Postoperative Oral Steroid Regimen for Allergic Fungal Rhinosinusitis (AFRS)
Postoperative systemic corticosteroids are strongly recommended for AFRS patients with a 6-month tapered regimen showing superior outcomes compared to shorter courses. 1, 2
Recommended Dosing Protocol
- Initial dosing should begin with prednisolone 1mg/kg/day for 1 week preoperatively and 0.5mg/kg/day for 4 weeks postoperatively 1, 2
- Continue with oral prednisolone 0.4mg/kg/day for the next 4 weeks 1, 2
- Taper to 0.2mg/kg/day for the next 2 months 1, 2
- Further taper to 0.1mg/kg/day for the final 2 months 1, 2
Evidence Supporting Long-Term Steroid Regimen
- A randomized trial by Prasad et al. demonstrated that a 6-month postoperative corticosteroid regimen reduced recurrence rates to 10% compared to 30% with a 2-month taper 1, 2
- Postoperative systemic corticosteroids have Level 1b evidence for improving short-term outcomes in AFRS 1, 2
- Long-term recurrence reduction with postoperative systemic steroids has Level 2b evidence 1, 2
- A randomized double-blinded placebo-controlled trial showed that all patients receiving oral steroids were asymptomatic at 12 weeks compared to only one patient in the placebo group 1, 3
Monitoring and Adverse Effects
- Monitor for weight gain, Cushingoid features, and steroid-induced diabetes mellitus, which were observed in patients receiving prednisolone 50mg daily for 6 weeks 1, 2
- All 12 patients in one study receiving oral prednisolone experienced some weight gain, 5 developed Cushingoid features, and 1 developed steroid-induced diabetes mellitus 1
- Regular blood glucose monitoring is recommended, especially in patients with risk factors for diabetes 2
Combination Therapy
- Combine oral steroids with intranasal corticosteroid sprays for optimal outcomes 1, 2
- A case-controlled study showed that combined postoperative oral and topical steroid therapy reduced recurrence rates to 15% compared to 50% with no steroid treatment 1
- Consider nebulized budesonide as an adjunct therapy, as it has shown superior efficacy to standard intranasal corticosteroid sprays in preventing recurrence (Level 1b evidence) 1
Common Pitfalls to Avoid
- Avoid premature discontinuation of oral steroids, as shorter courses have been associated with higher recurrence rates 1, 2
- Do not rely solely on systemic steroids without appropriate local therapy (intranasal corticosteroids) 2
- Avoid abrupt discontinuation of steroids; always use a gradual taper to allow the hypothalamic-pituitary-adrenal axis to recover 2
- Do not confuse recommendations for AFRS with those for CRS without polyps, as the latter does not benefit from postoperative oral steroids 4
Special Considerations
- Medical therapy alone is usually ineffective for AFRS; surgical intervention combined with medical therapy leads to improved clinical outcomes 1
- Preoperative systemic corticosteroids (1mg/kg for 10 days) can significantly reduce AFRS mucosa inflammation prior to surgery 1
- Consider the total steroid burden in patients with comorbid conditions like asthma who may be receiving both intranasal and inhaled corticosteroids 5