What are the treatment options for febrile (feverish) nasal congestion and nasal polyps in a patient with asthma who is unresponsive to leukotriene modifying agents (e.g. montelukast) and nasal corticosteroids (e.g. nasal steroids)?

From the Guidelines

For febrile nasal congestion and nasal polyps with asthma that persist despite leukotriene modifiers and nasal steroids, I recommend a multi-faceted approach. First, add an oral antibiotic such as amoxicillin-clavulanate 875/125 mg twice daily for 10-14 days to address potential bacterial sinusitis causing the fever, as suggested by the management of rhinitis and sinusitis guidelines 1. Continue the intranasal corticosteroid (such as fluticasone 50 mcg, 1-2 sprays per nostril twice daily) but ensure proper administration technique by tilting the head forward and aiming toward the outer eye, which is crucial for maximizing the effectiveness of intranasal corticosteroids 1. Consider adding a short course of oral prednisone, 40 mg daily for 5-7 days, to reduce polyp size and inflammation, as oral corticosteroids are effective in reducing symptoms and polyp size in severe nasal polyposis 1. Saline nasal irrigation twice daily with a solution of 240 ml distilled water, 1/4 teaspoon salt, and 1/4 teaspoon baking soda can help clear mucus and improve medication penetration. If symptoms persist after 4-6 weeks of optimized therapy, referral to an ENT specialist for evaluation for endoscopic sinus surgery is warranted, as functional endoscopic sinus surgery is a recommended treatment for rhinosinusitis associated with nasal polyposis 1. This comprehensive approach addresses the infectious component (fever), reduces inflammation (steroids), maintains asthma control, and mechanically improves nasal patency, which is in line with the guidelines for the diagnosis and management of asthma 1. The combination of systemic and topical treatments targets both the underlying inflammation driving polyp formation and the acute infectious exacerbation causing fever and congestion.

Some key points to consider in the management of nasal polyps include:

• The use of intranasal corticosteroids as the most effective medication class for controlling symptoms of allergic rhinitis, including nasal congestion 1.
• The potential benefits of adding a leukotriene receptor antagonist or an oral antihistamine to the treatment regimen, although the evidence suggests that intranasal corticosteroids are more effective 1.
• The importance of proper administration technique for intranasal corticosteroids to maximize their effectiveness 1.
• The potential need for referral to an ENT specialist for evaluation for endoscopic sinus surgery if symptoms persist despite optimized medical therapy 1.

Overall, the management of febrile nasal congestion and nasal polyps with asthma requires a comprehensive approach that addresses the underlying inflammation, infectious components, and mechanical obstruction, and is guided by the most recent and highest quality evidence 1.

From the FDA Drug Label

XOLAIR is an anti-IgE antibody indicated for: Moderate to severe persistent asthma in adults and pediatric patients 6 years of age and older with a positive skin test or in vitro reactivity to a perennial aeroallergen and symptoms that are inadequately controlled with inhaled corticosteroids Chronic rhinosinusitis with nasal polyps (CRSwNP) in adult patients 18 years of age and older with inadequate response to nasal corticosteroids, as add-on maintenance treatment

Treatment of febrile nasal congestion and nasal polyps with asthma despite leukotriene modifying agent and nasal steroids can be managed with XOLAIR (omalizumab), which is indicated for:

• Moderate to severe persistent asthma in adults and pediatric patients 6 years of age and older with a positive skin test or in vitro reactivity to a perennial aeroallergen and symptoms that are inadequately controlled with inhaled corticosteroids
• Chronic rhinosinusitis with nasal polyps (CRSwNP) in adult patients 18 years of age and older with inadequate response to nasal corticosteroids, as add-on maintenance treatment 2 2 2

From the Research

Treatment Options for Febrile Nasal Congestion and Nasal Polyps with Asthma

• Despite the use of leukotriene modifying agents and nasal steroids, treatment of febrile nasal congestion and nasal polyps with asthma can be challenging.
• According to 3, biologics that affect the type 2 inflammatory pathway have shown efficacy and safety in patients with chronic rhinosinusitis with nasal polyps (CRSwNP), including those with comorbid asthma.
• The use of biologics such as dupilumab, which targets the IL-4 receptor, has been approved for the treatment of CRSwNP, as demonstrated in the LIBERTY NP SINUS-24 and SINUS-52 trials 4.
• Other biologics, including omalizumab, mepolizumab, reslizumab, and benralizumab, have also shown positive results in phase 3 trials for the treatment of CRSwNP 4.

Medical Management of Nasal Polyps

• Topical nasal steroids are the treatment of choice for nasal polyps, as they significantly decrease polyp size, nasal congestion, and rhinorrhea, and increase nasal airflow 5, 6.
• Short courses of oral steroids may be needed to reduce polyp size, followed by maintenance therapy with topical steroids 5, 6.
• Surgery is reserved for patients in which polyps cause severe obstruction or recurrent sinusitis, and for patients for whom medical therapy has failed 5, 6.

Etiology and Evaluation of Nasal Congestion

• Nasal congestion can be caused by various factors, including allergic rhinitis, vasomotor rhinitis, chronic sinusitis, and upper respiratory viral infections 7.
• Evaluation of nasal congestion involves a thorough workup and diagnosis, including conservative treatments such as decongestant pharmacotherapy, antiallergy measures, and nasal dilation devices 7.