Chronic Rhinosinusitis with Nasal Polyps (CRSwNP): A Shared Decision-Making Approach for Patients and Providers (Recording)

This Webinar was recorded on March 12, 2026

Do you experience ongoing sinus symptoms such as nasal congestion, facial pressure, sinus pain, or loss of smell? If these symptoms don’t improve, they may be caused by nasal polyps or chronic rhinosinusitis with nasal polyps (CRSwNP), a chronic inflammatory sinus condition that can significantly affect quality of life. We invite patients and caregivers to join an upcoming educational webinar on nasal polyps and CRSwNP, designed to raise awareness, improve understanding, and empower individuals to take an active role in managing their condition.

Our speakers:

This patient-focused webinar brings together both lived experience and medical expertise:

• Rhonda Nelson will share her personal experience living with nasal polyps, including daily challenges, diagnosis, and navigating treatment. Rhonda was diagnosed with Aspirin-Exacerbated Respiratory Disease (AERD) in 2002 when she was 33 years old. As a patient advocate, she is dedicated to raising awareness of AERD, a condition that involves asthma, nasal polyps, and sensitivity to aspirin, and providing support for patients. 
• Andrew White, MD, FAAAAI, FACAAI, will explain nasal polyps and CRSwNP in clear, easy-to-understand terms and offer practical management tips. As an allergist and immunologist, Dr. Andrew White treats all types of allergic conditions, as well as those arising from immune system deficiencies. He frequently sees patients with asthma, hay fever, eczema, food allergies, skin allergies, and hives. Additionally, he diagnoses and treats immune deficiencies such as common variable immunodeficiency (CVID) and various other conditions that may increase the risk of infection. He also treats patients with chronic sinusitis and nasal polyposis. Aspirin-exacerbated respiratory disease (AERD), also known as Samter’s Syndrome, is another key area of focus.

Key Learning Topics

Participants can expect to gain a better understanding of:

• Common symptoms of nasal polyps and CRSwNP
• How chronic sinus inflammation affects breathing, sleep, and overall health
• Available treatments for nasal polyps, including medical and surgical approaches
• The importance of ongoing management and follow-up care
• How to talk with your healthcare provider and ask the right questions

CE is not available for this webinar.

Special thanks to Sanofi-Regeneron, AstraZeneca, and Amgen for sponsoring this educational campaign.

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Transcript: While this transcript is believed to be accurate, errors sometimes occur. It remains your responsibility to evaluate the accuracy and completeness of the information in this transcript. This transcript is not intended to substitute for professional medical advice.

Ruthie: Good afternoon, everyone. Thank you for joining us. I will wait just a minute to let everyone come in and get settled. We will start here in a few seconds. All right. Thank you again everyone for joining us today. I am the education program manager here at the Allergy and Asthma Network. We thank you for joining of Chronic Rhinosinusitis with Nasal Polyps: A Shared Decision-Making Approach for Patients and Providers. We have a great session planned today with a physician presenter and patient. A few notes. Everyone will be on mute to minimize distractions and noise. Today’s session is being recorded and will be available on our website within a few days in case you would like to revisit or share with family and friends. This webinar will last one hour and include time for questions and answers at the end. Feel free to submit questions through the Q&A box at the bottom of your screen. Someone from our team is managed during chat should you have or technical difficulties or have any questions throughout the webinar. You will receive a follow-up email in a couple of days with additional resources as well as a link to download your certificate of attendance. I would like to give a special thanks to our sponsors for sponsoring this educational campaign, AstraZeneca and AmGen. Without them, this presentation will not be possible. Let’s dive in, living with Chronic Rhinosinusitis and Nasal Polyps can impact quality of life and managing requires collaboration between patients and their health providers. Today’s program will highlight the importance of shared decision-making and developing individual treatment plans. We will begin by hearing directly from a patient who will share their personal experience living with Chronic Rhinosinusitis with Nasal Polyps followed by clinical insight and approaches to care and treatment options to promote shared decision-making. I would like to introduce our first speaker, Rhonda Nelson. Rhonda will share her journey with Nasal Polyps concluding challenges, paths to diagnosis and navigating treatment. Rhonda was diagnosed with exacerbated respiratory disease in 2002 at the age of 33. As a patient advocate she is dedicated to raising awareness about AERD, a condition commonly characterized by asthma, Nasal Polyps and sensitivity to asthma. She is supporting others living with the disease. With that, I will turn it over to you for you to share your story.

