Sinusitis and Nasal Polyp Medical Treatments

[Dr. Ashley Agan]
When patients walk into your clinic and you see that they have polyps, what happens after that? I assume if they haven't had a scan, they probably get a CT scan and you probably send them out on some topical therapies--maybe prednisone. What does that look like?

[Dr. Patricia Loftus]
Yeah. Like you said, we always try medical management first, and for chronic rhinosinusitis with nasal polyps, this is a disease where prednisone is actually recommended. We have guidelines that give us different options. However, patients with polyps, which are eosinophilia-driven, tend to do well with prednisone because they respond well to steroids. So, this is something that's recommended if the patient doesn't have any contraindications to it. In a patient who is treatment-naive and can take prednisone, I will do a steroid taper.

There's no specific taper that you should do. What I like to do is 40 milligrams for four days, 30 for four days, 20 for four days, 10 for four days. So, it's 40 pills over a 16 day taper. I would say that most rhinologists tend to not go higher than 40. From what I read, someone looked into it and found that the dosage that you hit had side effects and might've created lawsuits, or something along that line. They kind of found that 40 was okay to go up to. That's what most of us do. Also, I will definitely tell them to do saltwater rinses.

[Dr. Patricia Loftus]
We know there's a recommendation for intranasal corticosteroids. Intranasal corticosteroids that are FDA approved are Flonase for nasal polyps or the other nasal sprays. But as you guys know, we do tend to add our steroids to nasal rinses. I use budesonide nasa rinses for that. It is off-label technically. There's not robust data and I think mostly because it is off-label, but we know that it does work. What's nice about adding the budesonide is that with the rinse, it's higher volume, can kind of get into the nose and sinus cavities a little bit better.

I think pre-operatively, the budesonide and the rinse doesn't matter as much just because you don't have that open space yet. I think it's very important post-operatively. My patient who hasn't had surgery yet, I’ll prescribe a steroid taper, a saline rinse, an intranasal corticosteroid--whether it's Flonase or whether you add it into the nasal rinse. I won't do a CAT scan unless there is something concerning to me, just because there are some people who respond really well and can keep their polyps under control on topical steroids.

If they feel good, we might just have them come back in a couple months and see if the polyps have come back or if they're still doing okay on the topical medication. If they quickly come back, that's when we'll potentially discuss surgery and that's when I would get a CAT scan.

[Dr. Patricia Loftus]
These are all options that I would talk about with the patient. Biologics is a very new thing that we've been trying to do. We, as ENTs, have only been able to prescribe Dupixent since June of last year. It has not been that long that we've even been able to prescribe these biologics. There was a meeting with the NIH where everybody kind of met and they said, “Okay, when do we use these?” Because they are very expensive. It's like 38 grand a year to be on this medication. So, it's not something that you just kind of throw at anybody.

We feel that you really should fail all of the other stuff that we have. Definitely surgery first. Of course, there are those patients that may not be surgical candidates ever, and they could potentially be someone who can start on Dupixent without having surgery, but your typical patient, you want them to have had full surgery--meaning give them a revision surgery if there's ethmoid septations left or give them a revision surgery if they haven't had a Draf III. Try all the topical stuff, whether it's budesonide rinses, XHANCE, or stents with a steroid on them. So, try all that stuff, and if they are refractory to all of that, I have seen Dupixent work wonders.

Dupixent it's an IL-4 receptor medication that works on IL-4 and IL-13 since they share a receptor. That's what's really interesting about biologics in general. What we're trying to figure out is how we can work sort of downstream before polyp formation even happens. We used to just kind of just call sinusitis either, without polyps, right? But we know that it's so much more than that. We know there's TH1 inflammation where the cytokines tend to be IL-2 and tumor necrosis factor beta and interferon, and then TH2, which is polyp, which is your IL-4, 5 and 13.

We're trying to look at these cytokines and see if we can intervene at that portion of development of polyps. That's what Dupixent does. It works on these cytokines that you see in TH2 inflammation. I have seen it work wonders. It doesn't work for everyone, and there's still a lot of questions about it. For instance, how long do you give it a try until you decide it hasn't worked? Right now, we're kind of going off the asthma literature, because in asthma, they've had biologics for a much longer time for allergic asthma and atopic dermatitis. They've been dealing with biologics a lot longer than us, so we kind of look to them.

They usually do about four months or 16 weeks, and if there's been no change, we don't think it's going to work. But then there's also things like: how long do you leave the patients on for it? What we know so far is that, once the patients come off, the polyps tend to come back. So, is this a lifelong thing? So, you have to talk about that with the patients. Like, if we start you on this, this is going to be a shot every two weeks for what we think will be the rest of your life. That's a big deal, and then also, are there markers to decide who's going to respond and who isn't? Going back to one of your other questions, Ashley, was like, what things do you test for?

People will ask me, “Oh, do you test for IgE, and do you test for some of this eosinophilia?” These types of markers would be a biologic candidate in the future. Actually, currently, those things are not necessary to prescribe it. You really just have to show that they've tried other things, they failed, and that this is severely affecting their quality of life, and that you have polyps on endoscopy. So, quality of life would be smell loss and that kind of thing. You don't need to actually check those things to go on Dupixent. I don't usually check those early on, but if they were to see allergy or immunology, they might check them. There's still a lot that we don't know about Dupixent, but it is something that we should know about as ENTs treating polyps because there are those patients that will benefit from it.