Recent advancements in the management of allergic conditions have been significantly shaped by the use of biologics, as explored by William Eschenbacher, MD; Matthew Straesser, MD; Alice Knoeddler, MD; Rung-chi Li, DO; and Larry Borish, MD. Their research into allergic rhinitis (AR), chronic rhinosinusitis (CRS), and nasal polyposis (NP), particularly those characterized by Type 2high (T2) inflammation, has provided a new understanding of treatment potential and challenges.

AR, CRS with NP, and some forms of CRS are driven by T2 inflammation, involving eosinophils, basophils, mast cells, and cytokines like IL-4, IL-5, and IL-13. AR is typically an allergic reaction mediated by IgE antibodies. In this context, Omalizumab has emerged as an influential biologic by binding to IgE and thus limiting allergic reactions. It’s shown to improve nasal and ocular symptoms substantially, despite its official approval only for asthma and chronic idiopathic urticaria.

The growing focus on T2-targeted biologics has extended to Dupilumab, which acts on the IL-4 receptor and shows efficacy in reducing AR symptoms. IL-5/IL-5R-targeted therapies like mepolizumab are also gaining attention, particularly for their potential in improving quality of life for patients with asthma and associated upper airway conditions.

The management of CRS without NP has traditionally not included T2-targeting biologic treatments due to its classification as a type 1 or 3 inflammatory disease. However, recent studies suggest a subset of CRSsNPs patients could benefit from T2 biologics. Identifying these patients requires reliable biomarkers, possibly through analyzing eosinophil content in tissue samples during sinus surgery.

In nasal polyposis management, the success of biologics has been significant. Clinical trials with Omalizumab have shown improvements in nasal congestion and polyp scores. Other biologics, like Mepolizumab and Reslizumab, targeting IL-5, have indicated potential in symptom management and reducing surgical interventions. Dupilumab, which targets IL-4 and IL-13, has been FDA approved for CRSwNP due to its efficacy in clinical trials.

While these biologics present a new horizon for treating T2 inflammation-related AR, NP, and CRS, the high cost remains a barrier. Current treatment strategies, often involving medical combinations, are markedly more cost-effective. Future research must therefore evaluate the cost-benefit of biologics, considering their impact on quality of life and therapeutic positioning.

The contributions of Dr. Eschenbacher, Dr. Straesser, Dr. Knoeddler, Dr. Li, and Dr. Borish in detailing these developments underscore the importance of ongoing research and the development of effective, tailored treatments. Their meticulous work offers a foundation for future advancements in the treatment of immunological and allergic conditions.

Prof. Dr. Prahlada N.B
19 August 2023

Reference / Link to full article:

William Eschenbacher, MD1, Matthew Straesser, MD1, Alice Knoeddler, MD1, Rung-chi Li, DO1, Larry Borish, MD*,1,2, Immunol Allergy Clin North Am. 2020 November ; 40(4): 539–547. doi:10.1016/j.iac.2020.06.001. 

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