Utilization of Corticosteroid Delivery Systems for Treatment of Nasal Polyposis - Episode 12
A multidisciplinary panel discusses the role of EDU-FLU in their individual practices.
Anju Peters, MD: Let's move on from these studies to how you see a role for exhalation delivery systems fluticasone in your clinical practice. Naveen, you mentioned that you'd started a couple weeks after surgery. How about in your regular clinic setting where you're seeing patients who may have had surgery a while ago, or may never have had surgery, and then we'll go from you to both Dareen as well as Drew.
Naveen Bhandarkar, MD: We were talking about post-surgery use, but honestly, the role of exhalation delivery fluticasone based on the data can strictly be considered even before surgery. And if we focus on the data and the trials, specifically with what we saw with respect to polyp production, the curve supports certain numbers and percentages that we see as outcomes in the study. But if you look at the shape of the curve there's a gradual reduction over time in the average polyp score in the population of patients, and those are patients those of which did not have prior surgery and mixed with those who did have prior surgery. I really see a role for this in both the preoperative and post operative settings and based on the clinical trials maintenance of that therapy over time is important, and in my opinion it's independent of the decision whether to operate or not.
Anju Peters, MD: That makes sense. how about you Drew, where do you see EDS-FLU in your practice?
Andrew White, MD: I'll first just start by saying it's been very valuable, and I find it very useful in a lot of patients and one of the things that doesn't come across in some of the treatment guidelines is not all patients are coming to us with a nose that's completely full of polyps, and we're just deciding should we do surgery or should we do medicine. They're coming in in this varying levels of a continuum somewhere between there. So, some patients may have had surgery in the past, they're having some recurrence of symptoms. They're not in a place where they need another surgery, but they're having a lot of symptoms, and there's a lot of value to having some medical ways to try to tackle where these patients are at the same time as we're working with our ENT colleagues as to whether they're surgical candidates. For me this is a very easy step up in therapy. After maybe my first visit with them, we do some investigation and get them started on a therapy and then this is really something, right out of the gate I want to see how they are responding to. I would say it's been an invaluable addition to what I have to offer as a sinus doctor.
Naveen Bhandarkar, MD: Dr Peters do you mind if I mention one more thing?
Anju Peters, MD: Absolutely. Please do.
Naveen Bhandarkar, MD: I thought more about what Drew was saying, and it's important to mention one thing in terms of our algorithm. He mentioned the important about step up and it highlights the key importance that I failed to mention in my initial discussion on the role of exhalation release steroid. It's been a very important addition to our addition armamentarium for our treatment of nasal polyps because before we had this, I’d be operating we as a otolaryngologists could be operating on nasal spray failures, but now that we have this and we have data about its delivery and its efficacy in those patients who have not had surgery, which we saw in the trials. I would now see that in my practice at least, I'm operating on EDS fluticasone failures instead of nasal steroid spray failures, and I would imagine a lot of otolaryngologists, if they're not familiar with this yet, will do the same once they are.
Anju Peters, MD: In terms of step up, like before if someone doesn't need it for their comorbidities before I would consider a biologic, I would start EDS fluid in my practice. Like you said Drew, it's just one more thing. How about you Dareen? How do you see it in your practice?
Dareen Siri, MD, FAAAAI, FACAAI: All of you have stated it well. I tend to lean into things that are based on data, clinical trials. Previously the I was super in love with the steroid rinses with steroids implanted in them, or what I call steroid embedded nasal rinses because you get both the rinse and the steroid. I think long term for many of our patients that it became cumbersome, and like I said we have a tendency towards doing the least interventional as possible. Many patients just didn't sustain that. It was a little bit difficult to get. Maybe there was a cost issue. Maybe it wasn't ubiquitous, and the fact that we now have a medication that is more ubiquitous, much easier to get, and has been reinforced with clinical trials. We know the safety outcomes. We know the efficacy is really something that has been very valuable for my practice, rather than do something kind of shooting from the hip. And something that patients can sustain over time. That's really helpful, and I love the fact that you guys talked about pre-interventional, para-interventional, post-interventional because there is a wall, and we know the inflammation is going to be there for most patients. For most patients that is an underlying issue, and what I love about using cortical steroids topically, besides reducing the risk of systemic cortical steroids, is that whether they are–the majority of them I think we are finding out that those are typically teach to driven, but there is a subset that are not GH2 driven, and cortical steroids will work in both sets, and are helpful with the exception of some severe cases cystic fibrosis, or AFS, or things like that. We know at least the application of this we don't have to be too much about their active physiology whether they are GH1 or GH2 because we do know that steroids do work.
Anju Peters, MD: Thank you very much.
Transcript edited for clarity