Perioperative Use of Biologics in Patients with Chronic Rhinosinusitis with Nasal Polyps: What Is the Evidence?

Abstract

In selected patients with severe or uncontrolled chronic rhinosinusitis with nasal polyps (CRSwNP) who remain scheduled for endoscopic sinus surgery (ESS) despite guideline-based standard-of-care/appropriate medical therapy (SoC/AMT), clinicians increasingly face how biologic therapy should be used around surgery, including whether it should be initiated, continued, interrupted, or resumed. This Clinical Perspective examines perioperative biologic use around ESS, including safety, sequencing, postoperative disease control, and direct healing-specific evidence. SoC/AMT, including topical intranasal corticosteroids and saline irrigations, remains the baseline, and ESS remains a therapeutic intervention that removes inflammatory tissue, improves access for topical intranasal therapy, and initiates a dynamic repair program involving hemostasis, epithelial closure, barrier restoration, matrix remodeling, and later recurrence control. The available perioperative evidence is sparse, heterogeneous, and largely based on small studies; therefore, it is insufficient to support firm clinical recommendations about biologic sequencing. Among biological treatments, dupilumab has the most extensive perioperative and postoperative human evidence and no clear major operative-harm signal, although dedicated healing endpoints remain limited. Omalizumab provides supportive postoperative disease-control data, but healing inference remains indirect. Mepolizumab offers genuine perioperative exposure, with reassuring but incomplete healing-specific evidence. Tezepelumab and depemokimab have CRSwNP efficacy data but no evidence directly informing perioperative use around ESS. Current evidence cannot justify routine interruption of all biologics, default postoperative use for all patients, or class-wide equivalence. Agent-specific randomized studies and registries anchored in SoC/AMT are needed to define perioperative safety, efficacy, timing, and remucosalization-specific outcomes.