Pharmacological management of nasal polyposis

Nasal polyposis affects nearly 4% of the total population in Western countries, and presents a real challenge to the physician because of its severity, chronicity and recurrence rate. Characteristic histomorphological features of polyps are an eosinophilic inflammation and the destruction of connective tissue; recent research has focused on cytokines, chemokines, growth factors and metalloproteinases to explain these features, as the aetiology of nasal polyposis remains largely unclear. Currently, topical and systemic corticosteroids are first-choice drug therapy approaches, and good evidence from controlled trials is available for topical, but not for systemic, corticosteroid therapy. Surgery is indicated if adequate drug treatment fails, which often needs to be maintained after surgery. There is limited experience for other drugs, such as antihistamines, leukotriene antagonists and frusemide (furosemide), which may be added to corticosteroid therapy in selected patients. Aspirin (acetylsalicylic acid) desensitisation may be a therapeutic option for patients who do not respond to corticosteroids or surgery. Recently, antibiotics such as macrolides have been suggested to have therapeutic activity based on their anti-inflammatory properties but large-scale controlled trials are lacking. New approaches are currently evolving, specifically targeting eosinophilic recruitment (chemokine receptor 3, eotaxin) and inflammation (interleukin-4, -5, -13), immunoglobulin-E, or tissue remodeling by reducing the activity of metalloproteinases. This review summarises current knowledge on pathogenesis as well as established and future approaches in the pharmacological management of bilateral eosinophilic nasal polyposis.