Impact of Dupilumab Approval: Trends in Surgical and Biologic Treatment Pathways for Crswnp

Introduction: To evaluate how FDA approval of dupilumab has altered real-world sequencing of advanced therapies for chronic rhinosinusitis with nasal polyps (CRSwNP), specifically whether biologics function as escalation or replacement therapy in relation to functional endoscopic sinus surgery (FESS).

Methods: Adults with CRSwNP were identified from the TriNetX Research Network between 2019 and 2024. Four mutually exclusive treatment pathways were defined: surgery only, dupilumab only, surgery followed by dupilumab, and dupilumab followed by surgery. Annual incidence proportions were calculated using calendar-year CRSwNP cohorts as denominators. Temporal trends were assessed using binomial regression to estimate annual odds ratios (ORs).

Results: Among 77,621 patients, surgery-only management remained the most common pathway, accounting for 34.0–49.7% of annual incident cases (OR 1.09, 95% CI 1.08–1.10). Biologic-based pathways expanded rapidly after dupilumab approval. By 2024, nearly one in five advanced treatment initiations involved biologic therapy, driven primarily by growth in dupilumab-only management (1.37% to 9.27%; OR 1.38, 95% CI 1.35–1.41) and post-surgical escalation to dupilumab (2.18% to 7.63%; OR 1.19, 95% CI 1.17–1.22). Dupilumab with subsequent surgery remained relatively uncommon (0.32% to 1.41%; OR 1.22, 95% CI 1.16–1.28). All temporal trends were statistically significant (p < 0.001).

Conclusions: Surgery remains the dominant initial intervention for CRSwNP; biologics are increasingly integrated as both post-surgical escalation and standalone definitive therapy for a growing subset of patients. These findings indicate a shift from a linear escalation model toward an individualized, pathway-based approach to CRSwNP management, highlighting the need for flexible treatment algorithms and shared decision-making as biologic use expands.