What is the appropriate intravenous dose of Solu‑Medrol (methylprednisolone) for an adult with acute severe sinusitis without contraindications to systemic steroids?

Solu-Medrol (Methylprednisolone) is NOT Recommended for Sinusitis

Systemic corticosteroids, including intravenous Solu-Medrol, should not be used for acute sinusitis. The American Academy of Otolaryngology-Head and Neck Surgery explicitly discourages the use of systemic steroids for acute bacterial rhinosinusitis due to questionable efficacy and lack of evidence supporting their use 1.

Why Systemic Steroids Are Not Indicated

• Guideline-level recommendation against use: The 2015 AAO-HNS clinical practice guideline specifically lists systemic steroids among interventions with "questionable or unproven efficacy" that should be discouraged in acute bacterial rhinosinusitis 1.

• No benefit as monotherapy: Oral corticosteroids used alone show no benefit over placebo for acute sinusitis 1, 2, 3, 4.

• Minimal benefit even with antibiotics: When combined with antibiotics, oral corticosteroids provide only modest short-term symptom relief (number needed to treat = 7), but this evidence is limited by significant risk of attrition bias 1, 2, 3.

• No role for IV formulations: There is no evidence supporting intravenous methylprednisolone (Solu-Medrol) for sinusitis, and the guideline recommendations apply to all systemic corticosteroid routes 1.

What Should Be Used Instead

Intranasal corticosteroids are the appropriate steroid formulation for sinusitis, not systemic steroids 1, 5.

Recommended Treatment Algorithm:

1. First-line therapy:

   • Intranasal corticosteroids (mometasone, fluticasone, or budesonide) 2 sprays per nostril twice daily 5
   • High-volume saline nasal irrigation 1, 5
   • Analgesics (acetaminophen or NSAIDs) for pain 1, 6

2. Add antibiotics only if bacterial infection is documented:

   • Symptoms ≥10 days with purulent discharge, or
   • Severe unilateral facial pain/swelling with fever, or
   • "Double worsening" (initial improvement then worsening) 1, 6
   • Use amoxicillin-clavulanate 875/125 mg twice daily for 5-10 days 5

3. Continue intranasal steroids for 15-21 days during antibiotic course 5

Critical Pitfall to Avoid

Do not confuse oral/IV systemic corticosteroids with intranasal topical corticosteroids—they have completely different risk-benefit profiles and evidence bases. Intranasal steroids are recommended; systemic steroids are discouraged 1, 5.

The Only Exception (Not Applicable to Routine Sinusitis)

If a patient has chronic rhinosinusitis with severe nasal polyps (not acute sinusitis), a short course of oral prednisone 40-60 mg daily for 5-7 days with taper may be considered, but this must be combined with intranasal corticosteroids and is a completely different clinical scenario 5. This would never be given as IV Solu-Medrol 5.

Bottom Line

There is no appropriate injection dose of Solu-Medrol for sinusitis because it should not be used for this indication. Use intranasal corticosteroid sprays instead 1, 5.