Induction of oral steroids before topical steroids may help chronic rhinosinusitis with nasal polyps
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In patients with chronic rhinosinusitis and at least moderate nasal polyposis, an initial course of oral steroids before topical steroid therapy was more effective than topical steroid therapy alone in decreasing polyp size and improving olfaction.
Researchers conducted a parallel, blinded, randomized trial of 60 nonsmoking adults with or without asthma with chronic rhinosinusitis and moderate-sized or larger nasal polyps who were referred by their primary physicians to a specialty rhinology clinic in Tayside, Scotland. (More than 50% of the cohort had concomitant asthma treated with inhaled corticosteroids.) The study results appear in the March 1 Annals of Internal Medicine.
Patients were randomly assigned in a 1:1 ratio to receive oral prednisolone, 25 mg/d, or placebo for 2 weeks, followed in both groups by fluticasone propionate nasal drops, 400 µg twice daily, for 8 weeks and then fluticasone propionate nasal spray, 200 µg twice daily, for 18 weeks.
The mean decrease in polyp grade from baseline to 2 weeks was 2.1 units (SD, 1.1) in the prednisolone group and 0.1 unit (SD, 1.0) in the placebo group (mean difference between groups, −1.8 units [95% CI, −2.4 to −1.2 units]; P<0.001). The difference between groups was −1.08 units (95% CI, −1.74 to −0.42 unit; P=0.001) at 10 weeks and −0.8 unit (CI, −1.8 to 0.2 unit; P=0.11) at 28 weeks.
The mean decrease in hyposmia score from baseline to 2 weeks was 31.12 mm (SD, 30.1) in the prednisolone group and 1.41 mm (SD, 30.6) in the placebo group (mean difference between groups, −28.33 mm [95% CI, −42.71 to −13.96 mm]; P=0.002). The difference between groups was −16.06 mm (95% CI, −30.99 to −1.13 mm; P=0.03) at 10 weeks and −12.13 mm (95% CI, −30.55 to 6.29 mm; P=0.19) at 28 weeks.
Twenty-five participants (83%) in the prednisolone group improved by more than the minimal important difference in either polyp grade or hyposmia visual analogue scale at the end of 28 weeks, compared with 17 participants (57%) in the placebo group. Oral prednisolone therapy did not change levels of Staphylococcus aureus enterotoxin-specific IgE (P>0.05). No adverse events attributable to oral steroids were reported.
The applicability of these findings to patients seen only in primary care is unclear, the study authors concluded, writing “Future studies should consider whether an induction and maintenance approach should be considered at the point of first diagnosis of [chronic rhinosinusitis] with nasal polyposis (for example, in primary care) and whether it is beneficial in milder disease, in which ostiomeatal complex obstruction is less severe.”
ACP Internist recently published an article on managing chronic sinusitis.