Author(s)
Beverly Fu, BA, MA
Itzel Rubio-Jimenez, Ms
Michael Chang, MD
Zara Patel, MD, FARS
Jayakar Nayak, MD, PhD
Peter Hwang, MD, FARS
Noel Ayoub, MD
Affiliation(s)
Stanford University
Abstract:
Objectives: Biologic therapies have expanded treatment options for chronic rhinosinusitis with nasal polyps (CRSwNP), yet some patients ultimately require a change in biologic therapy. Identifying reasons for and clinical predictors of biologic switching may inform personalized biologic selection and shorten time to optimal therapy.
Methods: We retrospectively reviewed adults initiating biologics for CRSwNP between 2009-2025 at a tertiary center. Demographic, clinical, laboratory, radiographic, histopathologic, and Sinonasal Outcome Test-22 (SNOT-22) data were collected. Predictors of subsequent biologic change were analyzed.
Results: Among 400 patients, 70 (18%) switched biologics after an average of 38 months. All patients had a diagnosis of CRSwNP, which was the primary indication in 61%. Baseline demographics were comparable between groups. Switching was more common with omalizumab (39%) and mepolizumab (40%) than dupilumab (5%, p<0.01). Most from omalizumab or mepolizumab transitioned to dupilumab for inadequate CRSwNP control (42% and 50%); dupilumab was typically discontinued for adverse effects (39%). Compared with those maintaining initial therapy, switchers exhibited greater eosinophilia (p=0.03), fungal elements (p=0.02), radiologic air-fluid levels (p<0.01), asthma (p<0.01), AERD (p=0.01), and COPD (p=0.04). Baseline SNOT-22 scores were similar (p=0.20), but higher for switchers at 6 months (p<0.01). 59% achieved MCID 6-12 months after switching.
Conclusion: Most who switch biologics for CRSwNP typically transition to dupilumab due to inadequate symptom control. Biologic switching is associated with more complex inflammatory and comorbid disease. Early recognition of predictors may help optimize biologic selection.