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Alan Khadavi, MD, APC
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February 12, 2022 by Alan Khadavi

Xolair, Dupixent or Nucala for Nasal Polyps?

Xolair, Dupixent and Nucala all have the indication to treat chronic rhinosinusitis with nasal polyps. Conventional treatment involves nasal surgery (debulking polypectomy and sinus surgery to create open sinus cavities and improve ostiomeatal complex drainage). Many patients relapse despite medical and surgical treatment.

3 current medications are used to target type 2 inflammation to improve disease control.

Mepolizumab (Nucala) for Nasal Polyps

Xolair for Nasal Polyps

Dupilumab for Nasal Polyps

An indirect comparison from phase 3 placebo controlled trials were studied in an article titled “The Choice of Biologics in Patients with Severe Chronic Rhinosinusitis with Nasal Polyps.”

The relative improvements of nasal polyp scores saw a reduction with each of these medications:

  • Nucala (mepolizumab) 15% reduction
  • Xolair (omalizumab) 18% reduction
  • Dupixent (dupilumab) 35% reduction

So Dupixent performed better in improving the the Nasal Polyp Scores.

Total nasal endoscopic polyp score (TPS) Endoscopic scoring system Ranges 0-8. 0 = no polyps, 1 = polyps confined to the middle meatus, 2 = multiple polyps occupying the middle meatus, 3 = polyps extending beyond middle meatus, 4 = polyps completely obstructing the nasal cavity.

This trend was mirrored by relative improvements in health status with the 22 item Sinonasal Outcome Test score showing:

  • Nucala 21% reduction
  • Xolair 27% reduction
  • Dupixent 43% reduction

The 22-item Sinonasal Outcome Test (SNOT-22) is a validated patient-reported outcome measure for chronic rhinosinusitis and in many circumstances is used in rhinology/otolaryngology clinics to assess sinonasal symptoms in general.

All showed a significant improvement. All biologics improved nasal airway blockage and also reduced the need for rescue medical/and or surgical polypectomy.

The greater objective and subjective responses to Dupixent versus either Nucala or Xolair might reflect its effect on the type 2 pathway by blocking IL-4 and IL-13, suppressing IgE and FeNO, suggesting a more broader spectrum of action. All 3 of them reduced the need for rescue medication and nasal polyp surgeries.

The University of Pennsylvania Smell Identification Test (UPSIT), is a measure of sense of smell, with a higher value reflecting a better sense of smell.

UPSIT Classification. Volunteers considered as anosmia: score of 6 – 18, severe microsmia: score between 19 and 25, moderate microsmia: 26 – 30 in women and 26 – 29 in men, mild microsmia: 31 – 34 in women and 30 – 33 in men and normosmia: score of more than 34 in women and 33 in men. 
Dupilumab improved the scores higher than Nucala and Xolair.
Real world head to head comparisons are required in severe nasal polyps to determine which biologic would give the best response. Every patient needs to be individualized and other co-factors need to be assessed to determine the best medication forward. Further clarity is required to determine which patient will respond to the best biological medication for nasal polyps. Tezspire, currently approved for asthma, is also being investigated for nasal polyps.

 

Filed Under: biologics, Blog

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Dr. Alan Khadavi
Allergy & Asthma Specialist

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