What is the recommended prednisone (corticosteroid) dosage and treatment schedule for sinusitis?

Prednisone Dosing for Sinusitis

For acute post-viral sinusitis, prednisone 30 mg daily for 7 days as an adjunct to antibiotics provides modest short-term symptom relief, though the benefit is small and not sustained beyond 10-14 days. 1 For chronic rhinosinusitis, prednisone 25 mg daily for 2 weeks followed by intranasal corticosteroids is the recommended regimen. 2

Acute Sinusitis (Post-Viral or Bacterial)

Dosing Regimen

• Prednisone 30 mg daily for 7 days is the most commonly studied dose in acute post-viral rhinosinusitis 1
• Alternative regimens include weight-based dosing: 40 mg for 40-60 kg, 60 mg for 60-80 kg, and 80 mg for >80 kg bodyweight, given for 3 days 1
• Methylprednisolone 24 mg daily (8 mg three times daily) for 5 days is another validated option 1
• Betamethasone 1 mg daily for 5 days has shown efficacy in reducing facial pain and nasal congestion 1

Evidence for Efficacy

• Oral corticosteroids combined with antibiotics show a modest benefit with resolution of facial pain in 4-7 days (risk ratio 1.17,95% CI 1.05-1.30), meaning 11% more patients improve compared to placebo 1
• The benefit is not sustained at 10-14 days after treatment initiation 1
• Corticosteroid monotherapy (without antibiotics) is ineffective for acute sinusitis 3, 4
• The number needed to treat is 7 for short-term symptom improvement 4

Critical Limitations

• Nearly two-thirds of patients improve with placebo alone, making the absolute benefit small 1
• No difference in recovery rates at 7-14 days between corticosteroid and placebo groups 1
• Topical budesonide nasal spray (200 μg per nostril daily for 10 days) showed no benefit in acute sinusitis when combined with antibiotics 5

Chronic Rhinosinusitis Without Nasal Polyps

Dosing Regimen

• Prednisone 0.5 mg/kg daily tapered over 10 days (approximately 25-40 mg for most adults) 6
• Alternatively, prednisone 25 mg daily for 2 weeks followed by intranasal corticosteroids for maintenance 2
• Transition to intranasal corticosteroids (fluticasone propionate nasal spray) for long-term maintenance after oral course 2

Evidence for Efficacy

• Short-term oral prednisolone significantly improves SNOT-22 scores, nasal endoscopy findings, and CT scan scores at 2 months 6
• 52.5% of patients avoid surgery at 12 months after a single course of oral prednisolone 6
• Patients with symptom duration less than 11 months are most likely to benefit from oral corticosteroids 6
• Those with symptoms for 18 months or longer typically require surgical intervention despite oral steroids 6

Chronic Rhinosinusitis With Nasal Polyps

Dosing Regimen

• Prednisone 25 mg daily for 2 weeks is the optimal dose balancing efficacy and adverse effects 2
• Methylprednisolone 1 mg/kg tapered progressively over 21 days is an alternative regimen 7
• Always follow with intranasal corticosteroids for at least 10-12 weeks to maintain improvements 2

Evidence for Efficacy

• Oral corticosteroids combined with intranasal corticosteroids provide greater improvement in symptoms, polyp scores, and quality of life compared to intranasal corticosteroids alone 2
• Improvements in sense of smell, nasal airflow, and polyp size can persist for up to 12 weeks when followed by intranasal maintenance therapy 2
• There may be an important reduction in polyp size (mean difference -0.46 on a 1-4 scale) when oral steroids are added to intranasal corticosteroids 7

Special Populations

Patients with Diabetes

• Use prednisone 25 mg daily for 2 weeks rather than higher doses (40-60 mg) to minimize glycemic fluctuations 2
• Check blood glucose levels daily during treatment 2
• Monitor for hyperglycemia signs: increased thirst, frequent urination, fatigue 2
• Consider temporary adjustments to diabetes medications during treatment 2
• For severe diabetes concerns, consider a shorter course (7 days) or lower dose (15-20 mg) with closer glucose monitoring 2

Pediatric Patients

• Methylprednisolone 1 mg/kg tapered progressively over 15 days when combined with antibiotics 7
• This regimen showed a large effect size (mean difference -7.10 on a 0-40 symptom scale) at 30 days 7
• Side effects were reported in 8.9% of pediatric patients receiving oral corticosteroids 6

Adverse Effects and Monitoring

• Side effects are typically mild (nausea, vomiting, gastric complaints) and do not significantly differ from placebo 4
• Risk of significant adverse events is low with short courses (2 weeks or less) but increases with longer duration 2
• Risk of adrenal suppression is minimal with a 2-week course unless patient has had previous corticosteroid therapy 2
• Limit oral corticosteroid courses to 1-2 per year to minimize systemic adverse effects 2

Key Clinical Pitfalls

• Do not use oral corticosteroids as monotherapy for acute bacterial sinusitis—antibiotics are necessary 3, 4
• Avoid prescribing oral corticosteroids for chronic rhinosinusitis with symptom duration exceeding 18 months, as these patients typically require surgery 6
• Do not prescribe oral corticosteroids without a plan for intranasal corticosteroid maintenance in chronic rhinosinusitis, as benefits are not sustained without continuation therapy 2
• Dexamethasone 4 mg may be used for acute hyperalgic sinusitis (severe pain) but only as short-term adjunctive therapy with antibiotics, never as monotherapy 3