Severe, type 2 (T2)–driven chronic rhinosinusitis with nasal polyps (CRSwNP) commonly co-occurs with other T2 inflammation–related conditions such as eosinophilic asthma and aspirin-exacerbated respiratory disease (AERD; Samter’s triad). Its management often lies at the interface of Ear, Nose and Throat (ENT) and Respiratory Medicine. At a symposium organized by the Hong Kong College of Otorhinolaryngologists, three local and international experts shared real-world (RW) insights on multidisciplinary care pathways, as well as the effectiveness and strategic use of biologics with a focus on anti–interleukin (IL)-5 therapy (eg, mepolizumab), in achieving steroid- and surgery-free disease control.
RW insights from Spain
Multicentre study: Improved NPS and symptoms with mepolizumab
A retrospective, observational study of 47 patients with refractory CRSwNP from five hospitals in Valencia reported a significant reduction in nasal polyp size (mean change in nasal polyp score [NPS; 0–8], -2.56; p<0.0001]) after 6 months of mepolizumab treatment. (Figure 1A) [J Clin Med 2025;14;5248]
Moreover, 22-item Sinonasal Outcome Test score (SNOT-22; 0–110) improved across all domains (-25.29 points), translating into quality of life (QoL) gains. “Importantly, patients experienced significant improvements in their most bothersome symptoms [top five SNOT-22 rhinologic improvements: loss of taste/smell, -3; nasal congestion, -3; need to blow nose, -2; runny nose, -2; thick nasal discharge, -2],” reported Dr María Sandra Domínguez-Sosa of Hospital Universitario de Gran Canaria Dr Negrin, Las Palmas de Gran Canaria, Spain. (Figure 1B)
Among those with comorbid asthma, median Asthma Control Test (ACT) score improved by 8 points to 24 at 6 months with mepolizumab, with 84 percent achieving asthma control (ACT ≥20) vs 35 percent at baseline. Significant mean reductions in blood and tissue eosinophil counts (81 and 60 percent, respectively) indicated systemic and local anti-inflammatory control, highlighting mepolizumab’s dual benefits in patients with CRSwNP and asthma.
Single centre experience: Sustained benefit at 2 years
Domínguez-Sosa also shared findings from a retrospective observational study conducted at her centre among 84 patients (median age, 57 years) with treatment-refractory CRSwNP who had severely impaired QoL. At baseline, median blood eosinophil count (BEC) was 325 cells/μL, most patients had uncontrolled asthma (median ACT score, 17), 55 percent of patients had AERD, 88 percent had undergone prior endoscopic sinonasal surgery (ESS), and 92 percent had systemic corticosteroid (SCS) dependence. Median visual analogue scale (VAS)-smell score and VAS-nasal obstruction score were both 10/10. [Front Allergy 2026;7:1710163]
“Mepolizumab significantly improved NPS, VAS overall symptom score, VAS-smell, SNOT-22, ACT, total serum immunoglobulin E [IgE], BEC, and blood neutrophil count [BNC] at 6, 12 and 24 months,” Domínguez-Sosa reported.
“Notably, after 2 years of mepolizumab treatment, 44 percent of patients were classified as super responders based on our study’s modified criteria, and ≥78 percent of patients had good-excellent response by the European Position Paper on Rhinosinusitis and Nasal Polyps/European Forum for Research and Education in Allergy and Airway Diseases [EPOS/ EUFOREA] 2023 standard,” she highlighted. (Table)
Characterizing super responders and validating AI models for future prediction
Compared with non–super-responders, super-responders had higher baseline BECs and BNCs and lower AERD frequency. Cross-validation of these super-responder predictors using four machine learning models found XGBoost to have the best discriminative ability in predicting 2-year super-response to mepolizumab, correctly classifying 43 of 59 patients. BNC, BEC, and AERD were the most influential predictors with the highest mean absolute Shapley Additive Explanations (SHAP) values. [Front Allergy 2026;7:1710163]
“Specifically, high baseline BECs correlated with NPS improvements, and BNCs with sinonasal symptom VAS scores,” noted Domínguez-Sosa. “These pretreatment predictors could refine CRSwNP treatment strategies and facilitate personalized clinical decisions.”
