Utilization of Corticosteroid Delivery Systems for Treatment of Nasal Polyposis - Episode 18
Drs Anju Peters, Naveen Bhandarkar, Andrew White, and Dareen Siri review unmet needs and shared decision making in the treatment of nasal polyposis.
Anju Peters, MD: Drew, what would you think are the biggest challenges or areas of unmet need in treating these patients with CRS with nasal polyps?
Andrew White, MD: There's a lot of areas where there's still questions. I think, Dareen said, this is the age of the sinuses or something like that, you said. You know, we've had such a huge change in what we have, in terms of treatment, and the ways that we think about these patients, it's sort of like exploded in front of us. And that's even created some of the challenges, you know, now we've got all these options, what do we do with them? Some of the biggest challenges that I would say, and I'd be interested if you agree or disagree, but I think you know, defining like, what's our goal and our endpoint for some of these patients, we want them to feel better. But there's other dimensions to it, because these patients have surgical morbidity or you know, needing repeat surgeries, and they've got asthma, and some of them have NSAID sensitivity. What's our goal, and I think it's probably different with an individual patient. That would be one of the challenges is, you know, like when we take an individual patient in front of us, where do we go with them? I think another challenge now is where's the dividing line between medical and surgical therapy. Where do we sort of decide a patient has failed medical therapy and should go through surgery? And I think that's different in different situations, and the patients sometimes show up in our practices in different stages. That's a big challenge and unmet need is knowing where we advise patients in that. And I would say the other big unmet need or area that we need to focus on is, what if we have biomarkers or certain phenotypes of the disease that we can predict a little bit more about outcome or response to therapy. Because right now, it's sort of just view them all under the same lens. And you know, I think we all have different suspicions, maybe about how to interpret some of the biomarkers, but at the end of the day, we need a lot more information. I would say the biggest challenges that I see more from a scientific standpoint in approaching this.
Anju Peters, MD: Yes, that is one of the biggest questions that I feel we need to answer. Like even today, patient ask how long do I stay on these biologics? And I'm like, hmm. I totally agree with you. And you know, any one of you guys could chime in, what do you guys think are the greatest unmet needs for our patients with nasal polyps? And one thing that you mentioned earlier, Naveen, was the shared decision making and I think, Drew, you talked about it a little bit too, do you guys want to talk a little bit about that? We'll start with you, Naveen.
Naveen Bhandarkar, MD: So shared decision making. They're just talking with the patient on these different treatments, because we've gone over a lot of different options that we have available, but I don't think the decision to start one over the other, depending on the circumstances, all that cut and dry. Sometimes one of those might work better for somebody than another. You know, when it comes to implants, for example, they do have a limited duration, and they do have a certain effort involved in terms of placement. That patient must come in for an episode of care where this implant is placed on one or both sides, or in one or more sinuses for that treatment, and then they last certain duration. And then the question is what happens after that? Do we need to potentially repeat that versus considering something that may be longer term? Like certain topical steroids or even, you know, when to consider a biologic? A lot of that is really to do with what each patient's personal preference might be. If all of those treatments may have similar efficacies.
Anju Peters, MD: How about you, Drew? Any comments on unmet needs in terms of CRSsNP?
Andrew White, MD: The things that I think I struggle with, in my practice, you know, some of it is just accessibility of the treatments to the patients. And I recognize that a lot of these therapies have a lot of expense. And that's a frustrating part of our care delivery is that some of the things that we think might work best may not be an option for patients. That's always a consideration. And I think one of the unmet needs. And for some patients, you know, it's the relationship between the allergist and the otolaryngologist, you know, it's still sort of just by definition, they're all in different clinics. And, you know, my dream is to be able to have like a combined clinic where we can all work together. I know that does exist in places, but not where I'm at. But I just think that would be so much better for the patient to just have like, one long visit, and they just sort of all gets hashed out right at the same time. So those are - those would be sort of my things that I think are our areas for improvement.
Anju Peters, MD: How about you, Dareen? Any unmet needs you can think of?
Dareen Siri, MD, FAAAAI, FACAAI: Those are certainly great points, I would invite you to come from sunny, beautiful San Diego to visit us from the Cornfields. Because literally the other day, I sat in with a patient who was on a biological drug, who was also on EDS-FLU in an ENT clinic and talked about the pros and cons with my ENT colleague with the patient. That was cool to be able to do that. And then so in a unique area, of course, we have a lot more space than you do, less traffic. And certainly, I can see that being envisioned, very intimately as well at University of California, Irvine, or even Chicago where you know, they work closely together. It really is great to think about these medications that are coming down the pipeline. But certainly, thinking about some questions that we haven't addressed, such as, what about aspirin desensitization? That was a huge push. Is it safer now with ESP on board or biologics on board? I don't know. Is it effective? Is it still needed? What about other things? Allergy immunotherapy in those patients who do have type 2? Is it effective, needed? Those kinds of questions. I would love to know about these questions. It's some of those, as we are treating the patients. And again, they are complex patients with multiple issues to think about, what about some of these additional therapies that we've offered in the past? How needy are they? Or how needed are they? Those are good questions to address.
Anju Peters, MD: I totally agree. And maybe we could have a session with Drew, just talking about that stuff to us next time.
Transcript edited for clarity