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Breaking New Ground in CRSwNP: Updating CRSwNP Clinical Pathways to Integrate the Latest Therapeutic Advances Roundtable Module 3
CME/CE Information

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1 2 3
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Activity Information

Physicians: Maximum of 0.25 AMA PRA Category 1 Credit™

Nurse Practitioners/Nurses: 0.25 Nursing contact hour

Released: June 26, 2025

Expiration: June 25, 2026

Kathleen Buchheit
Kathleen Buchheit, MD
Anju Peters
Anju Peters, MD, MSCI
Stephanie S. Smith
Stephanie S. Smith, MD, MS

Introduction

 

Dr. Stephanie Smith (Northwestern Medicine): Hello, and welcome to our discussion on Breaking New Ground in CRS with Nasal Polyps: Expert Perspectives on Targeting Epithelial Cytokines.

 

[00:00:17]

 

Personalizing CRSwNP Management From Diagnosis to Biologic Therapy

 

First and foremost, I think it is important to recognize that CRS with nasal polyps is a very heterogeneous disease. Although it is most commonly driven by type 2 inflammation in many patients, there are many patients with mixed endotypes or type 1 and 3 inflammatory patterns.

 

The heterogeneity in the underlying endotypes, as well as the presentation and clinical features, calls for detailed phenotyping and endotyping.

 

[00:00:49]

 

Phenotyping and Endotyping in CRSwNP

 

There are several ways we approach phenotyping and endotyping in CRS with nasal polyps. We use different approaches in research than we do in clinic. I am going to tell you about the practical approaches that we use.

 

First, history. Of course, looking at symptom duration, typically 12 weeks or more of symptoms. We look at recurrence patterns and potential triggers. We will get more to those triggers in the next slide.

 

But secondly look at imaging. The standard is pretty much CT scoring. Looking at sinus opacification, which sinuses are involved and looking for that just soft tissue mucosal thickening.

 

Third, we use endoscopy. An endoscopy very objective measures of polyp size typically using a Lund-Kennedy score the total polyp score. This helps us characterize just the burden of polyp size.

 

Fourth, histology. This is where we transition from phenotyping into endotyping. Typically with biopsies generally from surgery. We look to identify patterns of inflammation. Eosinophils, if there are 10 or more per high power field, that can signify, or suggest type 2 inflammation. Whereas if we see more neutrophil pattern, I am thinking perhaps of other sorts of inflammatory patterns.

 

[00:02:23]

 

Classifying CRSwNP for Treatment Planning  

 

To further classify our patients with polyps for treatment planning, in terms of phenotypic attributes, we look at common comorbidities. Particularly asthma and allergic rhinitis are going to be considered as I think about treatment approaches and work closely with my allergy and immunology colleagues to best help our patients.

 

I definitely want to explore with my patients whether they may have aspirin-exasperated respiratory disease or NSAID-exasperated respiratory disease, because that typically signifies a more severe phenotype that is associated with a higher recurrence of polyp risk.

 

Then, of course, severe or uncontrolled nasal polyp disease is associated with asthma comorbidity, recurrence after surgery, and overall poor symptom control.

 

[00:03:17]

 

When to Consider Biologics for CRSwNP

 

When to consider biologic therapy for CRS with nasal polyps? There are several expert guidelines available. But in general, I will summarize by saying that most of these guidelines tend to recommend or point us to biologics when a patient has failed surgery or is unfit for surgery or does not want it.

 

Current guidelines with the available agents suggest that we look for a type 2 inflammatory pattern. Now each of the guidelines has some nuances with just to what degree that type 2 inflammatory pattern should be established. But those are general guidelines.

 

Typically, we are also recommending biologics when patients have more severe symptoms. Overall, when we are thinking about biologics versus surgery versus both, the decision really is based on polyp burden, types of inflammation as well as patient goals and prior therapies.

 

[00:04:28]

 

Shared Decision-making CRSwNP

 

Next we are going to discuss shared-decision making in CRS with polyps. It is always important to discuss the risks, benefits, costs and preferences of all available therapies to our best ability with our patients.

