What is the recommended oral corticosteroid (OCS) dose and how many times can it be repeated per year for patients with nasal polyposis?

Recommended Oral Corticosteroid Dosing for Nasal Polyposis

For patients with nasal polyposis, the recommended oral corticosteroid regimen is prednisolone 25-30 mg daily for 14 days, followed by maintenance intranasal corticosteroid therapy, and this should be limited to 1-2 courses per year.

Dosing Recommendations

Initial Oral Corticosteroid Course:

• Medication: Prednisolone or methylprednisolone
• Dosing options:
  • Option 1: Prednisolone 25 mg daily for 14 days 1, 2
  • Option 2: Methylprednisolone 32 mg daily for 5 days, then 16 mg daily for 5 days, then 8 mg daily for 10 days 1, 3
  • Option 3: Prednisolone 60 mg daily for 7 days, then reduced by 5-10 mg every 1-2 days until completion (17 days total) 1

Maintenance Therapy After Oral Course:

• Essential follow-up: Intranasal corticosteroid therapy (e.g., mometasone furoate 200 μg twice daily) 1, 2
• This maintenance therapy significantly extends the benefits of the initial oral corticosteroid course

Frequency Limitations

• Maximum frequency: 1-2 courses of oral corticosteroids per year 1
• This limitation is explicitly stated in the European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS) 2020 guideline

Clinical Benefits

The short course of oral corticosteroids provides:

• Significant reduction in nasal polyp size (effect lasts 8-12 weeks) 1, 2
• Improvement in sense of smell (most dramatic benefit) 1, 2
• Reduction in nasal congestion and other symptoms 1
• Enhanced efficacy of intranasal corticosteroids by opening nasal passages 2

Important Considerations

Patient Selection

• Best for patients with moderate to severe nasal polyposis 1
• Particularly effective for patients with:
  • Significant nasal obstruction
  • Anosmia (loss of smell)
  • Inadequate response to intranasal corticosteroids alone

Timing Considerations

• Consider oral corticosteroids:
  • When symptoms are severe and significantly impact quality of life
  • Before planned sinus surgery to reduce polyp size and facilitate the procedure 4
  • When intranasal corticosteroids alone are insufficient

Monitoring and Precautions

• Screen for contraindications to systemic corticosteroids
• Be aware of potential side effects:
  • Transient adrenal suppression (normalizes after treatment) 2
  • Temporary increase in bone turnover markers 2
  • Mood changes, insomnia, and gastrointestinal disturbances

Clinical Algorithm for Management

1. Initial Assessment: Confirm diagnosis of nasal polyposis through symptoms and endoscopic examination
2. First-line therapy: Start with intranasal corticosteroids
3. When to add oral corticosteroids:
   • If inadequate response to intranasal corticosteroids
   • When polyps are moderate to large in size
   • When quality of life is significantly impacted
4. Administer oral corticosteroid course: Prednisolone 25-30 mg daily for 14 days
5. Transition to maintenance: Continue with intranasal corticosteroids
6. Monitor for recurrence: Assess symptoms and polyp size
7. Limit retreatment: No more than 1-2 courses of oral corticosteroids per year

The highest quality evidence supports this approach of limited oral corticosteroid courses followed by maintenance intranasal therapy to maximize benefits while minimizing potential systemic side effects of corticosteroids.