Steroids for Sinusitis?

Despite solid clinical evidence that most sinusitis is caused by viral infections – 99% of which will improve without therapy – we frequently prescribe antibiotics. Some clinicians attempt to put the breaks on using antibiotics by reserving them for patients with “chronic sinusitis” (defined as at least 12 weeks of symptoms) or for those who fail conservative therapy with oral and nasal decongestants.

Others have proposed using intranasal steroids as an adjunctive therapy for sinusitis. But how effective are steroids alone or in combination with antibiotics?

Dr. Gail Hayward and colleagues at Oxford University, England, conducted an updated systematic review of the literature evaluating the efficacy of intranasal corticosteroids for acute sinusitis (Ann. Fam. Med. 2012;10:241-9). Their investigation focused on six randomized controlled trials (RCTs) comparing intranasal corticosteroids with placebo in 2,495 children or adults who had symptoms consistent with sinusitis and who presented to various ambulatory settings. Studies were excluded if they enrolled patients with chronic/allergic sinusitis or those with chronic underlying health conditions.

Corticosteroids used were budesonide (2 studies), fluticasone propionate (1 study), and mometasone furoate (3 studies). Five trials involved the antibiotics amoxicillin, amoxicillin/clavulanic acid, or cefuroxime. One study prescribed intranasal xylometazoline.

Five of the trials showed that intranasal steroids improved or resolved symptoms at 14 to 21 days (risk difference 0.08; 95% CI, 0.03-0.13; P = .004) with a number needed to treat of 14. Studies did not demonstrate improvement at 14 to 15 days. Higher doses of mometasone (800 µg) were associated with greater symptom improvement than lower doses (400 µg). Steroids were associated with improvement in facial pain, congestion, rhinorrhea, headache, and post-nasal drip. No significant increases in adverse symptoms were observed.

Although the number needed to treat for intranasal steroids is reasonable, patients may not want to pay the cost, or even the co-pay, for a medication that requires 2 to 3 weeks to lead to symptoms improvement or resolution. Cheaper options exist (i.e., decongestants). Questions remain as to whether we can use steroids instead of antibiotics for the treatment of sinusitis in selected patients. Until we have these data, tension between the clinician’s desire to judiciously prescribe antibiotics and the patient’s expectations for them will persist.

Jon O. Ebbert, M.D., is a professor of medicine and a primary care clinician at the Mayo Clinic in Rochester, Minn. He declares having no conflicts of interest. The opinions expressed are solely those of the author. Contact him at [email protected].

Despite solid clinical evidence that most sinusitis is caused by viral infections – 99% of which will improve without therapy – we frequently prescribe antibiotics. Some clinicians attempt to put the breaks on using antibiotics by reserving them for patients with “chronic sinusitis” (defined as at least 12 weeks of symptoms) or for those who fail conservative therapy with oral and nasal decongestants.

Others have proposed using intranasal steroids as an adjunctive therapy for sinusitis. But how effective are steroids alone or in combination with antibiotics?

Dr. Gail Hayward and colleagues at Oxford University, England, conducted an updated systematic review of the literature evaluating the efficacy of intranasal corticosteroids for acute sinusitis (Ann. Fam. Med. 2012;10:241-9). Their investigation focused on six randomized controlled trials (RCTs) comparing intranasal corticosteroids with placebo in 2,495 children or adults who had symptoms consistent with sinusitis and who presented to various ambulatory settings. Studies were excluded if they enrolled patients with chronic/allergic sinusitis or those with chronic underlying health conditions.

Corticosteroids used were budesonide (2 studies), fluticasone propionate (1 study), and mometasone furoate (3 studies). Five trials involved the antibiotics amoxicillin, amoxicillin/clavulanic acid, or cefuroxime. One study prescribed intranasal xylometazoline.

Five of the trials showed that intranasal steroids improved or resolved symptoms at 14 to 21 days (risk difference 0.08; 95% CI, 0.03-0.13; P = .004) with a number needed to treat of 14. Studies did not demonstrate improvement at 14 to 15 days. Higher doses of mometasone (800 µg) were associated with greater symptom improvement than lower doses (400 µg). Steroids were associated with improvement in facial pain, congestion, rhinorrhea, headache, and post-nasal drip. No significant increases in adverse symptoms were observed.

Although the number needed to treat for intranasal steroids is reasonable, patients may not want to pay the cost, or even the co-pay, for a medication that requires 2 to 3 weeks to lead to symptoms improvement or resolution. Cheaper options exist (i.e., decongestants). Questions remain as to whether we can use steroids instead of antibiotics for the treatment of sinusitis in selected patients. Until we have these data, tension between the clinician’s desire to judiciously prescribe antibiotics and the patient’s expectations for them will persist.

Jon O. Ebbert, M.D., is a professor of medicine and a primary care clinician at the Mayo Clinic in Rochester, Minn. He declares having no conflicts of interest. The opinions expressed are solely those of the author. Contact him at [email protected].

Despite solid clinical evidence that most sinusitis is caused by viral infections – 99% of which will improve without therapy – we frequently prescribe antibiotics. Some clinicians attempt to put the breaks on using antibiotics by reserving them for patients with “chronic sinusitis” (defined as at least 12 weeks of symptoms) or for those who fail conservative therapy with oral and nasal decongestants.

Others have proposed using intranasal steroids as an adjunctive therapy for sinusitis. But how effective are steroids alone or in combination with antibiotics?

Dr. Gail Hayward and colleagues at Oxford University, England, conducted an updated systematic review of the literature evaluating the efficacy of intranasal corticosteroids for acute sinusitis (Ann. Fam. Med. 2012;10:241-9). Their investigation focused on six randomized controlled trials (RCTs) comparing intranasal corticosteroids with placebo in 2,495 children or adults who had symptoms consistent with sinusitis and who presented to various ambulatory settings. Studies were excluded if they enrolled patients with chronic/allergic sinusitis or those with chronic underlying health conditions.

Corticosteroids used were budesonide (2 studies), fluticasone propionate (1 study), and mometasone furoate (3 studies). Five trials involved the antibiotics amoxicillin, amoxicillin/clavulanic acid, or cefuroxime. One study prescribed intranasal xylometazoline.

Five of the trials showed that intranasal steroids improved or resolved symptoms at 14 to 21 days (risk difference 0.08; 95% CI, 0.03-0.13; P = .004) with a number needed to treat of 14. Studies did not demonstrate improvement at 14 to 15 days. Higher doses of mometasone (800 µg) were associated with greater symptom improvement than lower doses (400 µg). Steroids were associated with improvement in facial pain, congestion, rhinorrhea, headache, and post-nasal drip. No significant increases in adverse symptoms were observed.

Although the number needed to treat for intranasal steroids is reasonable, patients may not want to pay the cost, or even the co-pay, for a medication that requires 2 to 3 weeks to lead to symptoms improvement or resolution. Cheaper options exist (i.e., decongestants). Questions remain as to whether we can use steroids instead of antibiotics for the treatment of sinusitis in selected patients. Until we have these data, tension between the clinician’s desire to judiciously prescribe antibiotics and the patient’s expectations for them will persist.

Jon O. Ebbert, M.D., is a professor of medicine and a primary care clinician at the Mayo Clinic in Rochester, Minn. He declares having no conflicts of interest. The opinions expressed are solely those of the author. Contact him at [email protected].