Adjunctive dual biologic therapy for persistent nasal symptoms in eosinophilic granulomatosis with polyangiitis (EGPA)

Eosinophilic granulomatosis with polyangiitis (EGPA) is an eosinophilic vasculitis frequently involving both upper and lower airways, commonly associated with severe asthma and chronic rhinosinusitis with nasal polyps (CRSwNP). Although anti-IL-5/IL-5R biologics such as mepolizumab and benralizumab are established therapies for maintaining systemic remission, a subset of patients continues to experience refractory sinonasal symptoms. We report two EGPA cases with well-controlled systemic disease under anti-IL-5/IL-5R therapy but persistent uncontrolled CRSwNP, who were treated with add-on dupilumab. Both patients demonstrated substantial improvement in sinonasal outcomes, as reflected by reductions in SNOT-22 and nasal polyp scores, alongside maintenance of systemic remission (BVAS = 0). These findings highlight the potential role of dual biologic therapy targeting distinct inflammatory pathways in selected EGPA patients with refractory CRSwNP. Careful patient selection and close multidisciplinary monitoring are essential to ensure safety and optimize efficacy. Further studies are warranted to confirm long-term effectiveness and safety profiles.