Though there’s no cure for chronic rhinosinusitis with nasal polyps (CRSwNP), treatments can relieve disruptive symptoms like congestion, losing your sense of smell, and breathing problems. Which treatments you use will depend on several things, including how serious your symptoms are and whether you also have other conditions like asthma or allergies. You’ll probably need a combination of treatments for best results.
Corticosteroid drugs are usually the first medical treatment for CRSwNP. They lessen swelling in your nasal passages by controlling inflammation. At the same time, they shrink polyps. Your doctor will most likely start you with a corticosteroid nasal spray. They may also recommend adding steroids to a nasal rinse (also called nasal irrigation) if your symptoms don't improve enough. Another option is a breath-powered device that delivers corticosteroids more deeply into your nose. If these methods don’t work well or your symptoms are serious, they may recommend that you take a corticosteroid by mouth for a short time.
If a bacterial infection or allergies are making your symptoms worse, your doctor might prescribe antibiotics or allergy medicines. If you have asthma along with CRSwNP, they may recommend a leukotriene modifier to block substances that lead to inflammation in your nasal passages
Endoscopic sinus surgery to remove the polyps and open up your sinuses is another treatment approach. But it doesn’t eliminate the need for corticosteroids. And nasal polyps often grow back after surgery. If this happens, you might need to get an implant in your sinuses that releases corticosteroid medication.
If you have serious CRSwNP that doesn’t respond to standard treatments, biologic drugs may be an option. Instead of just relieving symptoms, biologics target the inflammation that causes them.
What Are Biologics?
Biologics are made in a lab using proteins or genetic material from living cells, like those from humans, animals, plants, or bacteria. Scientists use advanced biotechnology methods to remove these biological substances and reproduce them. They might clone genes that produce certain proteins, or combine DNA molecules from different sources.
Making these drugs is a complex and expensive process. They’re often used to treat conditions that don’t respond to more conventional medications, such as many autoimmune conditions. You usually take them as a shot or get them through an IV infusion.
Because these medicines target particular molecules or responses in your body, they can control inflammation without suppressing your entire immune system. They may be more effective and cause less side effects than many traditional drugs.
Which Biologics Are Used to Treat Chronic Rhinosinusitis With Nasal Polyps?
The FDA has approved three biologics to treat CRSwNP. They include:
These drugs belong to a class of biologics called monoclonal antibodies. Monoclonal antibodies are lab-made versions (clones) of protective antibodies made by your immune system. Antibodies are proteins that attach to and block foreign substances in your body that could cause harm.
With CRSwNP, your immune system overreacts and causes inflammation in your sinuses. Monoclonal antibodies block certain substances or cells in your body that drive the inflammation. This can lessen swelling and improve symptoms like congestion and loss of smell.
What Are Interleukin Inhibitors?
Interleukin inhibitors are medicines that stop the action of immune system proteins called interleukins. These proteins help cells signal to each other in response to infections. Interleukins can become overactive and cause unnecessary inflammation responses, such as in chronic rhinosinusitis.
Two types of interleukin inhibitor drugs are used to treat chronic rhinosinusitis with nasal polyps. Each blocks a particular interleukin that’s involved in inflammation. They are:
- Interleukin-4 (IL-4)/interleukin-13 (IL-13) inhibitors. This class includes dupilumab.
- Interleukin-5 (IL-5) inhibitors. This class includes mepolizumab.
IL-4/IL-13 inhibitors
Dupilumab blocks interleukins IL-4 and IL-13 to help calm the overactive immune response in your body.
This medicine is FDA-approved to treat adults and children 12 and older who have chronic sinusitis with nasal polyps that’s not well-controlled. It’s meant to be used along with other medicines such as a steroid nasal spray or nasal irrigation.
In studies, people with CRwNP who took dupilumab had:
- Fewer and smaller nasal polyps
- Less congestion
- An improved sense of smell
Some people in the studies saw improvements in their sense of smell and nasal congestion within a week after they started taking dupilumab. Many noticed further improvements within a few weeks.
You take dupilumab as an injection under your skin once every two weeks. You can inject it yourself into your stomach or thigh. If someone else injects you, they can use the back of your upper arm. Your doctor will show you how to inject dupilumab so you can use it safely at home.
IL-5 inhibitors
Mepolizumab blocks the activity of interleukin IL-5. Specifically, it helps lower the number of eosinophils in your blood. Eosinophils are white blood cells made by IL-5. Too many of them can cause inflammation.
The FDA has approved mepolizumab for adults who have CRSwNP and haven’t responded well enough to nasal corticosteroids. It’s considered an “add-on” maintenance treatment, which means you still need to take other medicines while you use it.
In studies, people who took mepolizumab had:
- Improvements in nasal congestion
- Smaller nasal polyps
- Less need for repeat nasal surgery
- Less need for corticosteroid medicines
People in the studies who used mepolizumab saw significantly smaller polyps and improvement in nasal blockages by 52 weeks.
At first, you’ll get mepolizumab as an injection at your doctor’s office. Later, you can give it to yourself at home, once every four weeks. You can inject it into your thigh or belly. If a caregiver injects it, they can use your upper arm.
What Are Immune Globulin Antagonists?
Immune globulin antagonists are medicines that block a type of antibody that’s involved in creating immune responses in your body.
Omalizumab is an immune globulin antagonist originally approved to treat asthma. It stops the action of a substance called immunoglobulin E (IgE). When your body makes too much IgE, this promotes chronic inflammation.
