Baseline EPOS 2020 eligibility and real-world outcomes of dupilumab in CRSwNP: a longitudinal cohort study

Chronic rhinosinusitis with nasal polyps (CRSwNP) is often a type 2-driven inflammatory disease that markedly impairs quality of life. Dupilumab offers major therapeutic benefit but at high cost, underscoring the need for accurate patient selection. EPOS2020 introduced indication criteria for biologic therapy, yet their real-world predictive validity remains underexplored.

This study screened 224 CRSwNP patients treated with dupilumab between November 2019 and May 2025. Outcomes included Total Polyp Score (TPS), 22-item Sinonasal Outcome Test (SNOT-22), olfactory performance, and serum biomarkers. Patients were stratified into EPOS-eligible and ineligible groups based on EPOS2020 criteria, and responses were evaluated using minimal clinically important difference (MCID) thresholds and EPOS/EUFOREA response criteria. Predictors of adequate response were analyzed with logistic regression, and treatment trajectories with linear mixed-effects models.

EPOS2020 criteria could be assessed in 177 patients, of whom 76 met them at baseline. EPOS-eligible patients achieved greater improvements in TPS, SNOT-22, and olfaction, and were more likely to reach MCID for TPS. EPOS-eligible patients also had higher composite EPOS response scores, although "adequate EUFOREA response" rates did not differ. Non-steroidal anti-inflammatory drug exacerbated respiratory disease independently predicted adequate response, while higher baseline serum IgE was associated with faster improvement trajectories.

EPOS2020 criteria provide an effective framework for dupilumab allocation, although markers of active type 2 inflammation may better predict response than categorical eligibility alone.