Chronic rhinosinusitis (CRS) is an inflammatory disorder of the upper airways with an estimated prevalence of approximately 10% of the adult population (1). CRS comprises two major clinical phenotypes which include those with nasal polyposis and those without nasal polyposis (1). The latter of these is twice as prevalent (1). Though chronic rhinosinusitis (CRSwNP) with nasal polyposis is less common, it is most often coexistent with severe recurrent asthma. When CRSwNP is coexistent with asthma, CRSNP has more severe sinonasal symptoms and worse quality of life. IgE and eosinophil counts are often elevated in these individuals. Both CRSwNP and asthma exhibit epithelial barrier dysfunction and share type 2 immunopathology (2).
Asthma in the presence of nasal polyposis is more difficult to control, and more exacerbation prone with more extensive eosinophilic inflammation(2). One phenotype of CRSwNP with comorbid asthma is aspirin exacerbated respiratory disease (AERD)(2). This can also be referred to as Samter’s triad or nonsteroidal anti-inflammatory drug (NSAID)-exacerbated respiratory disease (NSAID-ERD), which affects 10% of individuals who have CRSwNP(2). The T2- driven mechanism underlying AERD and NSAID-ERD comprises of a dysregulated arachidonic acid metabolism and cysteinyl leukotriene overproduction (1). These pathways are also dysregulated in asthma. AERD develops suddenly in young adulthood. The natural course of disease typically demonstrates a pattern of persistent rhinitis, followed by asthma, and finally COX-1 inhibitor-induced reactions(2).
Until recently, medical therapies for CRSwNP have relied on nasal saline rinse and intranasal steroids. Once an individual has a flare in the CRSwNP, rescue oral corticosteroids are prescribed. Eventually, the individual is referred to endoscopic sinus surgery (3). Recently, biologic therapies have been introduced to the management of CRSwNP. These therapies work well as they target type 2 inflammation which is predominant in CRSwNP. A systematic review and network meta-analysis of more than 3400 patients with CRSwNP in 29 randomized trials demonstrated improvements in quality of life with dupilumab, omalizumab, mepolizumab, and benralizumab(3). Comparisons among biologics demonstrated that dupilumab is the most beneficial in improving quality of life, decreasing symptoms, improving smell, decreasing nasal polyp sign and decreasing the rate of rescue polyp surgery (3). There are many biologic therapies available to manage dupilumab.
Though the nose and lungs are often treated as separate entities, the control of the upper airway disease and lower airway disease in patients with CRSwNP and asthma is linked (2). Individuals that have severe asthma and comorbid CRSwNP should have the latter treated and optimized, which will improve overall asthma control.
1. Striz I, Golebski K, Strizova Z, Loukides S, Bakakos P, Hanania NA, Jesenak M, Diamant Z. New insights into the pathophysiology and therapeutic targets of asthma and comorbid chronic rhinosinusitis with or without nasal polyposis. Clin Sci (Lond) 2023; 137: 727-753.
2. Laidlaw TM, Mullol J, Woessner KM, Amin N, Mannent LP. Chronic Rhinosinusitis with Nasal Polyps and Asthma. J Allergy Clin Immunol Pract 2021; 9: 1133-1141.
3. Oykhman P, Paramo FA, Bousquet J, Kennedy DW, Brignardello-Petersen R, Chu DK. Comparative efficacy and safety of monoclonal antibodies and aspirin desensitization for chronic rhinosinusitis with nasal polyposis: A systematic review and network meta-analysis. J Allergy Clin Immunol 2022; 149: 1286-1295.