Is prednisone (a corticosteroid) safe to use in patients with a positive influenza (flu) test and concurrent sinusitis?

Prednisone Use in Patients with Influenza and Concurrent Sinusitis

Systemic corticosteroids like prednisone should be avoided in patients with acute post-viral rhinosinusitis (including influenza-related sinusitis), as the evidence shows no meaningful benefit on recovery and potential harm from immunosuppression during active viral infection. 1

Primary Recommendation Against Systemic Steroids

The European Position Paper on Rhinosinusitis and Nasal Polyps 2020 (EPOS2020) explicitly advises against systemic corticosteroids for acute post-viral rhinosinusitis based on moderate-quality evidence. 1 The guideline found that:

• Systemic corticosteroids provide no benefit on recovery at 7-14 days 1
• Only a small, clinically insignificant effect on facial pain exists at days 4-7 (with spontaneous recovery occurring in nearly two-thirds of placebo patients) 1
• The potential harm of systemic corticosteroids outweighs the minimal short-term symptom relief 1
• The numbers needed to treat do not justify the risks 1

Specific Concerns with Active Influenza

While the guidelines address post-viral rhinosinusitis generally, using systemic corticosteroids during active influenza infection carries additional theoretical risks:

• Corticosteroids suppress the immune response needed to clear viral infection 1
• The modest symptom benefit (if any) does not justify immunosuppression during acute viral illness 1
• No studies have specifically evaluated safety of systemic steroids during active influenza with concurrent sinusitis 2

Recommended Alternative: Intranasal Corticosteroids

Instead of systemic steroids, use intranasal corticosteroids if symptom reduction is deemed necessary: 1, 3

• Fluticasone propionate 50 μg per nostril twice daily for 14 days, OR 3
• Mometasone furoate 200 μg twice daily for 15 days, OR 3
• Budesonide 50 μg per nostril twice daily for 3 weeks 3

Intranasal corticosteroids provide local anti-inflammatory effects without systemic immunosuppression and have demonstrated effectiveness in reducing total symptom scores in acute post-viral rhinosinusitis. 1, 4

When Systemic Steroids Might Be Considered (After Viral Clearance)

The only scenario where short-course oral corticosteroids may be appropriate is after the acute viral infection has resolved and only in specific circumstances: 1, 4

• Severe intractable symptoms unresponsive to intranasal steroids 1
• Significant nasal polyposis 1, 4
• Marked mucosal edema preventing medication delivery 4
• Duration limited to 5-7 days maximum 1, 4

Critical Pitfalls to Avoid

• Do not prescribe systemic steroids during active influenza infection - the immunosuppressive effects during acute viral illness outweigh any potential benefit 1
• Do not use parenteral (injectable) corticosteroids - these carry greater risk of prolonged adrenal suppression and are contraindicated for rhinitis/sinusitis 1
• Do not assume antibiotics are needed - post-viral rhinosinusitis is self-limiting and antibiotics show no benefit 1
• Ensure patients direct intranasal sprays away from the nasal septum to prevent local complications 1, 4

Evidence Quality Note

The recommendation against systemic corticosteroids is based on four double-blind placebo-controlled studies showing minimal benefit with potential harm. 1 The evidence supporting intranasal corticosteroids is of moderate quality with demonstrated efficacy and superior safety profile. 1, 3