Rhonda: thanks so much for having me. I will start where most patients start and that is with the symptoms. For me, this began in my early 30’s and it really did take a couple of years to get a diagnosis of chronic CRS with Nasal Polyps and also my AERD diagnosis. How it started to me was with what I assumed was a cold. It was not really dramatic. It was constant. Every single day I was congested, my head felt full and what I call — thought were occasional symptoms or seasonal symptoms really became every single day symptoms for me. What made it more confusing and the reason I did not assume it was something other than a cold was because I had never really experienced seasonal allergies. I had never been diagnosed with asthma as a child. This all felt really new to me and really unexpected. There was pressure behind my eyes, just a dull, persistent feeling. Headaches that never really fully resolved. The constant congestion, the constant post drip and then what led into frequent sinus infections. My times were the hardest for me as I would wake up with uncontrollable coughing, wheezing and gasping for air. 

Sometimes it would take hours to get that under control. And night after night was this same cycle. Sneezing fits that would come in waves. I would sneeze dozens of times, over and over again. The coughing and wheezing was really unbearable. Every morning I woke up congested. Every night I struggled to breathe clearly. Lying down made it worse. Sleep was rarely restorative. I would wake up multiple times throughout the night. I never really felt rested. Doing daily exercise, I noticed that I would become winded faster than I really should have been. And I had a constant foggy feeling. Always tired and just not myself. My husband and I travel frequently and flights would almost always guarantee a flare. The pressure changes and dry air intensified everything. Daytime for me looked like mouth breathing, constant tissues, fatigue, irritability and brain fog. Then the one thing that slowly started to come into play was my sense of smell faded. At first it was really subtle. 

Then one morning I realized I could not smell my coffee. I cannot smell food cooking. I realized I could not smell smoke. That is when things really changed for me because in some ways smell is safety. It is also pleasurable. It is really sad when you cannot smell the things that make you happy. It is also a connection. This is really another turning point for me that was really alarming. I was trying to connect the dots. Months after months of these systems — symptoms getting no relief with over-the-counter meds, I realized this was not just seasonal allergies or a cold. But I still did not understand what it was and neither did the doctors I had been seeing. I begin adjusting my life grounded and I adapted. More tissues, more nasal sprays, more fatigued and really pushing through. 

What I have learned is when symptoms become constant instead of an occasional happening, that is a signal that there is something wrong and those symptoms began shaping my life and my schedule. That is not an inconvenience anymore. That is really impactful on the way you live. The part of the story that people don’t always talk about is how you feel when people say it is just seasonal allergies or it is just asthma. I stopped enjoying food the same way. I stopped fully trusting my body. I became hyper aware of my breathing. I felt really self-conscious about constant congestion and always needing to have the tissue. I also felt cautious about stepping away in certain circumstances to manage the symptoms. 

There were moments that I really felt dismissed. Again, friends in family saying it is just allergies or it is just allergies or asthma. Sometimes even filling dismissed in clinical settings when they would say you just have another sinus infection or it is just allergies. But what I was living felt far bigger than just. I had adjusted my life in ways I didn’t even really recognize until after diagnosis. I carried medications constantly. I plan to travel around flareups. And I was mentally prepared for recurring infections and steroid courses. All of this takes up space in your brain. You are constantly anticipating. You are constantly calculating, how will I feel tomorrow? Will this trip trigger my symptoms? 

Will I sleep tonight? Will my asthma flare? And that mental load is something that patients carry and carry heavily. For a long time I was treated for sinus infection after sinus infection after sinus infection which was with antibiotics and steroidS and nasal sprays. While all of these were temporarily relief, my symptoms came back. I saw multiple specialists over the course of two years. I followed all of the recommendations carefully but no one was initially connecting the dots. Because I have an extra component which is the AERD side of it. I am extremely allergic to aspirin. This through an extra hurdle into my situation. Before I understood what that was, I would take Tylenol. Just trying to manage that sinus pressure and pain and that would invariably set everything off and my symptoms would become worse. Even at times it caused anaphylactic episodes. At the time I still did not understand the connection between the Nasal Polyps, the asthma and the aspirin sensitivity. It took nearly two years for me to get an official diagnosis. And put a name to what the disease was. And that was really a very big turning point and it was a relief as well. Not because everything was suddenly fixed but because for the first time the pattern made sense. I have only had two surgeries to remove my polyps. I say only two because there are many patients that have multiple surgeries. After my first surgery I did have a recurrence of polyps and that required by second surgery. I was desensitized to aspirin. I worked with my team of physicians to find the right combination of medications to control my symptoms. Thanks to new medicines that we have and continuing research, today my management looks very different than it did 25 years ago. I also now and I always will completely avoid incense but I am now able to tolerate Tylenol. For the past six years I have been on a biologic therapy and that has been a big significant part of stabilizing my disease and maintaining the symptoms and managing them really well. In the beginning it was not one single treatment that changed everything. It was diligence. It was finding the right physicians. It was advocating for myself and it was making sure every doctor that I saw for whatever reason understood what AERD was. 