 

When we are thinking about biologics versus surgery, there is pros and cons. Biologics are often thought to be less invasive than surgery. They do have a slower onset. They do require ongoing therapy, and we do not know the end point of that in a lot of cases. There are also some symptoms of biologics that are currently available tend to alleviate better than others.

 

On the other hand, we have surgery that is the tried and true treatment coming from a surgeon here, but it does offer like a very fast and objective relief with removal of polyps that can open the pathways of the sinuses, restore mucociliary clearance, and then allow topical rinses and therapies to penetrate deeper into the sinus cavities.

 

However, we do know that a percentage of patients will recur and redevelop polyps after surgery and surgery is invasive and has some low but present risks.

 

[00:05:48]

 

Defining Shared Decision-Making

 

Shared decision-making processes are well established and are needed when medical decisions have health, financial or quality of life implications. There is an established process by which the healthcare provider shares information without bias and provides relevant options for testing or treatment, and discusses the severity and probability for harm, benefits and viable alternatives.

 

Patients then explore and identify their preferences and summarize what they understand in their own words that tool can be very helpful and then a mutual decision is made.

 

[00:06:26]

 

We Can Empower Patients  

 

We can best empower our patients by providing information that is clear and unbiased, allowing our patients time to digest and then come to their own decisions.

 

[00:06:39]

 

Tailored Treatment for Better Outcomes  

 

To summarize what we have talked about here, and we have been focusing on personalized or tailored treatment for better patient outcomes for patients with nasal polyps. To recap, classification of CRS with polyps is key to optimizing therapy both on a phenotypic and endotypic level when possible.

 

Biologics are transforming their treatment options, especially for those with type 2 inflammation or comorbidities. Always use our guideline-based criteria and shared decision-making processes for our patients.

 

[00:07:15]

 

Panel Discussion 

 

Now we will move on to our panel discussion. Anju and Katie, thank you for joining me here. Can I ask you, how do you identify candidates for biologic therapy at initial presentation?

 

Dr. Kathleen Buchheit (Brigham and Women's Hospital): Yeah, I am happy to start with that. In general, I will consider biologic therapy usually in someone who has already undergone endoscopic sinus surgery and has had recurrence of their nasal polyps and really has quite a high symptom burden.

 

We do not consider for patients who actually, might have polyps but feel pretty good. We are looking for the folks with really bad congestion, loss of smell, those folks that are having symptoms that really are spilling over into other domains or other areas of their life, like poor sleep, or missing lots of work in school and not feeling good. Certainly for folks who need to use a lot of courses of systemic corticosteroids.

 

For those folks, I definitely consider biologic therapy the first time I meet them. And often we will sometimes try some interventions that we can do, perhaps another course of steroids if it seems appropriate, or changing their intranasal corticosteroid regimen. But a lot of times if someone is coming to me and they have already had surgery and their polyps have come back and they are really symptomatic, I will consider it at that point.

 

Dr. Smith: Are you all giving a systemic steroid course a try before considering the biologic therapy?

 

Dr. Buchheit: No. Not usually. Usually, no. Especially because I think by the time people get to this point, they have already had them multiple times. We know very well that the benefit is really fleeting. They will feel excellent for maybe a few days or weeks after the course of systemic corticosteroids. But when they are that severe, the symptoms often come back pretty quickly.

 

I do have people who come to me really want to use more steroids and are really asking for it. That is when if they have done multiple courses of oral steroids over the past year or two, I will consider it.

 

Dr. Smith: Thank you.

 

Dr. Anju Peters (Northwestern University): I would say the same thing. Katie, just like you, if they initially come to me, if they have not had surgery and have not had systemic steroids. Many who have had systemic steroids, by the time they get to me, if they do not, then I definitely do try it because they are so miserable when they see us, especially if their asthma is not well controlled. I do believe in shared decision-making and also multidisciplinary care. I am lucky I work with some excellent sinus surgeons.

