What medications are approved for treating nasal polyps?

Currently Available Medications Approved for Nasal Polyps

Intranasal corticosteroids are the first-line FDA-approved medical treatment for nasal polyps, with fluticasone propionate and mometasone furoate being the most well-established options, while short courses of oral corticosteroids serve as second-line therapy for severe cases. 1

FDA-Approved Intranasal Corticosteroids

Primary Treatment Options

• Fluticasone propionate aqueous nasal spray is FDA-approved and highly effective for nasal polyps, typically dosed at 200 micrograms twice daily (2 sprays per nostril twice daily) 2, 3
• Mometasone furoate nasal spray is approved for nasal polyps, with standard dosing of 200 micrograms once daily (2 sprays per nostril once daily), though higher doses (400 micrograms daily) may be used for refractory cases 4
• Beclomethasone dipropionate aqueous nasal spray at 200 micrograms twice daily is effective, though evidence suggests fluticasone may have faster onset of action 3
• Budesonide nasal spray has demonstrated efficacy in reducing polyp size and preventing recurrence after surgery 5

Dosing Considerations

• Twice-daily dosing is more effective than once-daily dosing for optimal control of nasal polyps 1
• For adults age 12 and older using fluticasone propionate, the standard regimen is 2 sprays in each nostril daily; children age 4-11 use 1 spray in each nostril daily 2
• Duration limits apply: Children should not use intranasal corticosteroids for longer than 2 months per year without physician consultation 2

Oral Corticosteroids (Second-Line)

Indications and Efficacy

• Short courses of oral prednisone (25-60 mg daily for 5-20 days) are reserved for severe nasal polyposis and provide rapid reduction in symptoms, polyp size, and improved nasal airflow 6, 1
• Oral corticosteroids are particularly useful when polyps are large (grade 3) and the nose is severely blocked, making topical medication delivery difficult 5
• Prednisolone regimens commonly used include 35 mg reducing by 5 mg every second day over 14 days, or 50 mg once daily for 14 days 6

Treatment Protocol

• After initial reduction with oral steroids, maintenance therapy must be continued with intranasal corticosteroids to prevent recurrence 1
• The European Position Paper on Rhinosinusitis recommends 1-2 courses of systemic corticosteroids per year as a useful addition to nasal corticosteroid treatment in patients with partially or uncontrolled disease 6
• Oral methylprednisolone (32 mg/day tapering over 20 days) reduces symptoms for 4 weeks and polyp scores for 55 days 6

Adjunctive Therapies (Not FDA-Approved as Monotherapy)

Leukotriene Modifiers

• Montelukast 10 mg daily has shown subjective improvement in nasal polyp symptoms when used as add-on therapy to intranasal corticosteroids, though evidence is mixed 1, 6
• One study showed significant benefit for total symptoms, headache, sense of smell, and sneezing at 8-12 weeks when combined with oral and intranasal corticosteroids 6
• However, a more recent 2018 study found no significant difference when montelukast was added to mometasone furoate over 12 months postoperatively 6

Important Caveats

• Nasal decongestants (oxymetazoline, xylometazoline) are NOT recommended for chronic use in nasal polyps despite one small study showing benefit, due to concerns about rebound congestion 6
• The EPOS2020 steering group suggests in general not to use nasal decongestants in chronic rhinosinusitis with nasal polyps 6

Treatment Algorithm

1. Start with intranasal corticosteroids (fluticasone 200 mcg twice daily or mometasone 200 mcg once-twice daily) as first-line therapy 1, 3
2. For severe cases or large polyps (grade 3), add a short course of oral prednisone 25-60 mg daily for 5-14 days, then maintain with intranasal corticosteroids 6, 1
3. If inadequate response to standard-dose intranasal steroids, consider doubling the dose (e.g., mometasone 400 mcg daily) for refractory cases 4
4. Consider montelukast 10 mg daily as adjunctive therapy only in select cases, particularly with concurrent asthma or aspirin-exacerbated respiratory disease 1

Special Populations and Safety

• Intranasal corticosteroids do not increase blood pressure when used as directed 2
• Care should be taken in children, pregnant women, and elderly patients, especially those with comorbid asthma receiving both intranasal and inhaled corticosteroids 7
• Systemic corticosteroids carry significant risks including cardiovascular, metabolic, and musculoskeletal effects, necessitating the lowest effective dose for the shortest duration 8