticasone propionate 400 μg twice daily nasal drops for 3 months, followed by reducing the dose of fluticasone to the maintenance dose of 400 μg once daily, and antibiotics as required. Vaidyanathan and colleagues2Vaidyanathan S Barnes M Williamson P Hopkinson P Donnan PT Lipworth B Treatment of chronic rhinosinusitis with nasal polyposis with oral steroids followed by topical steroids: a randomized trial.Ann Intern Med. 2011; 154: 293-302Crossref PubMed Scopus (126) Google Scholar did a study in patients with severe chronic sinusitis with nasal polyposis in which they gave sequential prednisolone (25 mg once daily) and fluticasone propionate (400 μg twice daily) or placebo and fluticasone propionate (400 μg twice daily), and found that there was a 38% (prednisolone vs placebo, before fluticasone propionate) and a 34% (prednisolone vs placebo, both after fluticasone propionate) improvement in endoscopic nasal polyp score. This finding is similar to the findings in LIBERTY NP SINUS-24 (35% improvement) and LIBERTY NP SINUS-52 (30% improvement) in the nasal polyp score of patients receiving dupilumab compared with placebo.1Bachert C Han JK Desrosiers M et al.Efficacy and safety of dupilumab in patients with severe chronic rhinosinusitis with nasal polyps (LIBERTY NP SINUS-24 and LIBERTY NP SINUS-52): results from two multicentre, randomised, double-blind, placebo-controlled, parallel-group phase 3 trials.Lancet. 2019; 394: 1638-1650Summary Full Text Full Text PDF PubMed Scopus (443) Google Scholar Moreover, drug delivery with corticosteroid nasal sprays, such as mometasone furoate, to the ostiomeatal complex area is highly variable. In turn, this variability raises the pertinent question of whether the response to dupilumab would be the same magnitude in real life if given in addition to an optimal medical polypectomy. We would also be interested to know whether nasal polyposis responders to dupilumab were those with raised blood eosinophils (>300 cells per μL) or whether such patients have eosinophil-rich polyps on biopsy, especially because blood eosinophil counts are a strong predictor of the response to dupilumab in patients with severe asthma.3Castro M Corren J Pavord ID et al.Dupilumab efficacy and safety in moderate-to-severe uncontrolled asthma.N Engl J Med. 2018; 378: 2486-2496Crossref PubMed Scopus (812) Google Scholar BL reports personal fees from Sanofi; personal fees from AstraZeneca, Glenmark, Mylan, Teva, Novartis, Chiesi, Lupin, Dr Reddys, Vectura, and Cipla, unrelated to this Correspondence; and his son is an employee of AstraZeneca. CRK reports personal fees from Pfizer, AstraZeneca, and Chiesi, unrelated to this Correspondence. RC declares no competing interests. Efficacy and safety of dupilumab in patients with severe chronic rhinosinusitis with nasal polyps (LIBERTY NP SINUS-24 and LIBERTY NP SINUS-52): results from two multicentre, randomised, double-blind, placebo-controlled, parallel-group phase 3 trialsIn adult patients with severe CRSwNP, dupilumab reduced polyp size, sinus opacification, and severity of symptoms and was well tolerated. These results support the benefits of adding dupilumab to daily standard of care for patients with severe CRSwNP who otherwise have few therapeutic options. Full-Text PDF Dupilumab for nasal polyposis – Authors' replyWe appreciate the interest shown by Brian Lipworth and colleagues in our Article1 and would like to take this opportunity to address their comments. Full-Text PDF