Efficacy of Biologics in NSAID-ERD: United Airways From the Nose to the Bronchi

Nonsteroidal anti-inflammatory drug (NSAID)–exacerbated respiratory disease (NSAID-ERD), the clinical triad of chronic rhinosinusitis with nasal polyps (CRSwNP), asthma, and respiratory reactions to cyclooxygenase 1 inhibitors, is often challenging to manage, with many patients failing first-line therapies for CRSwNP and asthma. There are now 6 biologic medications approved for asthma and/or severe CRSwNP: omalizumab, mepolizumab, reslizumab, benralizumab, dupilumab, and tezepelumab. With the availability of respiratory biologic treatment for both asthma and CRSwNP, clinicians now have a multitude of additional management options for patients with NSAID-ERD. Herein, we review the currently available clinical trial and real-world evidence for biologic efficacy and safety in patients with NSAID-ERD, discuss the mechanisms of biologic therapy specific to NSAID-ERD, and review evidence regarding the use of biologic therapy versus endoscopic sinus surgery for CRSwNP in patients with NSAID-ERD. We propose a management approach for choosing biologic therapy or endoscopic sinus surgery paired with aspirin therapy after desensitization for patients with NSAID-ERD.