Challenges in the Use of Biologics for Chronic Rhinosinusitis with Nasal Polyps (CRSwNP)

Anju Peters, MD: So, Naveen, anything to add for these biologics, or in your practice what do you say the biggest challenge is associated with the use of biologics?

Naveen Bhandarkar, MD: That was a nice summary by Dareen and Drew on all the biologics, and labeled my section challenges, which is exactly that. It's challenging to discuss because we have different biologic and different criteria by which those biologics get approved, or treatment. I would say the biggest challenge in my practice at least is one, identifying what biologic to use because we don't really have, this was mentioned earlier I think, Drew did, about how we look at inflammation and what these different biologic targets, and what biomarkers we at this point have available to identify which one might work. All we can say at this point is that a patient has eosinophil if they have had a biopsy or surgery. But in the pre-operative patient it becomes very difficult maybe we must look at these associated G states. The second challenge is identifying where the biologic fits in a treatment algorithm for these patients. And Dr Peters I appreciate your contribution to the literature in the multi-disciplinary stepwise treatment algorithm that was published, which shed some more light on that and guide my practice in at least identifying some of those patients. I can start by summarizing what others have to say, that my understanding based on the algorithm is that biologics fit in a later line of therapy. After escalation of therapy to surgery after topical therapy including exhalation delivery fluticasone failure for patients that were recalcitrant at least when it comes to considering treatment for tis sole indication of nasal polyps. And for those patients who were poor surgical candidates, or declined surgery for whatever reason, but were still symptomatic, again, despite optimized topical steroid delivery, were considered good candidates for that therapy. And of course, these are guidelines, not every patient or situation is going to fit into that. We as clinicians need to make those decisions sometimes with shared decision making. But, in a large-scale overview I would say that's what I see now. That has shed some more clarity on these challenges, some of the challenges I have had before. So, I appreciate that.

Anju Peters, MD: I thank you for bringing those guidelines up. That was a consensus document with allergists ENT. We all need to figure out when to start which one, how long to leave them on, pre-surgery, with surgery, after surgery. And cost is one of the biggest challenges that we all face, and hopefully, they'll get cheaper.

Transcript edited for clarity