What is the role of steroids in treating sinusitis?

Role of Steroids in Sinusitis Treatment

Intranasal corticosteroids are the primary steroid therapy for sinusitis, providing modest but clinically meaningful symptom relief in acute cases and serving as maintenance therapy for chronic disease, while oral corticosteroids should be reserved for chronic rhinosinusitis with nasal polyps or treatment-refractory acute cases, not as routine therapy for uncomplicated acute sinusitis. 1, 2

Acute Sinusitis

Intranasal Corticosteroids

• Intranasal corticosteroids as adjunctive therapy increase symptom improvement rates from 66% to 73% at 15-21 days (number needed to treat = 14) in acute bacterial rhinosinusitis. 1
• Prescription options include mometasone, fluticasone, flunisolide, and budesonide; over-the-counter triamcinolone acetonide is available but lacks specific evidence for acute sinusitis. 1
• Start intranasal steroids at the time of diagnosis alongside antibiotics when treating acute bacterial sinusitis. 1
• Minor adverse events include epistaxis, headache, and nasal itching—these are generally well-tolerated. 1

Oral Corticosteroids - Limited Role

• Oral corticosteroids combined with antibiotics provide only modest short-term benefit, with resolution of facial pain in 4-7 days showing a risk ratio of 1.17 (95% CI 1.05-1.30), meaning only 11% more patients improve compared to placebo. 1, 3
• This benefit is NOT sustained at 10-14 days after treatment initiation. 1, 3
• Nearly two-thirds of patients (66%) improve with placebo alone, making the absolute benefit small. 1
• Oral corticosteroids as monotherapy (without antibiotics) are ineffective and should not be used. 1, 4
• If considering oral steroids for severe acute sinusitis unresponsive to initial treatment, use prednisone 30 mg daily for 7 days as adjunct to antibiotics. 3

Critical Pitfall

• The 2020 European Position Paper on Rhinosinusitis concludes that post-viral rhinosinusitis is self-limiting and systemic corticosteroids do not have a positive effect on recovery at 7-14 days. 1
• Avoid routine use of oral corticosteroids in uncomplicated acute sinusitis—reserve for treatment failures with marked mucosal edema or nasal polyposis. 1

Chronic Rhinosinusitis

Oral Corticosteroids for Acute Management

• For chronic rhinosinusitis with significant inflammatory component or nasal polyps, use prednisone 25 mg daily for 2 weeks followed by transition to intranasal corticosteroids for maintenance. 2, 3, 5
• This regimen produces significant reduction in total symptom score, nasal polyp size, and improves nasal airflow at 2 weeks. 2, 5
• Improvements in sense of smell, nasal airflow, and polyp size can persist for up to 12 weeks when followed by intranasal maintenance therapy. 2, 5
• The 25 mg daily dose provides optimal balance between efficacy and minimizing adverse effects. 2, 5

Intranasal Corticosteroids for Maintenance

• Following oral corticosteroid therapy, transition to intranasal corticosteroids (e.g., fluticasone propionate nasal spray) for long-term maintenance therapy. 2, 5
• Continue intranasal corticosteroids for at least 10-12 weeks after oral prednisone to maintain improvements. 2, 5
• Intranasal corticosteroids reduce inflammation, nasal polyp size, and improve nasal blockage, rhinorrhea, and loss of smell. 2
• Limit oral corticosteroid courses to 1-2 per year to minimize systemic adverse effects. 3, 5

Chronic Non-Infectious Sinusitis

• For chronic hyperplastic sinusitis (non-infectious), give consideration to systemic corticosteroids as primary therapy. 1
• Intranasal corticosteroids as adjunct to antibiotic therapy are helpful in treating recurrent acute and chronic sinusitis. 1

Special Populations

Pediatric Patients

• In children with acute post-viral rhinosinusitis, amoxicillin combined with fluticasone propionate nasal spray 50 μg per nostril twice daily for 14 days results in significantly more cures and lower symptom scores compared to amoxicillin alone. 1
• Monitor growth routinely (via stadiometry) in pediatric patients receiving intranasal corticosteroids, as these may cause reduction in growth velocity. 6
• A 1-year study showed fluticasone propionate nasal spray 200 μg daily had a point estimate for growth velocity 0.14 cm/year lower than placebo (not statistically significant), but the potential for growth suppression at higher doses cannot be ruled out. 6
• Titrate each pediatric patient to the lowest dose that effectively controls symptoms to minimize systemic effects. 6

