What are the EPOS (European Position Paper on Rhinosinusitis) guidelines for steroid dosing and duration in Acute Rhinosinusitis (ARS)?

EPOS Guidelines for Steroid Dosing and Duration in Acute Rhinosinusitis (ARS)

According to the European Position Paper on Rhinosinusitis and Nasal Polyps 2020 (EPOS 2020), intranasal corticosteroids are recommended as monotherapy for acute post-viral rhinosinusitis, while systemic corticosteroids are not recommended due to limited benefits and potential adverse effects. 1

Intranasal Corticosteroids

Dosing and Duration Recommendations:

• Fluticasone propionate nasal spray: 50 μg per nostril twice daily for 14 days 1
• Mometasone furoate nasal spray: 200 μg twice daily for 15 days 1
• Budesonide nasal spray: 50 μg per nostril twice daily for 3 weeks 1

Evidence for Efficacy:

• Intranasal corticosteroids significantly reduce symptom scores, particularly nasal congestion 1
• They provide faster symptom relief compared to placebo 1
• When used as monotherapy, intranasal corticosteroids show better outcomes than antibiotics or placebo 1

Specific Benefits:

• Significantly shortened time to clinical success 1
• Reduced percentage of days with minimal symptoms 1
• Improved quality of life metrics 1

Systemic Corticosteroids

EPOS 2020 Recommendation:

• Systemic corticosteroids are NOT recommended for acute post-viral rhinosinusitis 1
• This recommendation is based on:
  • Limited evidence of efficacy beyond short-term facial pain relief 1
  • Potential adverse effects outweighing benefits 1
  • Self-limiting nature of the disease 1

Evidence Assessment:

• Four double-blind placebo-controlled studies evaluated systemic corticosteroids (3-7 days duration) 1
• While there was a small but significant effect on facial pain at days 4-7, no difference was found in:
  • Recovery at 7-14 days 1
  • Resolution of nasal discharge 1
  • Long-term outcomes 1

Dosing in Studies (Not Recommended):

• Prednisolone: 30 mg/day for 7 days 1
• Betamethasone: 1 mg orally once daily for 5 days 1
• Prednisone: 40-80 mg (weight-based) for 3 days 1
• Methylprednisolone: 8 mg three times daily for 5 days 1

Special Populations

Children:

• Fluticasone propionate nasal spray: 50 μg per nostril twice daily for 14 days 1
• Budesonide nasal spray: 50 μg per nostril twice daily for 3 weeks 1
• Studies show improved outcomes when added to antibiotics in children 1

Allergic Fungal Rhinosinusitis (AFRS):

• While not specific to acute rhinosinusitis, EPOS 2020 provides guidance for AFRS 1:
  • Preoperative systemic corticosteroids reduce mucosal inflammation 1
  • Postoperative systemic corticosteroids improve short-term outcomes 1
  • Intranasal corticosteroids are useful for long-term control 1

Clinical Pearls and Pitfalls

• Common Pitfall: Overuse of systemic corticosteroids for routine ARS cases 1
• Pitfall: Relying on antibiotics as first-line therapy when intranasal corticosteroids have shown superior efficacy 1
• Pearl: Cost-effectiveness analyses show intranasal corticosteroids are more cost-effective than antibiotics 1
• Pearl: Intranasal corticosteroids can be used as monotherapy without antibiotics in post-viral rhinosinusitis 1
• Caution: Special care should be taken when using intranasal corticosteroids in children, pregnant women, and elderly patients, especially those with comorbid conditions like asthma 2

Algorithm for Management

1. Diagnosis: Distinguish between common cold (viral rhinosinusitis), post-viral rhinosinusitis, and bacterial rhinosinusitis 1
2. First-line therapy: Intranasal corticosteroids for post-viral rhinosinusitis 1
3. Duration: 14-21 days of intranasal corticosteroids 1
4. Monitoring: Assess for symptom improvement within 7 days 1
5. Consider antibiotics only if symptoms worsen or fail to improve after appropriate intranasal corticosteroid therapy 1