Which Is the Best Biologic for Nasal Polyps: An Updated Network Meta-Analysis.

BACKGROUND

Direct comparative efficacy data for biologics in chronic rhinosinusitis with nasal polyps (CRSwNP) remain limited, particularly for novel agents like tezepelumab, underscoring the need to identify optimal therapies for precision management.

OBJECTIVE

To rank the comparative efficacy and safety of dupilumab, tezepelumab, omalizumab, and mepolizumab versus placebo for CRSwNP using network meta-analysis.

METHODS

PubMed, Embase, Web of Science, and Cochrane Library were searched from inception through April 1, 2025. Randomized controlled trials (RCTs) in adults with CRSwNP comparing biologics against placebo were eligible. PRISMA-NMA guidelines were followed. GRADE methodology was employed for evidence certainty assessment. Two investigators independently extracted data. Fixed-effect model network meta-analysis was performed, with treatments ranked via surface under the cumulative ranking curve (SUCRA). The primary outcomes were Nasal Polyp Score (NPS) and safety metrics (proportion of participants with ≥ 1 adverse event). Secondary outcomes included Sino-Nasal Outcome Test-22 (SNOT-22), University of Pennsylvania Smell Identification Test (UPSIT), and Nasal Congestion Score (NCS).

RESULTS

Thirteen RCTs (n = 2304) evaluating four biologics versus placebo were included. Compared to placebo, NPS was significantly improved by dupilumab (WMD: -2.16, 95% CI [-2.44, -1.89]), omalizumab (WMD: 1.25, 95% CI [-1.52, -0.97]), mepolizumab (WMD: 0.90, 95% CI [-1.19, -0.62]), and tezepelumab (WMD: -1.50, 95% CI [-1.81, -1.19]). Dupilumab ranked first in efficacy outcomes (NPS, SNOT-22, UPSIT, and NCS, SUCRA ≥ 0.900, respectively). Tezepelumab ranked second in NPS (SUCRA: 0.720) and UPSIT (SUCRA: 0.749), while omalizumab ranked first in safety (SUCRA of adverse events: 0.064). GRADE assessments indicated that the certainty of the evidence was predominantly high for these key efficacy comparisons.

CONCLUSIONS

Dupilumab demonstrated the highest efficacy and safety profile. Tezepelumab showed comparable efficacy in NPS with omalizumab.