Steroid-Sparing Effects of Biologics in Chronic Rhinosinusitis with Nasal Polyps: Systematic Review and A Meta-Analysis of Randomized Controlled Trials

Abstract

Background

Chronic rhinosinusitis with nasal polyps (CRSwNP) presents significant management challenges, largely due to reliance on systemic corticosteroids (SCS) for symptom control. Advances in biologic therapies targeting type 2 inflammation have shown promise in reducing polyp burden, improving symptoms, and decreasing the need for SCSs and surgery.

Objective

This systematic review and meta-analysis compare the steroid-sparing efficacy of biologics and safety with other biologics or standard care in CRSwNP. Key outcomes include reducing SCS Use and drug safety.

Methods

We searched PubMed, Embase, Cochrane Library, Scopus, and the Web of Science. We included randomized controlled trials (RCTs) comparing biologics versus placebo/standard care in adults with CRSwNP. The primary outcomes were SCS reduction and safety. Meta-analyses, which use a statistical method called random effects models, were employed.

Results

This meta-analysis of seven RCTs (n = 3097) revealed that biologic therapies significantly reduce SCS use in CRSwNP patients (pooled proportion: 20.9%, 95% CI: 8.4%-37.0%), though with substantial heterogeneity (I² = 98.3%). Trial-level predictors included control-arm safety profiles (higher serious adverse events (SAEs) reduced treatment effects) [odds ratio (OR) 0.70]. In contrast, placebo-arm SAEs enhanced them [OR 1.81]) and sample size (larger trials showed diluted responses [OR 0.993 per patient]). These results highlight the role of trial design and baseline patient risk in determining the interest of the results. They further highlight the possibility for individualized strategies in terms of treatment and call for more in-depth studies with patient-level data to refine the steroid-sparing therapeutic strategy, providing an impetus for future work in this area.

Conclusions

The biologics, specifically dupilumab, represent a paradigm shift in treating CRSwNP, significantly decreasing the burden of SCS—their consistent safety and efficacy support integration into treatment algorithms for severe cases.