Would other biologics, such as omalizumab (anti-IgE) or reslizumab (anti-IL-5), be more effective for a patient with severe asthma and significant nasal symptoms already on Dupixent (dupilumab) for chronic rhinosinusitis with nasal polyps?

Should You Switch from Dupixent to Another Biologic for Nasal Symptoms?

No, you should not switch from dupilumab (Dupixent) to omalizumab or reslizumab for nasal symptoms, as dupilumab demonstrates superior efficacy for chronic rhinosinusitis with nasal polyps (CRSwNP) compared to other biologics. 1, 2, 3

Evidence Supporting Dupilumab as First-Line for CRSwNP

The most recent 2025 Rhinology guidelines explicitly recommend dupilumab as the first choice in CRSwNP patients, with other biologics reserved for specific circumstances. 1 This recommendation is based on:

Head-to-Head Comparison Data

The 2025 EVEREST trial—the first direct head-to-head comparison of respiratory biologics—definitively demonstrated dupilumab's superiority over omalizumab in patients with severe CRSwNP and coexisting asthma: 3

• Nasal polyp score reduction: Dupilumab achieved 1.60 points greater improvement than omalizumab (p<0.0001) 3
• Smell improvement (UPSIT): Dupilumab showed 8.0 points greater improvement than omalizumab (p<0.0001) 3
• Both primary endpoints strongly favored dupilumab with highly significant differences 3

Quality of Life and Symptom Control

Network meta-analyses confirm dupilumab's superior performance across patient-important outcomes: 2

• SNOT-22 improvement: -19.91 points (exceeding minimally important difference by more than twofold) 2
• Nasal symptom scores: -3.25 points (superior to omalizumab's -2.09 and mepolizumab's -1.82) 2
• Objective polyp reduction: Consistently superior across randomized trials and real-world studies 2

When to Consider Alternative Biologics

The 2025 guidelines specify only two scenarios where alternatives to dupilumab should be considered for CRSwNP: 1

Omalizumab

• Primary indication: Female patients planning pregnancy in the near future 1
• Secondary consideration: Allergy-driven asthma with elevated IgE 1, 2

Mepolizumab

• Specific indication: CRSwNP with co-morbid highly eosinophilic asthma 1
• Not recommended over dupilumab for nasal symptoms alone 2

Reslizumab

• No specific indication for CRSwNP in current guidelines 1
• Reserved for eosinophilic asthma without preferential nasal benefit 1

Critical Pitfall to Avoid

Do not assume that targeting different inflammatory pathways will provide better nasal symptom control. Dupilumab's dual blockade of IL-4 and IL-13 signaling addresses the fundamental type 2 inflammatory drivers of CRSwNP more comprehensively than single-target biologics. 4, 3

Optimization Strategy Before Switching

Before considering any biologic change, ensure: 5

• Adequate treatment duration: Biologics require weeks to months for full effect 1
• Continued intranasal corticosteroids: Dupilumab should be used as add-on therapy, not monotherapy 5
• Proper nasal corticosteroid technique: Verify administration method and adherence 5
• Evaluation of treatable traits: Address environmental triggers, compliance issues 1

When Dupilumab Truly Fails

If inadequate response persists after 6 months of optimized dupilumab therapy with proper intranasal corticosteroid use, consider: 1

1. Re-evaluate the diagnosis: Confirm type 2 inflammation with biomarkers (eosinophils, IgE) 1
2. Assess disease severity objectively: Nasal endoscopy, CT imaging 1
3. Consider revision surgery before switching biologics, as 63% of patients in dupilumab trials had previous surgery 2, 6
4. Only then consider mepolizumab if highly eosinophilic asthma is present 1

The evidence strongly supports continuing dupilumab rather than switching to omalizumab or reslizumab for nasal symptoms. 1, 2, 3