What is the role of corticosteroids (steroids) in the treatment of sinusitis?

From the Guidelines

Oral corticosteroids may be beneficial in the treatment of acute sinusitis, particularly when symptoms are severe or in patients with significant nasal polyps or allergic components, as evidenced by a meta-analysis showing a significant higher resolution of facial pain 4-7 days after start of systemic corticosteroid treatment compared to placebo 1.

Key Points to Consider

• The use of systemic corticosteroids in acute sinusitis may provide short-term relief of symptoms, especially when combined with antibiotics, as suggested by a Cochrane review from 2014 1.
• Intranasal corticosteroid sprays are the preferred treatment for chronic sinusitis, reducing inflammation, mucus production, and swollen tissues in the sinus passages.
• Potential side effects of oral steroids include mood changes, increased blood sugar, fluid retention, and suppressed immune function, while nasal steroids may cause local irritation, nosebleeds, or headaches.
• Steroids should be used cautiously in patients with diabetes, hypertension, glaucoma, or immunosuppression.

Treatment Recommendations

• For acute sinusitis, a short course of prednisone (typically 20-40mg daily for 5-7 days) may be prescribed alongside antibiotics when symptoms are particularly severe or for patients with significant nasal polyps or allergic components.
• For chronic sinusitis, intranasal corticosteroid sprays like fluticasone (Flonase), mometasone (Nasonex), or budesonide (Rhinocort) are recommended, used daily (typically 1-2 sprays per nostril) for several weeks or months.
• Initial treatment for most mild to moderate sinusitis cases should focus on saline irrigation, decongestants, and appropriate antibiotics if bacterial infection is confirmed.

Important Considerations

• The effectiveness of intranasal corticosteroids in treating sinusitis, especially in the long term, requires further study to conclusively demonstrate their benefits 1.
• Patient education on common and serious side effects of intranasal corticosteroids, as well as the importance of long-term adherence to therapy for chronic rhinosinusitis, is crucial 1.

From the FDA Drug Label

CLINICAL PHARMACOLOGY Mechanism of Action: Fluticasone propionate is a synthetic, trifluorinated corticosteroid with anti-inflammatory activity. Corticosteroids have been shown to have a wide range of effects on multiple cell types (e.g., mast cells, eosinophils, neutrophils, macrophages, and lymphocytes) and mediators (e.g., histamine, eicosanoids, leukotrienes, and cytokines) involved in inflammation.

The role of corticosteroids (steroids) in the treatment of sinusitis is to reduce inflammation.

• They have a wide range of effects on multiple cell types and mediators involved in inflammation.
• Fluticasone propionate, a synthetic corticosteroid, has anti-inflammatory activity.
• It can decrease nasal mucosal eosinophils and basophils in patients with allergic rhinitis.
• The direct relationship of these findings to long-term symptom relief is not known 2.
• A decrease in nasal symptoms has been noted in some patients 12 hours after initial treatment with fluticasone propionate nasal spray.
• Maximum benefit may not be reached for several days 2.

From the Research

Role of Corticosteroids in Sinusitis Treatment

• Corticosteroids, commonly referred to as steroids, have been studied for their effectiveness in treating sinusitis, including both acute and chronic forms 3, 4, 5, 6, 7.
• The evidence suggests that oral corticosteroids can be beneficial as an adjunctive therapy to antibiotics for short-term relief of symptoms in acute sinusitis, with a significant improvement in symptoms such as headache, facial pain, and nasal congestion 3, 4, 5.
• A study found that short-term oral steroids significantly improved symptoms and avoided surgical intervention in 52.5% of patients with chronic rhinosinusitis without nasal polyps (CRSsNP) 6.
• Another study suggested that oral corticosteroids as an adjunct therapy to intranasal corticosteroids or antibiotics may improve symptom severity, polyp size, and condition of the sinuses, but the quality of the evidence is low or very low 7.

Key Findings

• Oral corticosteroids were more likely to result in short-term resolution or improvement of symptoms than the control treatment in patients with acute sinusitis 3, 4.
• The use of oral corticosteroids as a monotherapy appears to be ineffective for adult patients with clinically diagnosed acute sinusitis 3.
• Short-term oral prednisolone significantly improved disease-specific health-related quality of life, patient-reported disease severity, and nasal endoscopy scores in patients with CRSsNP 6.
• The evidence for the long-term effects of oral corticosteroids on sinusitis is limited, and more research is needed to establish their efficacy and safety 3, 4, 7.

Adverse Effects

• Reported side effects of oral corticosteroids were mild, including nausea, vomiting, and gastric complaints, and did not significantly differ from those receiving placebo 3, 4.
• The use of oral corticosteroids requires careful consideration of potential side effects, and further studies are needed to ascertain appropriate dosage and treatment duration 6, 7.