Cheryl Martin (Host): Welcome to MDCast by Tampa General Hospital, a go-to listening location for specialized physician-to-physician content and a valuable learning tool for world-class health care. I'm Cheryl Martin. On today's episode, the latest updates on the treatment of nasal polyps and the emerging role of biologics.

Our expert, Dr. Mark Tabor. He's the Chief of Rhinology and Endoscopic Skull Base Surgery at the University of South Florida. Dr. Tabor specializes in complex sinus and nasal disease. He also directs the Sinonasal Malignancy Program at USF and Tampa General Hospital. Dr. Tabor, thanks for coming on.

Mark Tabor, MD: Well, thanks for having me.

Host: First, tell us how the treatment paradigm for chronic rhinosinusitis with nasal polyps evolved over the past few years, and what are the most impactful updates clinicians should be aware of today?

Mark Tabor, MD: Well, chronic sinusitis with nasal polyps is a relatively common problem, and what's changed over the past, say, five or six years or so is the advent of new medications called biologics. These are injectable medications, and they act to calm down parts of our immune system that are overactive and causing these polyps to form.

So in the past, we had surgery and we had steroid medication, and that was it. And both have their negatives and risks associated with them. So, biologics has been a game-changer because now we finally have a precision medicine that helps control this difficult problem.

Host: What factors should guide clinicians when deciding between continued conventional therapy, revision surgery, or initiating biologic treatments in patients with recurrent or refractory nasal polyps?

Mark Tabor, MD: Well, I think if somebody has we call comorbidities, for example, if you're somebody who has recurrent or bad nasal polyps, but you also have severe asthma, just doing surgery to remove the nasal polyps is not going to help your asthma. So, asthma and nasal polyps have very similar behind-the-scenes mechanisms going on.

So, if somebody has what we call comorbidities, meaning not just nasal polyps, but other types of related conditions such as difficult-to-control asthma or eczema, those would be a reason we'd think about using a biologic instead of conventional therapy such as repeated surgeries or steroid use.

Host: Please discuss the differences among currently available biologics for nasal polyps in terms of mechanism of action, patient selection, and real-world effectiveness.

Mark Tabor, MD: Sure. Well, in the United States, as of today, there are four different biologic drugs available that are indicated for nasal polyps. The earliest one, the first one we had was something called omalizumab or Xolair, and that blocks something called IgE, immunoglobulin E, and that's primarily found in allergic conditions. That was our first drug we had. It's probably our least effective of all of the biologics, but it's been out quite a while. It's safe, but we don't use it too much anymore because there are more effective medications. There's another drug called Nucala or mepolizumab that binds and blocks something called IL-5. Pretty effective, but probably on the grand scale is probably the lowest number two. Next would be what's called dupilumab or Dupixent. This has kind of been our workhorse, our go-to drug in the last maybe six years. That blocks some chemicals called cytokines IL-4 and IL-13. That drug works really well. It's an injectable that's given every two weeks. You can give it to yourself at home, and it shrinks the polyps remarkably in some cases. It helps improve nasal congestion. It makes it easier to breathe through your nose. And most importantly, it helps your sense of smell tremendously. Pretty safe drug.

And then, the newest one is what's called Tezspire. And Tezspire is the fourth drug we have that's also an injectable that's given once a month, and also very effective in some clinical trials. we've seen dramatic reduction in polyp size, dramatic improvement in sense of smell, and dramatic improvement in the ability to breathe through your nose.

Host: Dr. Tabor, what are the practical challenges and considerations such as cost, duration of therapy, monitoring, and adherence when incorporating biologics into routine clinical practice?

Mark Tabor, MD: That's kind of a long question. So, maybe we could take each part.

Host: Okay. Great.

Mark Tabor, MD: I'm not going to remember each one.

Host: Okay. Cost?

Mark Tabor, MD: So as far as cost goes, these drugs are expensive. They're injectables. They range somewhere $20,000, $30,000 a year, is what they cost. They are indicated—if you meet the criteria. If you have bad nasal polyps or recurrent nasal polyps and you meet the criteria and you have health insurance, the pharmacy benefit will pay for these drugs. So, especially if you have commercial insurance, most people have very little out-of-pocket cost if the drug is approved by their respective insurance company.

