What is the initial treatment for nasal polyps?

Initial Treatment for Nasal Polyps

Intranasal corticosteroids are the first-line treatment for nasal polyps, used twice daily to reduce polyp size, decrease inflammation, and improve nasal congestion, rhinorrhea, and sense of smell. 1, 2

First-Line Medical Management

• Start with intranasal corticosteroids twice daily as the cornerstone of therapy, which significantly reduces polyp size and controls symptoms including nasal obstruction and loss of smell 2, 3
• Specific effective agents include:
  • Mometasone furoate 200 mcg twice daily 2
  • Fluticasone propionate 200 mcg twice daily 4
  • Budesonide 128-200 mcg twice daily 2
• Twice-daily dosing is more effective than once-daily dosing for optimizing treatment effects 2
• Add nasal saline irrigation as adjunctive therapy to help clear mucus and improve medication delivery 2
• Patients typically start feeling relief within the first day, but full effectiveness requires several days of consistent use 5
• Intranasal corticosteroids do not cause rebound congestion and can be used for up to 6 months in adults (age 12+) or 2 months per year in children (age 4-11) 5

When Initial Treatment Fails

If symptoms remain severe or uncontrolled after 1-2 weeks of intranasal corticosteroids alone, add a short course of oral corticosteroids followed by maintenance intranasal therapy. 1, 2

• Oral prednisolone 25-60 mg daily for 7-21 days is effective for severe nasal polyposis 1, 2
• Common regimens include:
  • Prednisolone 50 mg daily for 14 days 1
  • Prednisolone 60 mg for 7 days, then 10 mg every other day, stopping on day 17 1
  • Methylprednisolone 32 mg/day for days 1-5,16 mg/day for days 6-10,8 mg/day for days 11-20 1
• Short courses of systemic corticosteroids significantly reduce total symptom scores and nasal polyp scores within 2-4 weeks 2
• After completing oral corticosteroids, maintenance with intranasal corticosteroids is essential to sustain beneficial effects and prevent recurrence 2, 3

Important Clinical Considerations

• Topical corticosteroids work best for small to medium-sized polyps (grades 1-2), while large polyps (grade 3) may require systemic corticosteroids or surgery first 6
• Intranasal corticosteroids primarily reduce polyp size and nasal congestion but have negligible effect on restoring sense of smell, whereas systemic steroids improve all symptoms including olfaction 7
• Direct nasal spray away from the nasal septum to minimize local side effects like irritation and bleeding 1
• Periodically examine the nasal septum for mucosal erosions, which may suggest increased risk for septal perforation 1

Common Pitfalls to Avoid

• Do not rely solely on short courses of systemic corticosteroids without maintenance intranasal therapy, as this leads to symptom recurrence 2
• Do not use nasal decongestants as monotherapy or for more than 3 days, as this can lead to rhinitis medicamentosa (rebound congestion) 1
• Do not use single-dose or recurrent parenteral corticosteroids, as these carry greater potential for long-term systemic side effects 1
• If symptoms do not improve after one week of intranasal corticosteroids, consider that the patient may have a sinus infection requiring additional treatment 5

Special Populations

• Children with nasal polyps should be evaluated for cystic fibrosis 8
• In children, use intranasal corticosteroids at the lowest effective dose and monitor growth 1
• Patients with aspirin-exacerbated respiratory disease (AERD) and nasal polyps may benefit from aspirin desensitization followed by long-term daily aspirin therapy to reduce symptoms and need for polypectomies 2
• Patients with comorbid asthma require careful monitoring of total corticosteroid intake from both intranasal and inhaled sources 3

Advanced Options for Refractory Cases

• For inadequate response to standard therapy, corticosteroid-eluting sinus implants placed in the ethmoid sinus can significantly reduce nasal obstruction and polyp grade (OR 0.34) 2
• Leukotriene modifiers (montelukast) may provide subjective improvement when added to intranasal corticosteroids, though evidence is mixed 1, 2
• Functional endoscopic sinus surgery (FESS) is reserved for cases when medical treatment fails to adequately control symptoms 2
• Post-operative maintenance with intranasal corticosteroids prevents polyp recurrence significantly better than placebo (RR 0.73) 2