Comparative efficacy and safety of monoclonal antibodies and aspirin desensitization for chronic rhinosinusitis with nasal polyposis: a systematic review and network meta-analysis

ABSTRACT

BACKGROUND

Chronic rhinosinusitis with nasal polyposis (CRSwNP) is an inflammatory condition of the upper airways. Optimal management is unclear.

OBJECTIVE

To compare the effects of monoclonal antibodies and ASA desensitization (ASA-D) for treatment of CRSwNP.

METHODS

We searched MEDLINE, EMBASE, CENTRAL, ICTRP, FDA and EMA databases from inception to Aug 4, 2021 for RCTs comparing the effects of monoclonal antibodies and ASA-D for CRSwNP. We conducted network meta-analysis (NMA) of sinusitis symptoms, heath-related quality of life (HRQoL), rescue oral corticosteroids and surgery, endoscopic and radiologic scores, and adverse events. We used the GRADE approach to assess certainty of evidence. PROSPERO CRD42020177334.

RESULTS

29 RCTs evaluating 8 treatments (n=3461) were included in the NMA. Compared to placebo, moderate-high certainty evidence showed that HRQoL (SNOT-22) improved with dupilumab (MD -19.91 [95%CI -22.50, -17.32]), omalizumab (MD -16.09 [95%CI -19.88, -12.30]), mepolizumab (MD -12.89 [95%CI -16.58, -9.19], ASA-D (MD -10.61 [95% CI -14.51, -6.71]) and benralizumab (MD -7.68 [95%CI -12.09, -3.27]). The risk of rescue nasal polyp surgery likely decreased with dupilumab (RD -16.35% [95%CI -18.13, -13.48]), omalizumab (RD -7.40% [95%CI -11.04, -2.43]), mepolizumab (RD -12.33% [95%CI -15.56, -7.22]) and ASA-D (RD -16.00% [95%CI -19.79, 0.21]; all moderate certainty). Comparisons among agents show with moderate-high certainty that dupilumab ranks among the most beneficial for 7 of 7 outcomes, omalizumab for 2/7, mepolizumab for 1/7 and ASA-D for 1/7.

CONCLUSIONS

Multiple biologics and ASA-D credibly improve patient-important outcomes, with clinically important differences in effects among agents, and dupilumab uniquely ranking among the most beneficial for all outcomes studied.