Certainly, if you don't have a prescription benefit plan, it's going to be a very high out-of-pocket cost. If your insurance covers it, great, you don't have much out-of-pocket cost. If your insurance doesn't cover it, the out-of-pocket cost can be tremendous.

Host: So, it's best to check that in advance.

Mark Tabor, MD: Sure. Yes.

Host: Duration of therapy.

Mark Tabor, MD: So, an excellent question. As of 2026, right now, if somebody asks, "How long am I going to be on this medication?" The most honest answer I can give is long-term. So, these drugs are blocking the specific type of inflammation that causes nasal polyps. So, it's not curing or fixing the problem, it's treating it, right? So if I were to take you off of the medication, the polyps would likely return. So at this stage, the answer to that question is indefinitely. We are constantly coming out with newer, better medications, and we may come out with a more permanent treatment in the future. But as of today, you would be on the medication indefinitely.

Host: Monitoring.

Mark Tabor, MD: Also great question. This is what we talk about in meetings and conferences and such. Not too much with these drugs. That's the one nice thing about the biologics. They are very safe. They're used in kids as young as six months. There really is no specific type of blood test or monitoring that we have to do.

Typically, I see a patient every six months or once a year, and I look in their nose with a scope that's called a nasal endoscope just to make sure that they're still doing well, make sure the polyps remain at the size we want them to be. But that's about it. There's not too much monitoring when somebody is on this medication. So, it's very easy to use.

Host: Great. And any comments on adherence when incorporating biologics into routine clinical practice?

Mark Tabor, MD: Very well adhered to. So, a lot of our treatments in the past had a lot of side effects. Kind of like one of the biggest ones I can think of was there's a subset of people with nasal polyps that also have severe asthma and allergy to aspirin. We call that aspirin, exacerbated respiratory disease.So, like, sometime we would take those patients and maintain them in high dose of aspirin. We call that aspirin desensitization. The adherence was really a problem because you're taking such high doses of aspirin have a lot of side effects, a lot of stomach problems. If you fall, you can bleed.

If you have to go through surgery, you have to stop the aspirin. The nice thing about the biologics are, as long as you're not having any of the side effects, which we can talk about, they are very well-tolerated. So, adherence has been excellent. And most people feel so much better on these medications, that there's no way they would stop.

Host: So looking ahead, how do you see emerging biologic agents and personalized medicine shaping the future management of nasal polyps?

Mark Tabor, MD: So, as far as future biologics for nasal polyps, there's new drugs constantly coming out. There are oral versions. So right now, they're all injectables. In the future, we'll probably have pill versions that you can take by mouth, just like the weight loss drugs like Ozempic or Zepbound, those types of drugs. You know, there are oral pill versions coming out, which will probably be very popular. Same with these biologics against nasal polyps. So, we will see oral formulations that you don't have to have an injection. We'll see those coming out in the future.

We're also seeing drugs being developed that last a long time. So, there's one being developed that could last potentially up to six months. So, maybe instead of getting a shot every two weeks, you get the shot couple times a year. I think those are probably the biggest as far as formulations and how they're given. And then, as far as personalized medicine goes, yeah, I mean, right now these are a form of personalized medicine.So, our old way of treating nasal polyps was either do surgery and cut them out or hit you with this really high dose of steroids, and that's very non-personalized, because it's kind of a shotgun approach of just throwing steroids at you. So with the biologics, we can block little molecular components in our inflammatory system.

So, it's much more precise, much more personalized. So, I think we're going to come out with more and more tests that we can look at an individual's sort of genetic predisposition and figure out what exactly is the chemical abnormality going on with our immune system, and we can target those with these small molecules like biologics. And our drugs will get more and more focused and have less side effects as they get more precise

Host: Dr. Mark Tabor, thank you so much for this update. Extremely informative, and I'm sure very encouraging to those who are facing and dealing with nasal polyps. Thank you so much.

Mark Tabor, MD: Yes, my pleasure to speak with you today. Thank you.

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