What is the recommended steroid taper regimen for chronic rhinosinusitis (CRS)?

Steroid Taper for Chronic Rhinosinusitis

For chronic rhinosinusitis with nasal polyps (CRSwNP), use a short course of oral prednisolone 25-60 mg daily for 7-14 days followed by long-term topical intranasal corticosteroids, not a traditional "taper" in the sense of gradually reducing oral steroids over weeks. 1

Oral Corticosteroid Regimen for CRSwNP

The evidence supports short, high-dose courses rather than prolonged tapers:

• Start with oral prednisolone 25-60 mg daily for 7-14 days as the initial treatment for moderate to severe CRSwNP 1
• The most studied regimen is prednisolone 25 mg daily for 14 days, which significantly reduces polyp size and improves symptoms, particularly olfaction 2
• Alternative regimens include 1 mg/kg daily for 2 days, then taper down until day 10 1 or 60 mg daily for 7 days followed by 10 mg every other day for 8-10 days 1

Critical point: The benefit of oral steroids is transient—symptom improvement is significant at 2-4 weeks but disappears by 10-12 weeks after treatment initiation 1. Polyp reduction persists slightly longer but also diminishes over time 1.

Transition to Long-Term Topical Therapy

Immediately after the oral steroid course, transition to topical intranasal corticosteroids for sustained control:

• Fluticasone propionate drops 400 μg twice daily for 8 weeks, then switch to fluticasone propionate spray 200 μg twice daily for ongoing maintenance 2
• Alternative options include mometasone furoate or budesonide at equivalent doses 1
• Continue topical steroids indefinitely (12 weeks to 52 weeks or longer) as they are the mainstay of CRS management 1

Delivery Method Matters

Nasal drops or irrigation deliver superior results compared to standard nasal sprays:

• Corticosteroid drops and nasal irrigation are more effective than spray formulations for reducing polyp size and improving symptoms 1
• Bi-directional exhalation devices show better efficacy than standard sprays 1
• Standard nasal sprays remain acceptable when drops or irrigation are not feasible 1

For CRS Without Nasal Polyps (CRSsNP)

There are no randomized controlled trials supporting oral corticosteroids for CRSsNP 1. Management should focus on:

• Topical intranasal corticosteroids as first-line therapy 1
• Saline nasal irrigation 1
• Oral steroids are not recommended for this phenotype 1

Common Pitfalls to Avoid

Do not use prolonged oral steroid tapers beyond 14-21 days for CRSwNP—the evidence shows no benefit for extended courses, and adverse effects accumulate with duration 1, 3. Short courses (7-21 days) are associated with transient adrenal suppression and increased bone turnover that resolves after stopping 2.

Do not rely on oral steroids alone without transitioning to topical therapy—the combination of initial oral steroids followed by topical maintenance is significantly more effective than topical therapy alone over 6 months 2.

Avoid using oral steroids for acute bacterial rhinosinusitis (ABRS)—a Cochrane review found no benefit for oral steroids as monotherapy in ABRS, and only modest short-term benefit when combined with antibiotics 1.

Preoperative Use

For patients scheduled for endoscopic sinus surgery:

• Oral prednisolone 30-60 mg daily for 5-10 days preoperatively reduces blood loss, improves surgical field quality, and decreases operation time 1
• Topical mometasone 200 μg twice daily for 4 weeks preoperatively provides similar benefits 1

Postoperative oral steroids show no significant benefit—two studies found no difference in SNOT-22 scores at 2-6 months after surgery with postoperative oral corticosteroids 1. Continue topical intranasal steroids postoperatively instead 1, 4.

Safety Considerations

Short courses of oral corticosteroids (7-21 days) are generally safe but can cause:

• Insomnia, mood changes, and gastrointestinal symptoms 1
• Transient adrenal suppression (resolves after stopping) 2
• Rare but serious risks include avascular necrosis and fatal varicella-zoster infection 1

Repeated or prolonged use increases risk of pneumonia, obesity, anxiety/depression, fractures, sleep apnea, diabetes, and hypertension 3. This underscores the importance of limiting oral steroid exposure and transitioning to topical therapy.