2016 Section 5 Green Book

Reprinted by permission of Am J Rhinol Allergy. 2015; 29(5):339-342.

Oral corticosteroids in the management of chronic rhinosinusitis with and without nasal polyps: Risks and benefits

David M. Poetker, M.D., M.A.

ABSTRACT Background: Oral steroids are synthetic mimics of adrenal cortex hormones and are considered a staple in the management of chronic rhinosinusitis due to their anti-inflammatory effects. Despite their common use, many providers are not familiar with the potential risks of the drugs. Methods: Literature review. Results: An overview of the existing data on the risks of oral steroids is presented as well as a review of the malpractice lawsuits with regard to oral steroid use and a discussion of the data that support the use of oral steroids in patients with chronic rhinosinusitis with and those without nasal polyps. Conclusion: It is essential for providers to be aware of the potential complications of a medication, the medical jurisprudence of the drugs, and the data that support their use. (Am J Rhinol Allergy 29, 339–342, 2015; doi: 10.2500/ajra.2015.29.4223) O ral steroids are a mainstay of treatment in the management of sinonasal inflammatory disease, are commonly used, and are

Hyperglycemia Steroids increase blood sugars by stimulating proteolysis, promot- ing gluconeogenesis, and inhibiting glucose uptake. 6 In addition, steroids cause an insulin resistance by decreasing the ability of adi- pocytes and hepatocytes to bind insulin. This effect can occur within hours of beginning therapy but seems to decrease with prolonged use. 6 Synthetic steroids are many times more potent than natural steroids at decreasing carbohydrate tolerance. 6 Upon cessation of the steroids, the inhibition of glucose uptake and metabolism usually returns to normal. 6 Despite their common use, the degree of hyper- glycemia caused by steroids has not been clearly established. Infection Although steroids increase circulating neutrophils by enhanced release from bone marrow and reduced migration from blood vessels, the number of lymphocytes, monocytes, basophils, and eosinophils decrease due to a migration from the vascular bed to lymphoid tissue. 7 Steroids can impair neutrophil function by reducing their adherence to vascular endothelium and their bactericidal activity; inhibit antigen-presenting cells by limiting chemotaxis, phagocytosis, and the release of cytokines; decrease the expression of inflammatory mediators; and may inhibit B-cell production of immunoglobulins. 7,8 Interestingly, steroid administration on an alternate day schedule has been shown to reduce their negative impact on leukocyte function. 8 Two large meta-analyses found that the rate of infections were significantly higher in patients treated with steroids. 9,10 Further re- view found that patients who received a daily dose of 10 mg per day or a cumulative dose of 700 mg of prednisone did not have an increased rate of infectious complications. 10 Although the disease processes for which the patients are being treated may themselves be independent risk factors for infection, close review of the included studies identified few patients with diseases known to increase risk for infection. 9,10 Additional studies demonstrated that patients treated with glucocorticoids are at increased risk for developing invasive fungal infections, pneumocystosis, and viral infections, especially in patients who have undergone bone marrow transplantation. 4,11–15 Wound Healing Steroids inhibit the natural wound healing process by decreasing the influx of macrophages, which may decrease phagocytosis as well as growth factor and/or cytokine production. 16–19 Steroids can also delay reepithelialization, decrease the fibroblast response, slow cap- illary proliferation, and inhibit collagen synthesis and wound matu- ration. 16,18,20

considered by many rhinologists to constitute a key component of “maximal” medical therapy. 1 Their anti-inflammatory effects to treat the inflammation associated with chronic rhinosinusitis (CRS) as well as their antifibroblast effects to reduce postoperative scar formation are the most common reasons for their widespread use. 2 Despite their common use, many providers are not familiar with the potential risks of the drugs. The objectives of this review were to present an overview of the existing data on the risks of oral steroids. This was not intended to be an exhaustive review because other articles exist that specifically outline those risks. 3 We plan to discuss what is known about specific risks, review the lawsuits regarding oral steroid use, and finally, discuss the data that support the use of oral steroids in patients with CRS, with and without nasal polyps. Morphologic Changes Redistribution of adipose tissue, a common effect associated with prolonged oral steroids, is known as “corticosteroid-induced lipodys- trophy” or “cushingoid” changes, and includes truncal obesity, facial adipose tissue (moon facies), and dorsocervical adipose tissue (buf- falo hump). 4 The rate and incidence is variable but has been reported to occur in 15% of patients in 3 months, with daily doses equivalent to 10–30 mg of prednisone. 4 Higher doses and longer durations of corticosteroids seem to increase the frequency of adipose tissue re- distribution. 5 The risk is reportedly higher in women, patients 50 years of age, and patients with either a high initial body mass index or a high calorie intake. 5 COMPLICATIONS OF STEROID USE From the Division of Otolaryngology, Department of Surgery, Zablocki VA Medical Center, Milwaukee, Wisconsin D. Poetker is a speaker for Intersect ENT and a consultant for GlaxoSmithKline Presented at the North American Rhinology and Allergy Conference, Boca Raton, Florida, February 7, 2015 Address correspondence to David M. Poetker, M.D., Division of Rhinology and Sinus Surgery, Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, 9200 W Wisconsin Avenue, Milwaukee, WI 53226 E-mail address: dpoetker@mcw.edu Copyright © 2015, OceanSide Publications, Inc., U.S.A.

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