All of this is not just hard on the patient. It is hard on the caregiver as well. The spouse or the family members watching it happen, they see our fatigue. They see our interrupted sleep. They see our frustration and often they are trying to help without fully understanding what is happening. But what gives me hope today is this. We have more awareness. We have a better understanding of the inflammatory pathways driving CRS with Nasal Polyps and AERD. We have targeted therapies that did not exist years ago and we have physicians who are listening more closely and patient communities where we all realize that we are not alone in this journey. Because when you understand what you are living with and you have the right team, it becomes more manageable. It is not necessarily easy, but it is manageable. And that is really a powerful difference. Thanks for having me. I appreciate all the work that AAN and all of the researchers are doing.

Ruthie: Thanks so much, Rhonda. Someone gave you a shout out saying thank you and that their son lives with it as well. Really important to have that perspective especially working on shared decision-making. With that I want to jump into our first poll question. Our first poll, what is your biggest challenge related to Chronic Rhinosinusitis with Nasal Polyps? That can be from a patient perspective or a provider perspective. You all should see that. We have some responses coming in. I will just give it a minute to have as many people participate as possible . All right. A lot of responses coming in as far as difficulty breathing or nasal congestion. The runner-up being recurrence, a big challenge is recurrence after surgery and treatment as well. With the third one coming up as understanding treatment options including the use of biologics. Fall — all really important that hopefully Dr. White will address in his presentation and we hope you’ll all have a better understanding of that. I will let a few more questions come in while I introduce Dr. White. Her second presenter Dr. Andrew White is a board-certified immunologist who treats a wide range of allergic and immune related diseases. His clinical practice includes caring for patients with asthma, food allergies, eczema and other skin related illnesses. He also manages Nasal Polyps with particular expertise in aspirin exacerbated respiratory disease or AERD like Rhonda shared with us. Thank you for being here with us today, Dr. White. I will turn it over to you.

Dr. White: Thank you so much. Thanks, Rhonda. That was very eloquent. The more important part of the talk was hearing your story and less important, what I will have to say. I think we have really underestimated how profound CRS with Nasal Polyps can affect quality of life. There is one quality of life studies or disease severity survey or you can compare diseases to each other to try to see how bad is Nasal Polyps compared to asthma compared to diabetes compared to these various illnesses that we get as humans. Nasal Polyps actually is very similar to the effect on quality of life as Parkinson’s disease. Very profound. You can imagine constantly living with a cold. It just wears you down over time. Thanks for your story, Rhonda. We will talk a little bit today. Part of the goal of today is reviewing shared decision-making which means the conversation you are having in the office with your doctor, deciding what your goal is and what the tools are, that can be used to achieve that goal, that is really a conversation. Some patients are going to talk about biologics. Some patients may be a comprehensive and not want to go that route. 

There are other options. Some patients, that is exactly what they are looking for. There are pros and cons. That is a big part of the conversation. My goal is to give you some of the language and the ways that we think about this in terms of inflammation and how we stratify these different therapies so that they are really well-informed as you have that conversation. Let’s talk about inflammation. We will talk about the need to have more than just the topical therapies and some of the pills. We will talk about what a biologic is and finally this really interesting connection between the nose and the sinuses and the lungs and we view that as one disease. The first question is inflammation. I have this all the time where patients come in and they say I feel inflamed. That is not really a way that doctors think about inflammation as a specific process that is going on in the body that is separate from having pain. There are different ways that our body can be inflamed. If we think about what inflammation really is, it is the fact that our body has been attacked or assaulted by something whether it is a virus. Usually it is an infection but it could be a toxin or a venom. Then it is going to disrupt the body to some extent. In our attempts to get rid of that, think about a bacteria or a virus, we will need to regulate and change how we need to get rid of some of the cells that are dying or get rid of the bacteria. We to do that with a variety of processes that I will go over with you. Not all inflammation is bad. If we get a virus infection, we need to get rid of it. 