TMH’s Airway Combine Clinic: Effective MDT care
“Our monthly Airway Combine Clinic brings together a multidisciplinary team [MDT] of ENT surgeons, pulmonologists, nurses, pharmacists, and sleep laboratory and day ward staff. It has run for >8 years for patients with obstructive sleep apnoea [OSA]. In 2024, the same MDT expanded its service to CRSwNP patients eligible for biologics [mepolizumab or dupilumab],” said Dr Andrew Chun-Lok Wong of the Department of Otorhinolaryngology, Tuen Mun Hospital (TMH), Hong Kong.
“We use the EPOS/EUFOREA 2023 criteria to determine eligibility for biologics. Patients must have bilateral polyps after ESS or be unfit for surgery, plus ≥3/5 other criteria, one being evidence of T2 inflammation [ie, tissue eosinophils ≥10/hpf, BEC ≥150 cells/μL, or total IgE ≥100 IU/mL],” he continued. [Rhinology 2023;61:194-202]
“We perform detailed pretreatment assessment and manage comorbid asthma. We also coordinate day ward biologic injections and follow-up to assess compliance and monitor adverse events,” reported Wong. “Joint management of CRSwNP and asthma has been very effective. With proper patient selection [those with T2 inflammation], we have seen substantial RW improvements, sometimes better than in clinical trials.” (Case 1)
A future direction is to establish the Hong Kong Eosinophilic-Associated Disease (EAD) MDT, an expert panel including specialists in EAD care, to raise awareness about early EAD diagnosis and promote appropriate cross-specialty referrals for improved patient care.
PWH’s One Airway Clinic: Optimizing patient selection for biologics
“The One Airway Clinic at Prince of Wales Hospital [PWH]/Chinese University of Hong Kong [CUHK] is a combined pulmonologist and rhinologist biologics clinic, collaborating with Queen Elizabeth Hospital, Pamela Youde Nethersole Eastern Hospital and Yan Chai Hospital on a multicentre local data collection initiative,” said Dr David Chun-Man Yeung of PWH and CUHK, Hong Kong.
Biologics are prescribed if patients satisfy the EPOS/EUFOREA criteria. (Case 2) “The CUHK protocol emphasizes capturing baseline symptoms and disease severity for every patient during the pretreatment session, with asthma assessment when relevant, before supervised first injection, counselling, follow-ups and further data collection [at 1, 3, 6 and 12 months, before discharge back to the parent team after 12 months], so response can be assessed, discussed with patients, and used to guide continuation decisions,” highlighted Yeung.
Refining response criteria with local data
“Data from our Multicentre Biologics Review in Hong Kong revealed that minimal clinically important difference [MCID], which reflects the smallest meaningful change perceived by patients, can help determine achievement of therapeutic targets in the presence of uneven response trajectories – for example, earlier improvement in nasal congestion vs slower or less predictable improvement in smell,” reported Yeung.
Additionally, adapting EPOS/ EUFOREA response criteria to local practice might more accurately reflect treatment response. “For example, rescue SCS or ESS is less commonly practised locally than in Western countries, or some patients may have well-controlled asthma before biologics treatment, making two out of five EPOS/ EUFOREA criteria less relevant, in which case the maximum therapeutic targets to be met would be reduced to three or four instead of five where appropriate, and treatment response defined by the percentage of adjusted therapeutic targets reached,” noted Yeung.
Yeung’s group also noted slight differences in response profiles between Asian and Western cohorts, possibly due to mixed endotypes in the Asian population. “We thus embarked on the CUHK Rhinology Endotyping Study 2 years ago, delving into CRSwNP endotyping and translational research,” he said.
Summary
With MDT care, optimized patient selection, and appropriate definition of response, mepolizumab can deliver meaningful and sustained benefits beyond expectation in the challenging management of CRSwNP.
This special report is supported by an education grant from the industry