Patients with Diabetes

• For patients with controlled diabetes requiring oral corticosteroids for chronic sinusitis, use prednisone 25 mg daily for 2 weeks rather than higher doses to minimize glycemic fluctuations. 5
• Check blood glucose levels daily during prednisone treatment in diabetic patients. 5
• Monitor for signs of hyperglycemia (increased thirst, frequent urination, fatigue). 5
• Consider temporary adjustments to diabetes medications during prednisone treatment. 5
• For patients with severe diabetes concerns, consider a shorter course (7 days) or lower dose (15-20 mg) with closer glucose monitoring. 5

Practical Prescribing Algorithm

For Acute Sinusitis (symptoms <4 weeks):

1. Start with antibiotics (amoxicillin or amoxicillin-clavulanate) PLUS intranasal corticosteroids for patients meeting criteria for acute bacterial sinusitis (symptoms ≥10 days or severe symptoms with fever, purulent discharge, facial pain). 1
2. Do NOT routinely add oral corticosteroids unless patient fails initial treatment after 3-5 days, demonstrates nasal polyposis, or has marked mucosal edema. 1
3. If adding oral steroids for treatment failure, use prednisone 30 mg daily for 7 days. 3

For Chronic Rhinosinusitis (symptoms ≥12 weeks):

1. Start with prednisone 25 mg daily for 2 weeks for patients with significant inflammatory component or nasal polyps. 2, 3, 5
2. Transition to intranasal corticosteroids (e.g., fluticasone propionate) immediately after completing oral course. 2, 5
3. Continue intranasal corticosteroids for at least 10-12 weeks to maintain improvements. 2, 5
4. Limit oral corticosteroid courses to 1-2 per year. 3, 5

Safety Considerations and Monitoring

Adverse Effects

• Short courses of oral corticosteroids (2 weeks or less) have low risk of significant adverse events. 2, 3
• Reported side effects with oral corticosteroids are mild (nausea, vomiting, gastric complaints) and do not significantly differ from placebo. 4
• Risk of adrenal suppression is minimal with a 2-week course unless patient has had previous corticosteroid therapy. 3, 5
• Intranasal corticosteroids may rarely cause nasal septum perforation—patients should direct spray away from the septum. 1
• Rare instances of wheezing, cataracts, glaucoma, and increased intraocular pressure have been reported with intranasal corticosteroids. 6

Drug Interactions

• Do NOT coadminister fluticasone propionate with ritonavir (highly potent CYP3A4 inhibitor), as this can significantly increase plasma fluticasone exposure and cause systemic corticosteroid effects including Cushing syndrome and adrenal suppression. 6
• Exercise caution when coadministering intranasal fluticasone with ketoconazole and other potent CYP3A4 inhibitors. 6

Contraindications and Precautions

• Use intranasal corticosteroids with caution in patients with active or quiescent tuberculous infections, untreated fungal or bacterial infections, systemic viral infections, or ocular herpes simplex. 6
• Patients who have experienced recent nasal septal ulcers, nasal surgery, or nasal trauma should not use nasal corticosteroids until healing has occurred. 6
• Examine patients using intranasal corticosteroids for several months periodically for evidence of Candida infection or other adverse effects on nasal mucosa. 6

Key Evidence Limitations

• Most trials of oral corticosteroids for acute sinusitis are performed in secondary care settings (ENT clinics) with radiological confirmation, limiting generalizability to primary care. 4
• Significant risk of attrition bias exists in many trials—worst-case scenario analysis shows no statistically significant benefit of oral corticosteroids. 4
• No trials report effects on relapse or recurrence rates for oral corticosteroids in acute sinusitis. 4
• The beneficial effects of oral corticosteroids are typically short-term; at 10-12 weeks after treatment initiation, the difference in symptom scores compared to placebo is no longer significant. 2