Having a fever is helpful. Producing a lot of mucus to trap it and get rid of it is helpful. Short-term information is helpful. We don’t want to get rid of all inflammation. But it is really this long-term inflammation where we run into trouble because it can harm the body. If we cannot turn that off, that is where problems develop. That is exactly what we see here with these polyps. The other thing I get a lot of questions in my practice are people say I have inflammation so I want to go on an anti-inflammatory treatment or I want to treat inflammation. The problem was that inflammation has a host of different ways it behaves in our body. I wanted to create this analogy. If you have a fire in your house, your anti-inflammatory treatment is going to be a fire extinguisher. You want to put out the flame. If you have an ankle sprain, an NSAID might be the appropriate treatment. But if you have a flood in your house, you are not going to reach for a fire extinguisher. Not in a flood. For this situation is the problem is a flood, an autoimmune problem, you might want a biologic or a really strong immune medication. That is the big difference here between these two. Maybe the third reaction could be an allergic reaction. Here you have an external flood. Turning off the water main to your house or using a fire extinguisher is not going to help even though those are good tools for other situations. That is why when we say inflammation, the term is meaningless. We need to talk about what kind of inflammation and what tools we have to block it if that makes sense. 

If we also look at it from an infection standpoint, we need to have different ways of fighting inflammation. We have bacteria. This is a bacteria in the upper left. We have these nasty looking viruses. These are hundreds to thousands -fold smaller than a bacteria. Bacteria live adjacent to ourselves. They infect the cell and change the DNA so that our own cells are creating more viruses. What about parasites or worms? These are bigger than a bacteria . They have multiple cells. A lot of the parts of our immune system that we used to to fight off bacteria don’t work because we don’t have cells big enough to deal with this so we have these different parts of our immune system. This is why all of our inflammation and the immune system is very specific to what its target is. We have a lot of different arms of the immune system. We have t cells, those are kind of like the main conductors. If you don’t have them, you usually cannot survive the first year or two of your life. They are really important for directing the entire response. It is like the conductor of a symphony. 

Then we have cells intended to kill the bacteria. Those are the micro phages on the left. We have other cells to help us with toxins and poison and venom and parasites. These cells are turned on by a variety of chemicals. We will focus more today on the allergy ones because that is relevant. We have IL 4 and IL 13, how are body signals the alarm to fight off this perceived problem. This is what we are dealing with what we are talking about polyps . I am guessing most people on the line either have a family member or they have this themselves. What you can see here in the middle, you have the eyes that you can see, the brain is above that. Underneath the eyes you can see those partially black holes. Those are the openings in the maxillary sinus is behind your cheeks. The very middle of that is your nasal passage. All of that area underneath your eye should all be black. That would be air. That is all of this inflammation and polyps growing down from the sinuses blocking the airway and affecting the ability to smell because it is coming from that area where the smells nerve comes from our brain. You can see the polyp itself on the right coming down out of the sinus. You can see it growing around the normal tissue, the normal part of her nose and the polyps should not be there. The polyp itself is not the cause of the problem. 

It is more of a symptom of the underlying inflation. For more information you have, the more polyp you grow and if you cannot control the inflammation, the polyp is going to come back. That is why repeated surgery is not always a good choice because you are not really addressing the problem of inflammation. We will talk about type two inflammation. It is a very weird name to call something type two. I will show you in a couple of slides where we dock on that name. That is the type of inflammation. Thinking about my analogy of a flyer — fire or a flood, type two is one of those types. If this is an internal flood then our treatment needs to be dealing with the water main and turning off the water main and not using a fire extinguisher. We will talk about how we target that inflammation. When that kind of inflammation is going bonkers in our nose and sinuses, to get thick mucus, we start to form polyps. 

All of that inflammation is affecting the area where the nerve comes out and for a sense of smell, you start to lose your sense of smell over time. Polyps are actually not dangerous but they are very different than polyps we think about them in the G.I. tract. They do not turn into cancer. They are just the result of information –inflammation. They are found in the nose and sinuses. They don’t affect other parts of the respiratory tract. They really affect congestion and sense of smell. They are not an infection in and of themselves but if you cannot drain something in your body properly, you are more likely to get infected. That is why patients often need to go on antibiotics a lot more often. This is why we think it happens. If people ask why, a lot of my patients say why can we just fix this. We are still doing research to try to understand that the one thing that is happening is you have something that really damages the lining of your respiratory tract, probably a virus but we don’t know that for sure. As Rhonda was saying, she felt like she had a cold and it just never went away. There is actually a chance that is what happened. It was a cold and it damaged the epithelium. Unfortunately for some of us, we cannot repair that. So you are left with this wound in your sinuses and your respiratory tract and over time your body says we have to try to heal this. 

