What is the recommended steroid treatment for nasal polyps?

Steroid Treatment for Nasal Polyps

Intranasal corticosteroids are the first-line treatment for nasal polyps, with short courses of oral corticosteroids recommended for severe cases or significant symptom exacerbations. 1

First-Line Treatment: Intranasal Corticosteroids

Recommended Options:

• Mometasone furoate nasal spray (200 μg twice daily) 2
• Fluticasone propionate nasal spray (200 μg twice daily) 3
• Budesonide nasal spray

Administration Tips:

• Twice-daily dosing is more effective than once-daily for symptom control 1
• Proper technique is essential:
  • Head tilted slightly forward
  • Spray directed away from nasal septum
  • Continue treatment consistently for optimal effect

Expected Benefits:

• Reduction in polyp size
• Improved nasal congestion/obstruction
• Enhanced sense of smell
• Decreased rhinorrhea
• Prevention of polyp recurrence after surgery

For Severe or Refractory Cases:

Short Course of Oral Corticosteroids:

• Prednisolone 25-60 mg daily for 7-14 days 1
• Follow with maintenance intranasal corticosteroids

Advanced Delivery Options:

• Corticosteroid-eluting sinus implants for recurrent polyposis after surgery
  • Significantly reduces need for surgery (OR 0.34)
  • Small but significant impact on nasal obstruction
  • Reduces nasal polyp score 1

Treatment Algorithm:

1. Initial Assessment:

   • Evaluate polyp size (grade 1-3)
   • Assess symptom severity (obstruction, smell loss, rhinorrhea)

2. Treatment Selection:

   • Small to medium polyps (grade 1-2): Start with intranasal corticosteroids
   • Large polyps (grade 3): Consider short course of oral corticosteroids followed by intranasal maintenance

3. Monitoring and Adjustment:

   • Evaluate response after 4-6 weeks
   • If inadequate response, consider:
     • Short course of oral corticosteroids
     • Referral for surgical evaluation
   • After surgery, continue intranasal corticosteroids to prevent recurrence

Important Considerations:

Safety Concerns:

• Local adverse effects of intranasal corticosteroids:

  • Epistaxis (6.9%)
  • Nasal irritation (3.2%)
  • Rare: nasal septal perforation, Candida infection 4

• Systemic effects (primarily with oral corticosteroids):

  • Growth suppression in children
  • HPA axis suppression with prolonged use
  • Potential ocular effects (cataracts, glaucoma) with long-term use 4

Pitfalls to Avoid:

1. Inadequate delivery: In severely obstructed noses, medication may not reach target tissue
2. Inconsistent use: Intermittent use reduces efficacy
3. Premature discontinuation: Continued use needed to maintain benefits
4. Improper technique: Poor spray direction can reduce effectiveness and increase side effects
5. Overlooking comorbidities: Asthma and aspirin-exacerbated respiratory disease make polyps harder to control 1

Special Populations:

Children:

• Monitor growth with long-term intranasal corticosteroid use
• Use lowest effective dose 4

Elderly:

• Similar efficacy and safety profile as younger adults 4

Patients with Asthma or AERD:

• More difficult to control; may require more aggressive therapy 1
• Consider leukotriene modifiers as add-on therapy

The European Position Paper on Rhinosinusitis and Nasal Polyps (2020) provides strong evidence supporting intranasal corticosteroids as the cornerstone of medical management for nasal polyps, with short courses of systemic corticosteroids reserved for more severe cases 1.