Dual clinical remission in severe asthma and chronic rhinosinusitis with nasal polyps: a comparative review of biologic therapies.

INTRODUCTION

Severe asthma and chronic rhinosinusitis with nasal polyps (CRSwNP) are frequent comorbidities driven by common Type 2 inflammatory pathways. While biologics target both conditions, a standardized definition for 'dual clinical remission' is lacking. This review evaluates the comparative efficacy of current biologics to propose a unified treatment strategy.

AREAS COVERED: We reviewed pivotal phase 3 and 4 trials (including SINUS-52, SYNAPSE, OSTRO, WAYPOINT, and the head-to-head EVEREST trial) evaluating dupilumab, mepolizumab, benralizumab, omalizumab, and tezepelumab. We analyzed outcomes regarding asthma control, nasal polyp reduction, and olfactory recovery. A new composite definition for dual remission - combining zero exacerbations/oral corticosteroids use with clinically meaningful sinonasal improvement - is proposed.

EXPERT OPINION: Achieving dual remission requires a biomarker-guided hierarchy. Dupilumab demonstrates superior efficacy in the 'sinonasal-dominant' phenotype, particularly for olfactory restoration, while anti-IL-5 agents are preferable for the 'exacerbation-dominant' eosinophilic phenotype. Emerging data from the WAYPOINT trial suggests tezepelumab (anti-TSLP) as a potent option for broad epithelial blockade. We advocate moving beyond isolated disease control toward a stratified 'United Airway' remission target guided by fractional exhaled nitric oxide, blood eosinophils, and immunoglobulin E levels.