So you start to create some inflammation in a misguided effort to repair it. That is where the problem seems to be broken. Even with all of our therapies right now, once we stop them, the problem pretty soon comes back. The next step is to try to understand how can we permanently heal this area so that it goes back to normal. That is really not really very close to that, to be honest but this is where a lot of the research is focusing on this barrier problem. This is where type two comes from. I am not going to go through all of the exact reasons we ended up calling it type 1, 2 and three but this is how we have landed as an immunology society. Type one is a program of inflammation that involves those cells that you see there, some neutrophils, certain types of T-cells and these other cells and NK cells. They are really identified by the types of chemicals they produce. These are called cytokines. Ultimately that inflammation is going to work best to either get rid of viruses or bacteria that live inside the cell. This is basically trying to kill things that are invading her own cells sin. The next is the type two. 

The main cells that are different here are the mast cells, if we have an allergic reaction to peanuts, it is because we have the mast cells that analyze that. These other cells are also really involved. Many of you with polyps will have higher levels of the e osiniphils in your blood. Some of these are treatment targets for us. If you think about why we have this type of immunity, it is really to help us deal with parasites or venom so if we get stung by a bee, that is our body’s attempt to try to neutralize that toxin. Finally, type three, we will not talk about this but this is looking at a different set of invasions. Fungus and bigger bacteria, strep infections or staph infection’s, those are going to be dealing with this type three immunity. I’m going to ask this question and then I will have Ruthie give us the answer. If you can answer this, our poll question number two, have you experienced recurring Nasal Polyps? Please answer and then I will let Ruthie give us the answer.

Rhonda: We might have shown you a couple of other questions. Feel free to answer question number one if you did not earlier and look toward answering number two. We have some responses coming in. Have you ever experienced Nasal Polyps that returned after treatment? Right now we have about 38% saying yes. We have a good amount of health professionals here so we have that as an option as well. They are here from their clinical standpoint. We have 14% saying no, no issues with recurring Nasal Polyps. About five people so far saying — 5% saying they are not sure. The yes has gone up to 33% now.

Dr. White: Very good. That is really the problem here. If you just get surgery to remove these, there is a pretty high percentage of patients where they will gradually have them return. In some situations they return quickly within six months. Other times it can be as long as a decade. That is why it needs to be pretty individualized for patients. Now we will switch and talk a little bit about treatment. As I think you have heard from Rhonda, a lot of the treatments that we have a really just temporary fixes. Antibiotics, steroid bursts, those are things that are going to get you back to baseline but for most patients the baseline is unacceptable. High recurrence rates, we do not want to have patients get surgery and one year later they are back where they started. That is because there is a core issue of inflammation. So there is a huge need to advance our treatment and that is really where we have seen this huge shift in the last decade in terms of what we have been able to offer and discuss with patients. I’m going to go over with you some of the treatments will the targets that we have. When we looked at that type two immunity, remember, this is where things have gone wonky in the sinuses. We know that these cells, IL four, IL five, IL 13 and IGE, these are all things that we can specifically target. We know that these are involved. We know that targeting them is safe for us. We don’t get very sick if we remove these from the equation. We will talk about how we have done that with some of the biologic therapies going forward. What are biologics? Biologics are targeted medications. 

Think about them as a drone or something that has a very specific target. They are made from living cells. They are actually antibodies. Just like we use antibodies with tetanus if we get a tetanus vaccination, these are created to have a specific target. Because they are antibodies, they cannot be given in a pill form. They have to be given by injection or sometimes intravenous infusions. They are very targeted which makes them very different from a steroid. If we went back to that type one, type two, type three picture, steroids would turn that all down. They are great treatments for inflammation. The problem is they have a whole set of problems that they cause as well. That’s why we don’t want to be using them as our default. We want to really be focusing on targeting them. These targets now are focused on more type two inflammation with the idea that we can prevent polyp regrowth. These are really made in a little bioreactor in a factory where they can figure out what you have on the left is a very specific shape. It is almost like a lock and key. We have to figure out how we can target this one thing and not target everything else just like the key to your front door. It will work in your door but not in any of your neighbors doors. Scientists are able to really target this and figure it out and spend a lot of money and do a lot of experiments to prove that you can safely do that and have it targeted specifically. That is exactly what we see here. You certainly can see side effects from this. 

