What corticosteroid is recommended for treating sinusitis?

Corticosteroid Treatment for Sinusitis

Intranasal corticosteroids are recommended as first-line therapy for both acute and chronic sinusitis due to their anti-inflammatory effects and documented efficacy in relieving nasal congestion. 1

Types of Corticosteroids for Sinusitis

Intranasal Corticosteroids (INCS)

• INCS are the most effective medication class for controlling major sinusitis symptoms including nasal congestion, rhinorrhea, and inflammation 1
• They work through anti-inflammatory mechanisms including decreased vascular permeability, inhibition of inflammatory mediator release, and reduction of inflammatory cell infiltration 1
• Common INCS options include:
  • Fluticasone propionate - a potent synthetic trifluorinated corticosteroid with high glucocorticoid activity and low systemic bioavailability (less than 2%) 2
  • Other available options include mometasone furoate, budesonide, and triamcinolone 1

Oral Corticosteroids

• Short-term oral corticosteroids (3-7 days) may be considered as adjunctive therapy in specific situations:
  • When patients fail to respond to initial treatment with INCS and antibiotics 3
  • In patients with marked mucosal edema 3
  • In patients with nasal polyps 3
• However, systemic corticosteroids do not have a positive effect on recovery at 7-14 days in post-viral rhinosinusitis 3
• The EPOS2020 guidelines advise against routine use of systemic corticosteroids in patients with acute post-viral rhinosinusitis due to limited benefits and potential harm 3

Treatment Approach for Different Types of Sinusitis

Acute Sinusitis

• INCS are recommended as helpful adjunctive therapy to antibiotics in acute sinusitis 3
• In children with post-viral sinusitis, the combination of INCS (fluticasone propionate) with antibiotics showed significantly better outcomes compared to antibiotics alone 3
• For acute hyperalgic sinusitis, short-term oral corticosteroids may be used as adjuvant therapy 3

Chronic Sinusitis

• INCS are the cornerstone of treatment for chronic sinusitis, with or without nasal polyps 1, 4
• For chronic sinusitis with nasal polyps:
  • Short courses (1-3 weeks) of systemic corticosteroids may be beneficial 4
  • Oral corticosteroids (prednisolone) for 2-3 weeks can reduce polyp size for up to 3 months after treatment 4
• For chronic sinusitis without nasal polyps:
  • Recent evidence shows short-term oral prednisolone (0.5 mg/kg tapered over 10 days) significantly improved symptoms, nasal endoscopy findings, and CT scan scores 5
  • This treatment helped 52.5% of patients avoid surgery at 12 months compared to 14.3% of controls 5
  • Patients with symptom duration less than 11 months were most likely to benefit 5

Administration and Safety Considerations

• Proper INCS administration technique is crucial:
  • Direct sprays away from the nasal septum to minimize local side effects 1
  • Periodically examine the nasal septum to ensure there are no mucosal erosions 1
• When used at recommended doses, INCS are not generally associated with clinically significant systemic side effects 1, 2
• Common side effects of oral corticosteroids include:
  • Gastrointestinal disturbances (RR 3.45) 6
  • Insomnia (RR 3.63) 6
  • Mood disturbances (though evidence is less clear) 6

Common Pitfalls and Caveats

• Failure to use proper INCS technique can reduce efficacy and increase side effects 1
• Unlike topical decongestants, INCS do not cause rhinitis medicamentosa and can be used long-term 1
• Oral corticosteroids should be used judiciously due to potential adverse effects, especially in patients with comorbidities like diabetes or hypertension 6
• For patients with chronic sinusitis, INCS should be continued even after surgical intervention 1, 7
• If symptoms do not improve after 3-4 weeks of appropriate INCS therapy, consider referral to a specialist 1

Combination Therapy Approach

• For optimal results, INCS should be used in conjunction with saline nasal irrigation 1
• In severe cases of chronic sinusitis with nasal polyps, consider a short course of oral corticosteroids in addition to INCS 1, 7
• Antibiotics should only be added when there is evidence of bacterial infection 1