Utilization of Corticosteroid Delivery Systems for Treatment of Nasal Polyposis - Episode 13
Drs Anju Peters, Naveen Bhandarkar, Andrew White, and Dareen Siri discuss their approach to changing treatment for patients with chronic rhinosinusitis either with or without nasal polyps.
Anju Peters, MD: Let's move on to our next segment, which is switching treatments from cortical steroids to role of biologics in CRS with nasal polyps. Let's start with you Drew, what would prompt you to change treatment, switch therapies for your patients either with or without nasal polyps?
Andrew White, MD: I would say that the most compelling piece of information is how the patient feels. We don't care about as much of how their CAT scan looks or even necessarily their nasal exam, a lot of it's being driven by their symptom burden. I do find patients sometimes who have polyps and aren't overly bothered by it, we don't need to step up their therapy. But it's the patient that comes back and saying, " I'm still having lots of congestion. I still don't have a sense of smell." So, that's a big part of what would prompt me to change. The other things would be if a patient progresses to the point where they need surgery again, that's sort of probably a failure of medical management as they need to keep going back to the operating room. And then I think the other things would be thinking about comorbidities, so in a sinus disease patient who's asthmas still out of control despite a lot of good topical therapy to the sinuses. We may need to think about going in a different direction. That's how I would approach that question.
Anju Peters, MD: Do you guys have anything to add to that Naveen or Dareen?
Naveen Bhandarkar, MD: I can go first. I like what Drew said about the decision to consider surgery, and I agree completely that as otolaryngologists we should be thinking about the symptoms and the patients clinical condition rather than the objective presence of inflammation or polyps, because a lot of times, especially in these very difficult to treat patients for recalcitrant patients we never really can achieve a normal CT scan, or even a normal physical examine or endoscopy, and I agree in mind the decision to operate is based on not the persistence of polyps, but a persistence, or inadequate response of their symptoms to medication. Maybe considering some of those co-morbid conditions as well, including their asthma status. When it comes to topical steroids, I may try different ones in the initial setting, but a lot of times in my practice, especially at a tertiary care center, people have been on these things already because at least 3 of them are available over the counter, I don't see a role for switching topical steroids. And then generally speaking, at that point I would try exhalation delivery fluticasone, and if that's not achieving an adequate response, at that point theirs not a lot of switching that I do. I know that topical steroid irrigations are an option, but to me as a non-FDA or aka off label therapy, I generally don't try that before surgery, and we have pretty good data that tell us that these irrigations don't penetrate the sinuses unless the patients had surgery. After surgery it's kind of the same thing, steroids are sort of in one general bucket, and I'm interested to hear what we all say when we talk about biologics and switching therapy there because those have a little bit more certain variability in how they might work in different patients.
Anju Peters, MD: Anything to add to that Dareen?
Dareen Siri, MD, FAAAAI, FACAAI: It's great that we're talking about these patients in this context because it's not necessarily step wise and linear, and just like Drew was saying earlier, this continuum of patients, that they will wax and wane in terms of their disease, and I have seen patients when I do endoscopy with very small polypoid changes and they have significant symptoms, and some people with a huge burden and they're not complaining. It is important to think individual and context in each individual patient, and in addition to that, to think that it doesn't have to be add a step, wait 3 months, add a step, wait another 3 months, and kind of like Naveen said, in parallel, we can be thinking about applying these therapies while we're considering if this a significantly burdened patient. Should we consider other therapies along with it?
Transcript edited for clarity