Introduction
Chronic rhinosinusitis with nasal polyps (CRSwNP) is a prevalent condition characterised by a significant impact on quality of life and productivity, with frequent recurrence after both medical and surgical treatment(1). Oral corticosteroids are effective at achieving short term symptom improvement(2, 3), but benefit is limited due to the risk of side effects which accrue with repeated use (4). Surgery has been shown to achieve more durable symptomatic benefits (5), but is associated with pain and discomfort, time for recovery, a small but definite risk of serious complications(6), and, based on previous data, more than one in 5 patients will require another surgery within 5 years of follow-up(5). Poor disease control is commonplace, driving the search for alternative treatment strategies.
Monoclonal antibodies (Mabs) are biological treatments that target specific inflammatory mediators or immune cells. Growing understanding of the pathophysiological pathways found in CRSwNP and evidence of efficacy in similar patterns of Type 2 inflammation found in asthma and atopic dermatitis have led to trials evaluating use in CRSwNP. As such therapies are evaluated and are shown to be effective, it will be essential to consider where they should be placed in current treatment pathways for CRSwNP, particularly with respect to the use of corticosteroids and surgeries.
We set out to create Consensus Guidelines, based on current evidence and relative risks of adverse effects and the costs of different treatments, that reflect the views of the British Rhinological Society (BRS) Council on where the use of biologics should be positioned within treatment pathways for CRSwNP, specifically in the setting of the National Health Service (NHS). These guidelines were created in early 2021 and it is anticipated that they will evolve as further evidence accrues and the relative costs and availability of treatments change.