Which is more effective for nasal polyps, Dupixent (dupilumab) or Tezspire (tezepelumab)?

Dupilumab is More Effective Than Tezspire for Nasal Polyps

Based on the highest quality evidence, dupilumab (Dupixent) should be the preferred biologic for chronic rhinosinusitis with nasal polyps (CRSwNP), as it is the only FDA-approved monoclonal antibody with established guideline support and extensive phase 3 trial data demonstrating superior efficacy across all patient-important outcomes. 1

Current FDA Approval Status and Guideline Recommendations

• Dupilumab is the only monoclonal antibody specifically approved and recommended by guidelines for CRSwNP treatment. 1
• The European Position Paper on Rhinosinusitis (2020) explicitly states that "dupilumab is the only monoclonal antibody that is approved for the treatment of CRSwNP at the moment" and advises its use in patients meeting criteria for biologic therapy. 1
• The Joint Task Force on Practice Parameters (2023) identifies dupilumab as producing the most beneficial improvements in disease-specific quality of life (SNOT-22 mean difference: -19.91 points) and nasal symptom scores (mean difference: -3.25 points) compared to all other biologics. 1

Comparative Efficacy Data

Quality of Life and Symptom Improvements

• Dupilumab achieves clinically relevant improvements exceeding the minimally important difference by more than twofold in SNOT-22 scores (mean difference: -19.61 points, 95% CI: -22.53 to -16.69), based on meta-analysis of 784 participants across two phase 3 studies. 1, 2
• Dupilumab demonstrates superior nasal congestion reduction (mean difference: -0.86,95% CI: -0.98 to -0.75) compared to baseline. 1
• Rhinosinusitis disease severity measured by VAS shows significant improvement with dupilumab (mean difference: -2.54,95% CI: -2.84 to -2.23). 1

Objective Measures of Disease Control

• Nasal polyp score reduction with dupilumab is substantial (mean difference: -1.79,95% CI: -2.01 to -1.56), representing the primary endpoint in pivotal trials. 1
• Lund-Mackay CT scores show significant improvement (SMD: -1.50,95% CI: -1.84 to -1.16), indicating reduced sinus opacification. 1
• Olfactory function measured by UPSIT demonstrates marked improvement (mean difference: 10.83,95% CI: 9.59 to 12.08). 1
• Dupilumab significantly improves lung function in patients with comorbid asthma (FEV1 mean difference: 0.21L, 95% CI: 0.20 to 0.22). 1

Tezepelumab Evidence Status

• Tezepelumab (Tezspire) lacks FDA approval for CRSwNP and has no guideline recommendations for this indication. 2
• While a 2025 phase 3 trial (WAYPOINT) demonstrated tezepelumab efficacy in CRSwNP with improvements in nasal polyp scores (mean difference vs. placebo: -2.07) and nasal congestion (-1.03), this represents a single recent study without established guideline integration or FDA approval for this indication. 3
• The American Academy of Allergy, Asthma, and Immunology guidelines explicitly state that clinicians should "not assume tezepelumab has equivalent evidence to dupilumab, omalizumab, or mepolizumab for CRSwNP." 2

Treatment Algorithm for Biologic Selection

First-Line Biologic Choice

• Initiate dupilumab 300mg subcutaneously every 2 weeks after a 600mg loading dose for patients with severe CRSwNP who have failed intranasal corticosteroids for at least 4 weeks. 1, 2, 4
• Dupilumab is particularly advantageous for patients with comorbid atopic dermatitis, providing dual indication benefits. 2
• Continue background mometasone furoate nasal spray during dupilumab therapy. 4

Patient Selection Criteria

• Confirm CRSwNP diagnosis by direct visualization of nasal polyps with mean baseline polyp scores around 6 (indicating severe disease). 1
• Document inadequate response to intranasal corticosteroids used for minimum 4 weeks. 1, 2
• Consider patients with high disease burden (SNOT-22 scores typically >40) who value improvement in quality of life and nasal symptoms. 1

Monitoring and Follow-Up

• Assess nasal polyp scores, SNOT-22, nasal congestion, and olfactory function at 16-24 weeks. 4, 5
• Evaluate need for rescue surgery or systemic corticosteroids as secondary outcomes. 1
• Monitor for conjunctivitis, the most notable adverse effect specific to dupilumab (occurring in approximately 2% of CRSwNP patients). 1

Safety Considerations

• All biologics demonstrate similar low rates of adverse events leading to discontinuation, with no significant difference from placebo in overall adverse event rates. 1
• Common adverse events with dupilumab (nasopharyngitis, injection-site reactions, headache) occur at rates comparable to or less than placebo. 1
• Dupilumab-associated conjunctivitis, while notable in atopic dermatitis trials, appears less frequent in CRSwNP populations. 1

Critical Pitfalls to Avoid

• Do not initiate biologics without first ensuring adequate trial of intranasal corticosteroids for at least 4 weeks, as this represents the conditional nature of guideline recommendations. 1, 2
• Avoid selecting tezepelumab for CRSwNP based solely on recent trial data without considering the lack of FDA approval and guideline support for this specific indication. 2
• Do not assume blood eosinophil levels predict dupilumab efficacy in CRSwNP, as efficacy is consistent across eosinophilic status subgroups. 6
• Ensure proper baseline documentation including nasal polyp scores, CT imaging, and quality of life measures to track treatment response. 5