The FDA has approved omalizumab to treat adults with CRSwNP who have tried nasal corticosteroids but haven’t found enough relief.
Clinical trials showed people with CRSwNP who took omalizumab had:
- Smaller nasal polyps
- Less congestion
Study participants saw these benefits in as little as four weeks.
A health care professional will inject omalizumab at your doctor’s office for the initial treatments. After three doses, you can inject it yourself at home. You should take it every two to four weeks. You can inject omalizumab in the front of your thigh or stomach. If someone else gives you the injection, they can use your upper arm.
How Effective Are Biologics?
Studies show that biologics work well for about 60%-70% of people with CRSwNP who use them. Most people have less congestion, smaller nasal polyps, and an improved sense of smell. But they don’t work well for everyone.
It’s not clear how long people need to take these drugs or whether they can taper off their usage once they get long-term symptom relief. Experts recommend that doctors evaluate how well the treatment is working at least every six months.
At this point, there are no head-to-head clinical trials to compare the effectiveness of dupilumab, mepolizumab, and omalizumab. But scientists have looked at different data on the medicines, and some reports have suggested that dupilumab may improve symptoms the most.
What Are Common Side Effects of Biologics?
Like any medicine, biologics can cause side effects. What kind of problems you might notice may depend in part on which drug you take.
Common side effects of dupilumab include:
- Skin reactions from the injection
- Swelling, redness, or itching in the eye or eyelid
- Blurry vision
- Eosinophilia (a high count of certain white blood cells)
- Inflammation of your stomach lining (gastritis)
- Joint pain
- Trouble sleeping
- Tooth pain
If you take mepolizumab, you may notice these common side effects:
- Headache
- Injection site reactions
- Back pain
- Tiredness
- Mouth/throat pain
- Joint pain
The most common side effects of omalizumab are:
- Headache
- Injection site reactions
- Joint pain
- Upper belly pain
- Dizziness
Are Biologics Safe?
Biologics are generally considered safe, but like most drugs they can sometimes cause serious side effects.
For example, dupilumab may cause:
- Severe allergic reactions
- Eye problems like pain, blurry vision, or other vision changes
- Inflammation of your blood vessels (in people who have asthma)
- Severe joint aches and pain
People who use dupilumab should get regular eye exams since the drug sometimes causes eye complications. They should also avoid using live vaccines (those made with weak forms of a living virus or bacteria, such as the chickenpox and rotavirus vaccines). That’s because using biologics makes you slightly more likely to get infections.
Mepolizumab has been known to cause:
- Severe allergic reactions
- Low blood pressure
- Rash
- Hives
- Herpes zoster infections (which can cause shingles)
Your doctor may recommend that you get a shingles vaccine before you start using mepolizumab, since it could raise your risk of getting the infection that causes shingles.
Omalizumab contains a boxed warning because it may cause a life-threatening allergic reaction. Some other serious side effects of this medicine include:
- Cancer
- Inflammation of your blood vessels (in people who have asthma)
- Fever, muscle aches, and rash
- Parasite infections
- Heart and circulation issues
Who Shouldn’t Take Biologics?
You don’t need biologics if you can effectively manage your symptoms with other treatments like corticosteroids and surgery.
People who are allergic to any of the ingredients in biologics should avoid them.
Additionally, if you’re pregnant, plan to become pregnant, or nurse a baby, you may not be able to take a biologic. Talk to your doctor about the risks.
Tell your doctor about all the medical conditions you have and the medicines you take before you start on a biologic. Your doctor may suggest a different treatment if you have certain health issues.
How Much Do Biologics Cost?
Biologics can be pricey. But most people don’t pay the list price. Your out-of-pocket costs will depend on which treatment you use and your insurance coverage. Every policy is different, so talk to your provider about your specific plan. Some policies may require you to try less expensive treatments before using biologics.
Here are some examples of out-of-pocket costs:
- The list price of dupilumab is $3,803.20 per carton.
- The list price for a single dose of mepolizumab is around $3,689.
- The list price of omalizumab runs about $30,000-$60,000 a year.
Drug companies offer various assistance programs, coupons, and copay cards to make these medicines more affordable. These plans can often be used with or without insurance. You can check the drug companies’ websites for more information.
Some nonprofit organizations also provide financial assistance.
6 Things to Consider When Choosing a Treatment
There’s a lot to consider when choosing a treatment for chronic rhinosinusitis with nasal polyps. Here are some things to keep in mind:
Past treatments. Have you tried over-the-counter or prescription corticosteroid nasal spray? You might want to start there first. Your doctor will consider how you responded to other treatments when recommending a new one.
Your symptoms. If they’re mild, nasal rinses or corticosteroid sprays might do the job. If they’re more serious, you may need surgery or a biologic drug.
Side effects and safety. Treatments that affect your immune system, such as oral corticosteroids and biologics, can cause troublesome side effects in some people. Take a look at all the possible warnings before you opt for a treatment.
Your preferences and lifestyle. If you take a biologic, you need to be OK with injecting yourself regularly. People who are afraid of surgery should look for alternatives to that option.If you find it difficult to use medication every day, nasal corticosteroids might be inconvenient for you.
Cost. While most types of corticosteroids are relatively inexpensive, surgery and biologics can be costly. Try to figure out how much you will need to pay out-of-pocket before you choose a treatment.
Other health conditions. Your doctor will consider your medical history and other health conditions you have before they recommend a treatment. For example, if you also have asthma, they might consider mepolizumab since it’s also used to treat that condition. If you have heart or lung disease, surgery might not be right for you.