Removing some part of our immune system is not necessarily going to always be completely harmless but because it is a very specific part, we have a little more of an understanding of what that might end up from a safety standpoint or a side effect standpoint and certainly much safer than a lot of the other bigger immune medications and the pill medications we have had. We will talk briefly about steroids because that is the default and pretty much everybody on the line has had asthma or sinus problems and probably has gotten a steroid burst at some point. That could be a first pack or a shot. Only talk about safety, the systemic versions of that, the pills, the shots, those are very bad for us. They can cause immediate improvement in symptoms but longer-term use of these medicines cause all kinds of problems that can increase risk for diabetes, cause osteoporosis, there are mood changes when you take it. It can affect your vision with cataracts and glaucoma. That is quite a bit different from the topical treatments. If we think about nasal sprays or inhalers or skin creams, those are safe. Very high doses you potentially could get a little bit of these side effects but they are generally considered to be very safe. You can talk to your doctors about that. When we use the word steroids, not if they are systemic, not particularly bad or concerning if you use them topically in the nose as a spray. Unfortunately even one steroid burst can be associated with risks. 

Many of you, may be over the last five years you have started to get the sense from your doctors that they are being stingy with giving systemic steroids and that is because there are increased risks of things like blood clots, fracture, bad infection in the 30 days after one dose of that. This is not like it is a huge risk but when you say what is the average risk of someone walking around of getting a blood clot, very low. It is about 17 fold higher if you are — I’m sorry. About three fold higher if you get a dose of prednisone in that period of 30 days. That is why we really want to make sure we are always using it when it is absolutely necessary or coming up with some other ways to approach the inflammation. The big differences here come steroids like I said. Very quick relief. A lot more risks associated with this. The biologic therapies, these are much more targeted. Far safer than the systemic steroid risks. But they are expensive. They don’t always have great access for patients. A lot of times patients are concerned about taking something on a regular basis for a prolonged period of time which is what the intention is with the biologics. Sometimes maintaining them is also a challenge. Here are the ones that we have. I will not go through this in great detail but we have four Biologics that are now FDA approved for treating CRSwNP. 

They all have other things they can treat. A lot of times your doctors will go over this with you. If you have a problem with hives, that would make two of these drugs a better choice for you than others. This will always factor into the decision and hopefully any doctor is taking this into account. This is where they target. I will not spend a lot of time but just showing you Dupilumab is going to target these two chemical cytokines. Tezepelumab blocks TSLP. Omalizumab is going to target IGE. All right. Let’s see how many of you have asthma and Nasal Polyps, not just Nasal Polyps alone.

Ruthie: If you did not have a chance to answer question one or two, now’s your chance for question three. I have asthma but no Nasal Polyps or no to both. We have about 23% saying I have both. About six people, 6% saying they have Nasal Polyps but not asthma. About 11% saying they have asthma but not Nasal Polyps. Really the majority of our attendees having both. Right now about 36%.

Dr. White: Great. Thanks. That is pretty consistent with medical studies. About 40% to 60% of patients with Nasal Polyps also have asthma. They travel together. We will talk about that in our last couple of minutes. We now think about Nasal Polyps and asthma is really a single disease. If you see a pulmonologist, they will likely be more focused on asthma. EMT surgeons are going to be more focused on Nasal Polyps. But all of us should be thinking about this as a shared pathway of inflammation. They are both driven by type two inflammation a lot of therapies work for both of them. There are some really interesting ways that they are connected that we don’t even really totally understand. For example, if you put a little grass pollen deep in the lungs of a patient with asthma, the next day you can detect that their noses are inflamed more than the day before. The fact that these both occur together, is really manifestations of the same disease. Some things that we try to tell other clinicians are that the things that would predict these diseases are both happening in the same person. Really profound loss of smell. Patients that have really significant problems with nasal congestion, lots of recurring infections. They are ones who will often have problems with their respiratory tract. The opposite is true as well. People who use a lot of inhalers and have very poor asthma control, about one third of them will also have problems with their sinuses. One of the things that we really know and this is in many studies. If you treat the polyps, the asthma often will improve. A lot of patients will tell you that when their sinuses flareup, their asthma does. Or if their sinuses are worsening, their asthma is also much more difficult to control during that time. There are studies that show that just getting sinus surgery alone can temporarily improve asthma. Really interesting how these things are connected. We call this the United airway or the unified airway. This is how we view that these are connected even though the throat is a different part of the respiratory tract. It is not like what is happening in the upper part does not travel down and affect the lower part. Both of these things influence each other. When we are considering a treatment, we really should be thinking through his art treatment going to be able to target all of this type two — is our treatment going to be able to target all of this type two inflammation. That is the main goal of these therapies, to target the entire unified airway. The similarities here, both of these diseases are characterized by much of the same inflammation, the same cytokines . 

