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For a comparatively short piece, this article manages to pack in a lot of important information about a complex emerging area of rhinology – immunologically targeted therapy (biologics). Immunologically targeted therapy is a rapidly progressing and expanding domain which is already making big changes to treatment in a range of disease areas. Given the inroads that such treatments are now making into ENT, such an ‘update’ review is very timely. A basic overview of the relevant pathophysiology/immunological processes is given, including the relative roles of T-helper type 1(Th-1), Th-2 and Th-17 type responses, their associated cytokines and examples of some diseases with similar immune profiles. Some of the key current biologic treatments in the field are discussed, including IL-4 receptor-alpha (Rα) subunit blockade with dupilumab, IL-5 and IL-5Rα blockade, and IgE blockade with omalizumab. Dupilumab is reported to have achieved statistically significant reductions in endoscopic nasal polyp score, SNOT-22 score and serum IgE in a randomised placebo-controlled trial with 30 patients in each arm. Both IL-5 (reslisumab and mepolizumab) and IL-5 Rα blockade (benralizumab) are discussed. Although mepolizumab appeared to reduce the need for surgery in CRSwNP in a randomised controlled trial, outcomes appear mixed for IL-5 pathway blockade overall in CRS. Data from a reslizumab trial is reported to indicate that (similar to studies of IL-5 blockade in other diseases) patients with a higher baseline eosinophil count may respond better to IL-5 blockade. Omalizumab data is ambiguous in the paper due to a grammatical error, but reference to the original article shows that this achieved a significant reduction in nasal endoscopic polyp scores. A discussion is also made of current cost concerns and lack of robust cost-benefit data, as well as future directions in the field, including the current lack of predictive biomarkers for response to therapy. Overall, worth a look for the busy ENT surgeon in search of a quick update in the field.

Updates on current evidence for biologics in chronic rhinosinusitis.
Nasta MS, Chatzinakis VA, Georgalas CC.
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Matthew Coates

Freeman Hospital, Newcastle-Upon-Tyne, UK.

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