 

I will have them see the patient as well. I feel like most patients do well with surgery. Unless they have another comorbidity, which to me says the disease will recur, such as allergic fungal sinusitis or AERD or severe asthma. Those people I will start biologic right away and still have them see the surgeons. Otherwise it is really we all decide together and they get one surgery and then if the disease comes back, then I will lean more towards the biologic.

 

Dr. Smith: Thank you. Yeah, I agree. I think I probably see more steroid naive patients than you do who are coming in thinking they have a deviated septum because they are all blocked up or whatnot. But I think as soon as I see polyps, hopefully in that conversation, I will say if these do not respond to the algorithmic approach, we will consider biologics and they are candidates right off the bat.

 

Dr. Buchheit: I was just going to add really quick one thing, which is that, as part of this shared decision-making process, I am not a surgeon, but I make it clear to patients that revision surgery is always an option. There are people that are really interested in doing that and maybe how to really actually like good response to the initial surgery for a long time and want to go back to see their otolaryngologist or see one of my colleagues, and discuss that further. So that is always part of the discussion as well.

 

Dr. Smith: Great. Thank you. Yeah, there is a lot in the ENT conversation about completion of surgery. How complete was the surgery? When we are considering revision versus pivoting to biologics a lot of times.

 

Our next question is how do you involve patients in the decision to switch biologics?

 

Dr. Peters: I could start on this one. I mean, I think typically we would not switch a biologic if someone has a good response. The only time really to consider switching is if they either are not having a good response, all of a sudden have another comorbidity that another biologic may treat better, or they have adverse effects from the biologic.

 

Again, this is also shared decision-making. I have some patients who are on dupilumab for example, and have a rash or have some arthralgias, but they have had such good response to dupilumab for their asthma and polyps that they do not want to switch, while others are not even sure that dupilumab is causing their arthralgias but want to switch. I think a lot of this is shared decision-making, unless someone has severe enough adverse effects or it is no benefit at EUFOREA says assess them six months and they do not have a benefit, then I would switch them.

 

If they have partial benefit, we may continue on for another year and use again EUFOREA guidelines, but always with shared decision-making.

 

Dr. Buchheit: Yeah, I would agree. I think the exact same thing. I have seen that there are folks who have really like a very rapid response, and there are other patients where it takes a little bit more time. I think giving them that good six-month trial and setting that expectation upfront, and also setting the expectation with the patients that, hey, this may not be an overnight improvement. It is going to take a little bit of time for all that inflammation to go down, can be helpful.

 

When we reach that six-month point or later and they have gotten very little benefit, I think it is reasonable to involve them in that discussion.

 

Dr. Peters: The one other thing that I just thought of is sometimes this decision is made for us by their insurance companies. If one is not covered, then we may have to switch them to a different one.

 

Dr. Buchheit: Yeah, we have run into that too. It can be frustrating, especially if they are doing well on the one they are on.

 

Dr. Smith: So speaking of timing, what factors determine your duration and perhaps your dosing schedule of biologic therapy?

 

Dr. Buchheit: That is a great question. When I start a patient on biologic, they will ask me the question how long will I be doing this? I say if you do well on it, you will continue it really long term. This is a chronic disease management tool. This is not really a curative option. But what we have learned is that once patients are really doing very well on drug and has very minimal symptoms, we can often deescalate at least the frequency of the dosing in some patients. This is off label. This is not necessarily on-label use of the drug. But there is actually a lot of real world publications supporting this for actually multiple biologics.

 

I think that it is something that you can introduce as a concept to your patients who are under excellent control, doing well on biologic therapy.

 

Dr. Peters: That is exactly what I say because the question comes up, how long do I have to stay on it within us discussing biologics with patients? I tell them we have evidence that potentially you could spread it out. In other disease conditions, we know, like for chronic urticaria, our guidelines tell us when to spread it out. I am hoping as we have more research in CRS with nasal polyps, our guidelines will do the same.

 

Dr. Smith: Great. Well, thank you so much for joining us today.

 

Dr. Buchheit: Thank you for having us.

 

Dr. Peters: Thank you.

 

[END OF TRANSCRIPT]