If you have looked carefully at that list of the four Biologics in addition to the mall being approved for polyps, they are also all approved for asthma. They work for both. Just to restate that same point, these things are connected. We want our treatment for polyps to also improve asthma. And then this is really how we are doing this disease. We want to consider the treatment from the tip of the nose to the bottom of the lung and treat it all simultaneously. When you are talking with your provider, this is a very personalized approach to care. Not everybody necessarily needs to go on a biologic. Many times we can control this with topical sprays and probably 20% to 30% of patients, a single surgery can really work for a prolonged period of time. We don’t want to neglect that. Patients are just going to have different things that are important for them. 

For some patients, the sense of smell might be the driving factor. For other patients, it is the recurring infection and the need for antibiotics. It might be missing work or other life events. We really want to go through what is most important to you and we have a conversation back-and-forth. Your job as a patient is to advocate for and think through your main goal if you have to prioritize the top three things you really want to see happening. What would be number one? Obviously I will ask a lot about what was tried in the past. If you had surgery a year ago and you are only totally blocked up again, we will not talk about getting another surgery. We will focus on something else. The questions you can ask, what kind of inflammation do I have. There are different ways we think about this. It is almost always going to be type two inflammation. But there are different strengths of that. Patients like Rhonda that have AERD tend to have very aggressive type two inflammation. Other patients, it might be more mixed making it more difficult to treat. Certainly talking about the symptoms you are noticing that her coming back and then very good to ask about what are the pros and cons of a biologic. Are they an option for me? Are they something that we think would really help and are there other things that they can do for me as well if you have other parts of your body being affected by type two inflammation problem. Here is the key take away. 

Nasal Polyps are really the end result of chronic inflammation. But it is a very specific type of inflammation and we need to target that. We can use the topical sprays, we can use certain pill medications and surgery sometimes can help with this. The end result is if those aren’t working, we have these very exciting targeted treatments that can target specific types of type two inflammation. Your goal should be that we keep this under control. Control is going to be defined partly by you. If you feel like your symptoms are not controlled, that is an important conversation to have. Sometimes your doctor might also say you feel OK but I’m not happy with how this is going. Our growing too quickly — polyps are growing too quickly. Things have changed so much in the last decade. It is a really exciting place. Most patients can expect that we can get this under very good control and get quality-of-life back to a very good level. Biologics definitely are some of the most exciting advances that we have in the last, actually since I started practicing 25 years ago. This is not like it is the path that everyone needs to go. Mostly we want you to be aware of it, know what questions to ask and something you can think of as you go forward and talk with your doctor. I will turn it over to Ruthie for the Q&A.

Ruthie: Awesome. Thank you so much, Dr. White. Some awesome information shared. It could not have done it better with Rhonda sharing her story as well. Will take some questions from all of our attendees. I will direct the first one to Rhonda. Rhonda, what challenges did you face when trying to find the right treatments or care for your condition?

Rhonda: It was — because it was many years ago, it was just to find a healthcare professional that would get beyond that seasonal allergy, cold, to put the doyts together and to understand. I guess my frustration — I see my frustration now when I look back. It really was just a matter of — AERD was not well known then. I cannot blame, really. I hate to use that word but I cannot blame physicians because we were all still learning about it. But that was the biggest challenge was to get a definitive diagnosis so that then we could start to try whatever different medications were available and find the right treatment plan.

Ruthie: Thank you for that. Our next question for Dr. white from another clinician. He would like an elaboration and hopefully a better explanation about recurring Chronic Rhinosinusitis with Nasal Polyps with biologics. I believe he is saying an example, aisle 4, 5 is available in our modern medical community.

