Prednisone Dosing for Chronic Sinusitis
For chronic sinusitis with nasal polyps, a short course of oral prednisone at doses ranging from 25-60 mg daily (typically starting at 40-60 mg) for 7-21 days is effective, but neither 20 mg nor 40 mg as fixed doses throughout treatment is the standard approach—dosing should start higher and taper progressively. 1
Evidence-Based Dosing Strategy
The available guideline evidence does not support fixed-dose prednisone at either 20 mg or 40 mg throughout the treatment course. Instead:
- Studies demonstrating efficacy used methylprednisolone at 1 mg/kg (approximately 50-80 mg for average adults) with progressive dose reduction over 7-21 days 1, 2, 3
- The European Position Paper on Rhinosinusitis and Nasal Polyps 2020 reviewed five randomized controlled trials using oral prednisolone in dosages ranging from 25-60 mg for 7-20 days, all showing significant symptom improvement 1
- A typical regimen would be: start at 40-60 mg daily for 5-7 days, then taper over the remaining 7-14 days 1
When Oral Steroids Are Indicated
Oral corticosteroids should be reserved for specific situations in chronic rhinosinusitis:
- Severe nasal polyposis with marked symptoms 1
- Failure to respond to intranasal corticosteroids and antibiotics (when bacterial infection documented) 4, 5
- Marked mucosal edema 4
- When rapid symptomatic improvement is needed 6
Critical Limitations of Oral Steroids
The benefits of oral corticosteroids are temporary and disappear by 10-12 weeks after treatment 1, 2:
- At 2-4 weeks post-treatment, there is significant reduction in total symptom score (SMD -1.51,95% CI -1.08 to -1.57) 1, 2
- At 10-12 weeks, the symptom improvement is no longer significant (SMD -0.13,95% CI -0.41 to 0.15) 1
- Nasal polyp scores show more sustained improvement at 10-12 weeks (SMD -0.51,95% CI -0.80 to -0.21), but this still represents only modest benefit 1
Mandatory Combination Therapy
Oral corticosteroids should never be used as monotherapy for chronic sinusitis 4:
- Must be combined with intranasal corticosteroids, which should be continued long-term after the oral steroid course ends 1, 4
- Intranasal corticosteroids are the most effective medication class for controlling nasal congestion, rhinorrhea, and inflammation 4, 7
- Saline nasal irrigation should be added for enhanced effectiveness 4
- Antibiotics should only be added when bacterial infection is documented (minimum 3-week course for chronic infectious sinusitis) 1, 4
Adverse Effects to Monitor
Short courses of oral corticosteroids carry risks even at these doses 1, 2:
- Insomnia (RR 3.63,95% CI 1.10 to 11.95) 2
- Gastrointestinal disturbances (RR 3.45,95% CI 1.11 to 10.78) 2
- Mood changes and behavioral disturbances 5, 2
- Temporary blood glucose elevation in diabetic patients 5
Chronic Rhinosinusitis WITHOUT Nasal Polyps
There is no evidence supporting oral corticosteroids for chronic rhinosinusitis without nasal polyps 1, 2:
- All randomized controlled trials of oral steroids for chronic sinusitis enrolled only patients with nasal polyps 2
- For chronic rhinosinusitis without polyps, treatment should focus on intranasal corticosteroids (used for at least 8-12 weeks) plus saline irrigation 1, 4
Common Pitfalls
- Using oral steroids without concurrent intranasal corticosteroids—this fails to maintain benefits after the oral course ends 1
- Using fixed low doses (like 20 mg throughout) rather than starting higher and tapering—this deviates from evidence-based protocols 1
- Prescribing oral steroids for chronic rhinosinusitis without polyps—no evidence supports this 2
- Failing to continue intranasal corticosteroids long-term after the oral steroid course—benefits will not be sustained 1
- Not instructing patients on proper intranasal corticosteroid technique (spray away from septum)—reduces efficacy and increases epistaxis risk 4, 7