Consensus on the management of united airways disease with type 2 inflammation: a multidisciplinary Delphi study

Abstract

Background Scientific evidence on patients with multimorbid type 2 asthma and chronic rhinosinusitis with nasal polyps (CRSwNP) from a united airways disease (UAD) perspective remains scarce, despite the frequent coexistence of these entities. We aimed to generate expert consensus-based recommendations for the management of UAD patients. Methods Using a two-round Delphi method, Spanish expert allergists, pulmonologists and otolaryngologists expressed their agreement on 32 statements (52 items) on a 9-point Likert scale, classified as appropriate (median 7–9), uncertain (4–6) or inappropriate (1–3). Consensus was considered when at least two-thirds of the panel scored within the range containing the median. Results A panel of 30 experts reached consensus on the appropriateness of 43 out of the 52 (82.7%) items. The usefulness of certain biomarkers (tissue and peripheral blood eosinophil count, serum total IgE, and fraction of exhaled nitric oxide [FeNO]) in the identification and follow-up of type 2 inflammation, and assessment of the response to biologics, were agreed. Some of these biomarkers were also associated with disease severity and/or recurrence after endoscopic sinus surgery (ESS). Consensus was achieved on treatment strategies related to the prescription of anti-IL-4/IL-13 or anti-IgE agents, concomitant treatment with systemic corticosteroids, and combining or switching to biologics with a different mechanism of action, considering a number of UAD clinical scenarios. Conclusion We provide expert-based recommendations to assist in clinical decision-making for the management of patients with multimorbid type 2 asthma and CRSwNP. Specific clinical trials and real-world studies focusing on the single-entity UAD are required to address controversial items.

Pulmonology for the rhinologist

“…Baseline IgE is often also included in the evaluation of a patient's endotype. A consensus study on the management of united airways disease with type 2 inflammation agreed on the usefulness of these biomarkers in the identification, follow-up and assessment of response to biologics [69]. However, IgE level has not been found to be a useful predictor of anti-IgE therapy efficacy [70].…”

Airways Type-2 Related Disorders: Multiorgan, Systemic or Syndemic Disease?

“…Despite the availability of diverse medical and surgical approaches for addressing and treating CRS, the burden of the disease remains significant on epidemiological, economic, and social fronts. Furthermore, the often interconnected nature of CRS with other UA diseases, whether viewed from a pathophysiological or clinical standpoint, has the potential to mutually amplify the burden of both conditions [11]; hence, the distinction between upper and lower airways is artificial, since the upper and lower respiratory tracts are both components of one, "united airway" system [12][13][14].…”