Dr. White: I guess I don’t know the question in there. There is the decision of who is the patient type eligible for a biologic and in general the recommendations are that this is — you would advance to a biologic after a patient has had recurrence after surgery. We still feel like surgery could be an appropriate treatment and prevent a patient from going on a biologic so we really want to have that be the default for most patients. We don’t have great ways to predict who is going to have early recurrence. Generally the path default is surgery first, good topical therapy, then if you have recurrence, at that point we move on to a biologic. We don’t wait for the patient to be completely measurable and full of polyps. It is just when the writing is on the wall. Then the question could be if you are on a biologic, do you still get recurrence? What do you do? That can definitely happen. Fortunately we do not see that a ton because biologics work quite well. There are certainly a group of patients who do not respond. Sometimes they may need a different target. If you look at the OIGE vs TELP, we don’t have a good way to prevent — predict that. When symptoms are more controlled, we will move over to a different topic. Those are the questions about polyp recurrence. We look for polyp recurrence to find a group we want to start a biologic on. Then we will consider switching.

Ruthie: Another question for you, Dr. white. Someone just sharing about their son’s journey on a biologic. His biologic was interrupted due to changing insurance plans and symptoms and condition was worse and he had another allergic reaction with his skin, etc.. Now he is afraid he will die without the biologic. Have you seen anything with someone who has had a biologic and then come off of them?

Dr. White: Yes. So, the medicines are not studied to look at the post treatment phase or necessarily coming off of them. But in all of the studies that were done there is usually a period of time with the patients are off the therapies. These are usually FDA approved studies. For Dupilumab for example, the patients were on it for six months to a year and then they see what happens when they stop it for a period of time. Majority of patients will have recurrence usually within six months. It seemed like it could be longer for others. Unfortunately that is the expectation, that this will recur. I think the concern about how they will do if they are off of it long-term is valid. There are lots of ways that we tried to get biologics for patients. I would say we would not expect that the person would just not be able to have access to them at all if they have been working. That is an understandable question and concern.

Ruthie: Thank you for answering that. Our next question is for Rhonda. What advice would you give someone who has recently been diagnosed with Chronic Rhinosinusitis and Nasal Polyps or AERD?

Rhonda: Do your research. I always tell people keep a journal of your symptoms. Keep a journal of when you experience flares and really advocate for yourself when you are in front of your team. When you see your physicians, we have a very short window of time and they do not see us every day. The more information you can give when you see your physician about what you are experiencing, about your symptoms, the better communication will allow for you and your medical team to develop an appropriate plan. That has gone a long way from me in working with my group of physicians.

Ruthie: Thank you. There was another question with a follow-up asking how do you advocate for your own health as well? That kind of ties into that response. We have time for one more question. We have had a lot. Let me go through and get one. There is a statement and a question. Dr. White, with all of the available biologics, improvement in Chronic Rhinosinusitis with Nasal Polyps symptoms is 20% to 50%. Are we looking at the right path of physiology with Chronic Rhinosinusitis with Nasal Polyps ?

Dr. White: I don’t know if I would say that we only get 20% to 50% improvement. There are certainly non-responders and some of the biologics probably work better than others. There is a valid concern there that not all polyps and asthma are type two. Of those patients are challenging because our target is missing the mark. We don’t have good ways to figure that out before we start treatment. We start treatment because we expect the medicines will work and if they don’t, then we do wonder do they have a tight three process that is causing polyps. If they have a type three process and we are giving them a type two drug, it is likely not going to work very well. That is probably the next phase of where we need to go in studying this disease. Everyone is clamoring for some sort of test that we can do on the front end because it would be much better if we could do a test and it turns out we don’t have type two. We should work to reduce this drug. The problem is there is not a drug for these other pathways so we are stuck, you have type two, let’s try that and if that doesn’t work, then we have to come up with a struggle. I would say that the percentage improvement, some of our biologics is much better than 20% to 50%.

Ruthie: Thank you so much for answering that. I know we have several other questions that we were not able to get to. Please remember that this session was recorded and will be available in a couple of days. Hopefully you can review it and watch it and some of our questions were answered throughout the presentation. A special thanks to Rhonda Nelson for joining us and sharing her story and again Dr. White for his wisdom and clear and engaging presentation. We really hope that everyone had a great take away from today. Please be sure to register for our next webinar on severe asthma. You will receive a link to this recording as well as supplemental information and a link to download your certificate of attendance after today and you should get that in a couple of days from Zoom. Please be sure to complete the evaluation at the end of the webinar. Thank you again. From everyone at Allergy and Asthma Network, another thanks to Dr. White and Rhonda Nelson for joining us. We hope everyone has a good afternoon. Bye-