Best medications for chronic sinusitis identified, says study

Patients struggling with chronic sinusitis and nasal polyps can greatly benefit from dupilumab, a biologic drug whose effectiveness was evaluated by researchers at McMaster University.

However, the drug is expensive and may not be as available as other treatments.

A McMaster-led international team evaluated the efficacy and safety of seven biologics and aspirin desensitization by systematic review and network meta-analysis of 29 randomized controlled trials involving more than 3,400 patients. The study has been published in the Journal of Allergy and Clinical Immunology.

Results showed that the one drug, dupilumab, greatly improved overall patient wellbeing, including restored smell and taste, reduced nasal blockages and facial pain, and meant less need for steroids and surgeries to remove polyps.

“Our findings show that dupilumab is among the most effective for seven out of seven positive patient outcomes, giving us clear evidence regarding the best sinusitis treatments,” said lead author Derek Chu, assistant professor of medicine in clinical immunology and allergy at McMaster.

“Patients, clinicians, and policy makers can now be fully informed on how to select from the full menu of treatment options.”

He added that chronic sinusitis with nasal polyps is an inflammatory disease of the upper airways. It can be debilitating in terms of quality of life, work productivity, the need for repeated polyp surgeries and medicines that may have significant side effects. For those sensitive to aspirin therapy, it can produce life-threatening reactions. Sinusitis costs healthcare systems billions of dollars each year.

Other treatments, such as omalizumab, mepolizumab, benralizumab, and aspirin therapy all greatly improved one or two key outcomes such as sinusitis symptoms or quality of life.

In comparison, dupilumab consistently ranked among the most effective treatment for multiple outcomes of sinusitis symptoms, quality of life, sense of smell, need for rescue surgery, need for rescue systemic corticosteroids such as prednisone, nasal polyp size, and radiographic severity. All biologics seemed similarly safe to each other, and each had an improved safety provide compared to aspirin therapy.

The study is the first of its kind to systematically compare the effectiveness and safety of multiple sinusitis treatments, aiming to better inform patients, doctors and policymakers regarding what therapies can best treat this often-crippling condition.

First author Paul Oykhman said typical existing therapies for sinusitis are nasal saline rinses and intranasal steroids, with oral corticosteroids and/or sinus surgery used in the event of flare-ups or treatment failure. Many patients have rapid polyp regrowth and need multiple surgeries, and oral steroids like prednisone which have long-term harmful effects.

However, Oykhman, an assistant clinical professor of immunology and allergy, added that new biologic medications like dupilumab cost up to tens of thousands of dollars per person per year, meaning ensuring equitable treatment access for patients is key.

“Choosing between these competing treatment options must balance key clinical differences in effects against contextual factors such as cost and patient values and preferences,” said Oykhman.

The research will inform the clinical guidelines being developed for management of chronic rhinosinusitis with nasal polyposis by the American Academy of Allergy, Asthma and Immunology and the American College of Allergy, Asthma and Immunology, who funded the study, said Chu.

“We anticipate our findings will inform clinical practice globally on the management of this condition. As well, we anticipate these findings will have broad implications to the public and health systems.”

Sinusitis affects millions, with global data showing 12-15 per cent of people have sinusitis and one to three per cent suffer nasal polyps. Many of these patients also have asthma and hay fever.

Approximately 10 per cent of patients with sinusitis and nasal polyps have aspirin-exacerbated respiratory disease including potentially life-threatening aspirin/non-steroidal anti-inflammatory drug hypersensitivity, asthma and sinusitis.