What is the best intranasal (in the nose) steroid for nasal polyps?

Mometasone Furoate is the Most Effective Intranasal Steroid for Nasal Polyps

Mometasone furoate nasal spray is the most effective intranasal corticosteroid for treating nasal polyps based on the strongest evidence, demonstrating superior efficacy in reducing polyp size and improving nasal symptoms. 1

Evidence-Based Rationale

Efficacy of Mometasone Furoate

• Mometasone furoate nasal spray (MFNS) has been specifically approved for the treatment of nasal polyposis in both the US and EU, being the only once-daily corticosteroid spray with this specific indication 2
• Clinical trials demonstrate that MFNS significantly reduces:
  • Bilateral polyp grade scores (p<0.001) 3
  • Nasal congestion/obstruction (p<0.001) 3
  • Loss of smell (p<0.001) 3
  • Anterior rhinorrhea (p<0.001) 3
  • Postnasal drip (p<0.001) 3

Rapid Onset of Action

MFNS shows remarkably quick symptom improvement:

• Anterior rhinorrhea: significant relief by day 2 4
• Nasal congestion: significant relief by day 3 4
• Postnasal drip: significant relief by day 5 4
• Sense of smell: significant improvement by day 13 4
• Peak nasal inspiratory flow: significant improvement by day 2 4

Dosing Considerations

• Standard dosing: 200 μg once daily 1
• For more severe cases: 200 μg twice daily provides superior reduction in congestion/obstruction (p=0.039) compared to once-daily dosing 3

Delivery Methods

The European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS 2020) notes that different delivery methods may impact efficacy:

• Nasal sprays are standard and effective for most patients 1
• For post-surgical patients, high-volume budesonide irrigation may provide better distribution 1
• Corticosteroid-eluting implants (releasing 1350μg mometasone furoate over ~90 days) show significant benefits in:
  • Reducing nasal obstruction/congestion (p<0.001) 1
  • Reducing bilateral polyp grade (p=0.018) 1
  • Decreasing need for revision surgery (OR 0.34) 1

Comparison with Other Intranasal Corticosteroids

While multiple intranasal corticosteroids show efficacy, mometasone furoate demonstrates particular advantages:

• Fluticasone propionate: Effective (SMD -0.50; 95%CI [-0.76, -0.23]) but less evidence for polyp-specific approval 1
• Budesonide: Effective (SMD -1.35; 95%CI [-2.60, -0.11]) but typically requires twice-daily dosing 1
• Mometasone furoate: Effective (SMD -0.37; 95%CI [-0.53, -0.22]) with specific approval for polyps and once-daily dosing option 1, 2

Safety Profile

• MFNS is well-tolerated with minimal side effects 3, 2
• No clinically relevant drug interactions with other tested medications 2
• No impact on ocular safety (intraocular pressure or lens opacity) 1
• Local adverse events are typically mild to moderate in severity 1

Clinical Algorithm for Intranasal Steroid Selection for Nasal Polyps

1. First-line therapy: Mometasone furoate nasal spray

   • Initial dose: 200 μg once daily
   • For severe symptoms: Consider 200 μg twice daily

2. For patients with inadequate response after 4-6 weeks:

   • Consider short course of systemic corticosteroids (e.g., prednisolone) followed by continuation of MFNS
   • Consider alternative delivery methods (high-volume irrigation if available)

3. For recurrent polyps after surgery:

   • Consider corticosteroid-eluting implants if available
   • Continue MFNS as maintenance therapy

4. For patients unable to tolerate mometasone:

   • Alternative options: fluticasone propionate or budesonide

Common Pitfalls to Avoid

• Inadequate administration technique: Ensure proper head position and spray direction to reach the middle meatus
• Insufficient treatment duration: Continue treatment even after symptom improvement to prevent recurrence
• Suboptimal dosing: Consider twice-daily dosing for severe cases
• Overlooking concurrent conditions: Address allergic triggers or other inflammatory factors that may contribute to polyp formation
• Monotherapy limitations: For large polyps (grade 3), topical therapy alone may be insufficient; consider short-term systemic steroids or surgical intervention 5

Mometasone furoate nasal spray represents the optimal choice for intranasal steroid therapy in nasal polyposis due to its proven efficacy, rapid onset of action, convenient dosing options, and favorable safety profile.