The role of intranasal corticosteroids in chronic rhinosinusitis with nasal polyposis treated with dupilumab

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a complex immunological disease of the upper airways characterized by a type 2 inflammatory endotype [[1], [2], [3], [4]]. The European Position Paper on Rhinosinusitis and Nasal Polyps 2020 suggests medical treatments as first line therapy, including intranasal and systemic corticosteroids [1]. Functional Endoscopic Sinus Surgery (FESS) is performed when patients are uncontrolled by medical treatment, while biologic agents, such as dupilumab, are usually administered as a third line treatment [1].

Recurrence after FESS can be higher than 60 % and the non-adherence to prescribed long term medical therapy is one of the main reasons [[5], [6], [7]]. Indeed, two meta-analyses showed that regular use of intranasal steroids after FESS reduces the risk of CRSwNP recurrence [8,9]. Therefore, follow-up examinations after surgery are mandatory to promptly identify and treat relapses [10].

IL-4 and IL-13 cytokines have a key role in establishing and sustaining type 2 inflammation and in tissue remodeling. Dupilumab is an inhibitory murine-derived fully human monoclonal antibody which acts against IL-4Rα blocking IL-4 and IL-13 pathways concurrently. It is used for type 2 endotype-related diseases, like asthma and atopic dermatitis. Dupilumab has been recently approved for the treatment of uncontrolled severe CRSwNP and it seemed to be more effective than other biologicals (i.e. mepolizumab and omalizumab) in network metanalyses [[11], [12], [13]]. However, direct head-to-head trials and real-world studies are mandatory to confirm dupilumab superiority. Type 2 cytokines released by innate lymphocytes 2 (IL2) and T helper 2 (Th2) cells are responsible for eosinophils recruitment. However, sometimes CRSwNP is associated to neutrophilic inflammation (type 1 or 3), especially in Asian subjects [1].

EPOS 2020 guidelines recommend concomitant regular administration of intranasal corticosteroids (ICS) during biological treatment [1]. However, adherence to ICS therapy is not always optimal [10].

The aim of this observational retrospective study was to evaluate the ICS role in patients with CRSwNP who underwent treatment with dupilumab. We collected data about objective and subjective outcomes according to adherence to regular administration of intranasal corticosteroids.

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