For sinusitis, would you prescribe pseudoephedrine or nasal steroids?

From the Guidelines

For sinusitis, nasal steroids are generally preferred as first-line treatment, especially for chronic cases, as they reduce inflammation in the nasal passages and sinuses, according to the most recent and highest quality study 1.

Treatment Options

• Nasal steroids like fluticasone (Flonase) or mometasone (Nasonex) can be used 1-2 sprays in each nostril once or twice daily as directed on the package.
• Pseudoephedrine (Sudafed) is more appropriate for short-term relief of congestion, particularly in acute sinusitis, with a typical dose of 60mg every 4-6 hours or 120mg extended-release every 12 hours, not exceeding the maximum daily dose.

Considerations

• Pseudoephedrine should be used cautiously in people with high blood pressure, heart problems, or glaucoma, and is available behind the pharmacy counter due to its potential misuse in manufacturing illicit drugs 1.
• Nasal saline irrigation and adequate hydration are also recommended alongside medication for optimal management of sinusitis 1.

Special Cases

• In persistent cases lasting more than 10 days or with severe symptoms, antibiotics may be necessary, and a healthcare provider should be consulted.
• Topical decongestants can be considered for short-term and possibly for intermittent or episodic therapy of nasal congestion, but are inappropriate for regular daily use due to the risk of rhinitis medicamentosa 1.

From the FDA Drug Label

Fluticasone Propionate Nasal Spray, USP relieves allergy symptoms caused by pollen, mold, dust and pets. Fluticasone Propionate Nasal Spray, USP helps relieve a broad range of symptoms from many allergens. For example, Fluticasone Propionate Nasal Spray, USP helps with: nasal congestion.

For sinusitis, I would give nasal steroids, such as Fluticasone Propionate Nasal Spray, USP, because it helps relieve nasal congestion and other allergy symptoms. 2 2

• Nasal steroids are preferred over pseudoephedrine for long-term relief of sinusitis symptoms.
• Pseudoephedrine is a nasal decongestant that can provide quick relief for sinus congestion, but it may not be suitable for long-term use. 3

From the Research

Treatment Options for Sinusitis

• For acute sinusitis, the use of oral corticosteroids as an adjunctive therapy to oral antibiotics may be modestly beneficial for short-term relief of symptoms, with a number needed to treat to benefit of seven for resolution or symptom improvement 4, 5.
• However, the evidence is limited, and there is a significant risk of bias, highlighting the need for high-quality trials to establish the efficacy of systemic corticosteroids in acute sinusitis 4, 5.
• For chronic rhinosinusitis, topical (intranasal) corticosteroids are used to reduce inflammation in the sinonasal mucosa, but there is insufficient evidence to suggest that one type of intranasal steroid is more effective than another 6.
• The combination of large volume low-pressure nasal saline irrigation and fluticasone propionate may be an effective treatment for pediatric acute rhinosinusitis, with improved clinical scores and peak nasal inspiratory flow measurements 7.
• Intranasal fluticasone propionate irrigations have been shown to be safe, with no significant effects on salivary cortisol levels, intraocular pressure, or the development of posterior subcapsular cataracts in postsurgical chronic rhinosinusitis patients 8.

Comparison of Pseudophed and Nasal Steroids

• Pseudophed is not mentioned in the provided studies, but nasal steroids, such as fluticasone propionate, have been shown to be effective in reducing inflammation and improving symptoms in acute and chronic sinusitis 4, 5, 6, 7, 8.
• The choice between pseudophed and nasal steroids would depend on the specific clinical context and patient needs, but nasal steroids may be a more effective option for reducing inflammation and improving symptoms in sinusitis.