What is the appropriate dose of methylprednisolone (Solu‑Medrol) for acute sinus disease in an adult without contraindications?

Methylprednisolone Dosing for Acute Sinus Disease

For acute sinusitis in adults, oral methylprednisolone 24 mg three times daily (72 mg/day total) for 5 days is the evidence-based dose, though this provides only modest short-term symptom relief and should be reserved for severe presentations with significant facial pain or obstruction. 1

Specific Dosing Regimen

The European Position Paper on Rhinosinusitis (EPOS 2020) evaluated methylprednisolone specifically for acute post-viral rhinosinusitis and found that 8 mg of methylprednisolone three times daily (24 mg/day total) for 5 days significantly reduced craniofacial pain at day 4, though it did not improve overall recovery rates at 14 days. 1

However, a more aggressive regimen was studied in chronic rhinosinusitis with nasal polyps: oral methylprednisolone 32 mg/day for days 1-5, then 16 mg/day for days 6-10, then 8 mg/day for days 11-20 (20-day tapering course). 1 This higher-dose regimen showed symptom reduction lasting 4 weeks and polyp size reduction lasting 55 days. 1

Dose Equivalency Context

Understanding corticosteroid equivalencies is critical to avoid underdosing. Methylprednisolone is 5 times more potent than hydrocortisone, meaning 48 mg of methylprednisolone equals 60 mg of prednisone or 10 mg of dexamethasone. 1 The commonly prescribed methylprednisolone dose pack (4-mg tablets starting with 6 tablets on day 1, tapering over 6 days) provides only 84 mg total—equivalent to just 105 mg of prednisone over 6 days, which is substantially underdosed compared to recommended regimens. 1

Clinical Effectiveness and Limitations

Systemic corticosteroids provide only modest benefit for acute sinusitis. When combined with antibiotics, oral corticosteroids showed:

• Significant reduction in facial pain and nasal congestion at days 3-7 (risk difference 20%, 95% CI 6-34%) 2
• Smaller effect when analyzed against placebo alone (risk difference 12%, 95% CI 5-19%) 2
• Benefits primarily for severe presentations, with minimal effect in typical primary care populations 3

Critical caveat: The methylprednisolone study in EPOS 2020 showed no difference in clinical or radiological recovery at 14 days, only short-term pain reduction at day 4. 1 This suggests the benefit is symptomatic and temporary rather than disease-modifying.

When to Consider Systemic Steroids

Reserve systemic corticosteroids for:

• Severe facial pain or pressure that significantly impairs function 1
• Marked nasal obstruction unresponsive to intranasal corticosteroids 1
• Patients with chronic rhinosinusitis with nasal polyps as adjunct to intranasal steroids (1-2 courses per year maximum) 1

Do not use routinely for uncomplicated acute sinusitis, as the effect size is small and most cases are viral and self-limited. 4, 3

Preferred Alternative: Intranasal Corticosteroids

Intranasal corticosteroids are the preferred first-line treatment for acute sinusitis, showing significant benefit with minimal systemic effects:

• Mometasone furoate 200 μg twice daily for 15-21 days provides significant symptom improvement 1
• Benefits increase with higher doses and longer duration (21 days superior to 14 days) 5
• Particularly effective for nasal congestion and facial pain 1

Practical Dosing Algorithm

1. Mild-moderate acute sinusitis: Intranasal mometasone 200 μg twice daily for 15-21 days 1

2. Severe acute sinusitis with significant facial pain: Consider oral methylprednisolone 24 mg three times daily for 5 days as adjunct to intranasal steroids 1

3. Chronic rhinosinusitis with polyps (uncontrolled): Oral methylprednisolone 32 mg daily × 5 days, then 16 mg daily × 5 days, then 8 mg daily × 10 days (20-day taper) as adjunct to intranasal steroids 1

Important Safety Considerations

Even short courses carry risks including hyperglycemia, sleep disturbances, mood changes, and weight gain. 1 Most adverse effects are mild and acceptable for 5-14 day courses, but patients with diabetes, psychiatric conditions, or bone disease require closer monitoring. 1 The risk-benefit ratio favors intranasal over systemic steroids for most patients with acute sinusitis. 5