The treatment of nasal polyps can be broadly categorized into four categories:
1. Topical or systemic steroids
2. Allergy therapy
3. Procedures- insertion of steroid eluting stents (SINUVA or PROPEL), or nasal polyp and sinonasal surgery
The use of biologics for nasal polyp treatment is relatively new (since 2019). Biologics are medications that specifically target and inhibit inflammatory pathways in the immune system. By reducing inflammation, biologics are thought to shrink and decrease the formation of nasal polyps. As of today, there are only two FDA approved biologics for the use of nasal polyposis: Dupixent (dupilumab) and Nucala (mepolizumab). A third biologic, Xolair (omalizumab), is currently undergoing clinical trials.
Patients sometimes ask me which biologic is best for treatment of their nasal polyps. At this point, however, there have not been any head-to-head studies that compare both biologics. There have been independent studies of both respective biologics that have shown promising results for the treatment of nasal polyps. Dupixent has been FDA approved since 2019 and I have seen great clinical results over the years. However, today, I will focus on the newest biologic to obtain FDA approval for nasal polyps, Nucala (mepolizumab).
Nucala is an injectable medication that has been used for the treatment of eosinophilic-driven diseases since 2015. These diseases include: adult & pediatric severe esoinophliic asthma, eosinophilic granulomatosis with polyangitis, and hypereosinophilic syndrome. As of July 2021, Nucala has a new indication for the treatment of chronic sinusitis with nasal polyposis in adults whose disease is not controlled with topical intranasal steroids.
In the SYNAPSE trial, Nucala was found to improve both nasal polyp size and nasal obstruction compared to placebo. Patients on Nucala were also shown to have a significant decrease in the need for revision (or repeat) surgery, as well as an overall improvement in quality of life as measured by the SNOT-22 score. Furthermore, there was an overall decrease in the need for steroid use in patients that were using Nucala vs. placebo. Adverse reactions generally appeared well tolerated (1% systemic reactions, 2% injection site reactions, <1% herpes zoster, 3% immunogencity, >5% oropharyngeal pain and arthralgia). In this study, only patients with a recent previous history of nasal polyp surgery were included.
SYNAPSE trial showing an improvement in a nasal VAS obstruction score and endoscopic nasal polyp score with Nucala vs. placebo.
Han et. al, SYNAPSE, The Lancet, April 16, 2021.
How does Nucala work to treat nasal polyps? It is known that up the majority of patients with recurrent nasal polyps have an eosinophilic driven inflammation. Nucala is known to be an IL-5 inhibitor. IL-5 is a major cytokine responsible for the propagation of eosinophils. By inhibiting IL-5, Nucala decreases blood eosinophil levels. It is theorized that this process is what may result in improvement of symptoms and a decrease in the need for surgery in patients with recurrent nasal polyps who undergo treatment with Nucala.
There are many reasons why I am excited about Nucala. The main reason is that it gives me yet another tool in my arsenal to treat nasal polyps in my patients. I find this medication as an especially useful option in my patients that have recurrent polyps despite previous surgery or have contraindications to undergoing surgery. I believe this medication is also a great option for my nasal polyp patients who also have a concomitant eosinophilic disease such as asthma. Furthermore, Nucala is currently the only biologic medication for nasal polyps that is dosed as a once-monthly injection. This less frequent dosing of a medication means less overall doctor visits and improved patient convenience. I am very excited to offer Nucala as it gives my patients a wider array of options to manage their nasal polyps.