Medical Management of Chronic Rhinosinusitis with Nasal Polyposis
Summary of Recommendations
- The network meta-analysis linked to this guideline showed that delivery method of INCS was potentially important. INCS stent, spray, and exhalation delivery system (EDS) are among the most beneficial of the INCS delivery methods across multiple patient-important outcomes.
- The costs, availability, accessibility, and practical implications of the different methods of INCS delivery are likely to influence patient decision making.
- There is moderate certainty of evidence for the safety of INCS spray but safety may vary among the other delivery options. There is low or very low certainty in the safety of INCS using delivery methods other than spray.
- INCS have small treatment effect sizes. Patients with severe or rapidly recurrent disease may value more treatments with larger reductions in symptoms.
- There is probably uncertainty in the value and importance patients put on the outcomes that patients consider critical to decision making.
- For patients who have a symptom for which the improvement was considered to be important while receiving treatments other than biologics (i.e. INCS, surgery, or ATAD), not using biologics may be preferred.
- For patients using INCS for at least 4 weeks and who continue to have high disease burden, or for patients who have higher disease severity at presentation, biologics may be preferred over other medical treatment choices.
- There is variability in efficacy among the biologics and this may influence the overall choice. See Table 1 for more information.
- Patients who value not having the burden of payment and insurance approvals may be less likely to choose biologics. Patients who want to avoid the inconvenience of trialing potentially less effective medical therapies may prefer biologics.
- In AERD specifically, biologics may be preferred over aspirin therapy after desensitization (ATAD) for patients who have increased risk of harms associated with daily aspirin therapy, or in patients who value the most efficacious therapies and/or patients who wish to avoid a strict daily oral medication regimen and its associated initial desensitization procedure.
- Patients with comorbid diseases that lead to a dual indication for biologic treatment may be a reason to choose biologics in general and even specific biologics.
- Consider risks that impact the safety of performing an aspirin desensitization such as severe poorly controlled asthma. Or risks that impact safety of long-term aspirin use such as conditions or treatments that increase bleeding risk.
- Biologics may be preferred over ATAD in AERD for patients who have increased risk of harms with ATAD or in patients who value the most efficacious therapies and/or avoiding a strict daily oral medication regimen and its associated desensitization procedure.
- Patients intolerant to NSAIDs and who require an NSAID for alternative indications may prefer ATAD over other options.
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Recommendation Grading
Overview
Title
Medical Management of Chronic Rhinosinusitis with Nasal Polyposis
Authoring Organizations
American College of Allergy, Asthma, and Immunology
American Academy of Allergy, Asthma & Immunology
Publication Month/Year
November 9, 2022
Last Updated Month/Year
April 1, 2024
Supplemental Implementation Tools
Document Type
Guideline
Country of Publication
US
Document Objectives
Chronic rhinosinusitis with nasal polyposis (CRSwNP) is an inflammatory disease of the nasal mucosa and sinuses that lasts at least 12 weeks. It affects about 2% to 4% of people with symptoms such as smell loss, nasal obstruction, thick nasal drainage, and facial pressure. Some patients with CRSwNP also have comorbid asthma and develop acute respiratory reactions to nonsteroidal anti-inflammatory drugs. Patients with this clinical triad of conditions are classified as having aspirin (or nonsteroidal anti-inflammatory drug)-exacerbated respiratory disease (AERD). CRSwNP is important because it negatively impacts quality of life. While there is no known cure for CRSwNP, there are many different management options. Although optimal patient outcomes require systematic summaries of all available evidence, guidelines for the management of CRSwNP have historically not explicitly considered such summaries. Furthermore, several trials of interventions for CRSwNP were recently completed, calling for the need for updated clinical guidelines. These guidelines are based on updated and original systematic reviews of evidence conducted and reported separately. The panel followed best practices for guideline development recommended by the Institute of Medicine and the Guidelines International Network (GIN) and used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess the certainty in the evidence and formulate recommendations.The recommendations, along with key remarks and conditions to consider when choosing treatments, are listed in Table I.
Inclusion Criteria
Male, Female, Adult, Older adult
Health Care Settings
Ambulatory, Outpatient
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Scope
Treatment, Management
Diseases/Conditions (MeSH)
D012852 - Sinusitis, D009298 - Nasal Polyps
Keywords
rhinosinusitis, nasal polyps, chronic rhinosinusitis, crswnp, crs
Source Citation
Rank MA, Chu DK, Bognanni A, Oykhman P, Bernstein JA, Ellis AK, Golden DBK, Greenhawt M, Horner CC, Ledford DK, Lieberman J, Luong AU, Orlandi RR, Samant SA, Shaker MS, Soler ZM, Stevens WW, Stukus DR, Wang J, Peters AT, The Joint Task Force on Practice Parameters GRADE Guidelines for the Medical Management of Chronic Rhinosinusitis with Nasal Polyposis, Journal of Allergy and Clinical Immunology (2022), doi: https://doi.org/10.1016/j.jaci.2022.10.026.
Bognanni A, Chu DK, Rank MA, Bernstein J, Ellis AK, Golden D, Greenhawt M, Hagan JB, Horner CC, Ledford DK, Lieberman J, Luong AU, Marks LA, Orlandi RR, Samant SA, Shaker M, Soler ZM, Stevens WW, Stukus DR, Wang J, Peters AT. Topical corticosteroids for chronic rhinosinusitis with nasal polyposis: GRADE systematic review and network meta-analysis. J Allergy Clin Immunol. 2022 Dec;150(6):1447-1459.
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 Apr;149(4):1286-1295.
Chu DK, Lee DS, Lee KM, Schunemann HJ, Szczeklik W, Lee JM. Benefits and harms of aspirin desensitization for aspirin exacerbated respiratory disease: a systematic review and meta-analysis. Int Forum Allergy Rhin. 2019;9:1409-19.