Dose tapering and treatment de-escalation of biologic therapies in chronic rhinosinusitis with nasal polyps: a narrative review.

Background: Biologic therapies have transformed the management of severe chronic rhinosinusitis with nasal polyps (CRSwNP), particularly in patients with uncontrolled type 2 inflammation. Although dupilumab, omalizumab, mepolizumab, benralizumab, tezepelumab, depemokimab, and stapokibart have demonstrated substantial clinical efficacy, the optimal duration and maintenance strategy for biologic therapy remain uncertain. The chronic nature of CRSwNP and the high cost of biologic treatment have stimulated growing interest in dose tapering and treatment de-escalation. Objective: To review the current evidence on biologic dose tapering in CRSwNP, summarize published tapering strategies, evaluate clinical outcomes, and discuss patient selection, monitoring, and future research priorities. Methods: A narrative review of the published literature on biologic dose tapering and treatment optimization in CRSwNP, including pivotal clinical trials, prospective observational studies, real-world cohorts, and current guideline recommendations. Results: Current evidence, derived predominantly from prospective observational studies and real-world cohorts, suggests that gradual extension of biologic dosing intervals can maintain disease control in carefully selected patients with sustained remission. Most studies reported preserved improvements in nasal polyp score, symptom burden, olfactory function, asthma control, and quality of life after extending treatment from every 2 weeks to every 4 weeks, with some patients successfully maintaining remission at 6-, 8-, 10-, or 12-week intervals. However, available evidence remains predominantly observational, and tapering protocols, eligibility criteria, and definitions of remission are heterogeneous. Conclusion: Biologic dose tapering represents a promising treatment optimization strategy for carefully selected patients with stable CRSwNP, particularly those receiving dupilumab. However, standardized tapering protocols and high-quality randomized controlled trials are required before routine implementation. Future research should focus on biomarker-guided patient selection, long-term clinical outcomes, and the cost-effectiveness of biologic dose optimization.