xRead - Nasal Obstruction (September 2024) Full Articles

20426984, 2021, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/alr.22741 by Stanford University, Wiley Online Library on [01/07/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License

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Orlandi et al.

diagnosis of CRSwNP with varying degrees of severity of the disease amongst the studies. Three studies had no minimal grade of nasal polyps for inclusion, 2 required moderate-to-severe bilateral polyps, and 3 studies only included severe nasal polyposis. All studies reported positive results for short course of oral corticosteroids compared to placebo (5 studies) or no treatment (2 studies). Corticosteroid courses ranged from 14-21 days and included prednisone, prednisolone and methylprednisolone. Total doses ranged from 210 mg to over 1000 mg of prednisone equivalent. The review reported low quality evidence of an improve ment in disease-specific health-related QoL as well as in disease severity after treatment with oral corticosteroids compared to the controls at various time points. After the treatment period had ended, there was no difference in the change from baseline symptom severity between the treat ment groups. There was evidence that immediately after treatment, oral corticosteroids provided improvement in nasal polyp scores. The magnitude of this improvement months after treatment may not be sustained. A high risk of bias existed for both statements. When analyzing data on the side effects of corticos teroids, there was low quality evidence of increase in insomnia and gastrointestinal disturbances in the steroid group. There was low quality evidence regarding mood disturbances between the 2 groups and any difference between groups was unclear. The second review evaluated the data on oral corticos teroids as an adjunct in patients with CRSwNP. 1614 The authors identified 2 studies, only 1 of which included adults. This study was an unblinded, quasi-randomized controlled trial in 30 adults with CRSwNP based on endo scopic examination. Patients were treated with a 21 day course of topical INCS alone, oral methylprednisolone alone, or both. The included outcome was the endoscopic nasal polyp score measured on a 4 point scale. The patients receiving the oral corticosteroids plus topical intranasal steroids had an improvement in the nasal polyp score com pared to the topical intranasal corticosteroid alone, though there was a high risk of bias in these data. Providers must also consider the potential risks associ ated with oral corticosteroid use. A cost analysis compared the risks of corticosteroids with those of sinus surgery in CRSwNP patients. The authors evaluated reported compli cation rates, QoL changes and Medicare costs between the 2 treatments. They concluded that the breakeven thresh old, favoring surgery over medical therapy, occurred when more than 1 corticosteroid course was given every 2 years in CRSwNP patients, once per year in CRSwNP patients with asthma, and twice per year in AERD patients. Of note, CRSsNP patients were not included in the analysis. 1615

In summary, evidence exists to support short-term use of oral corticosteroids, either alone or as an adjunct, in symp tomatic treatment and polyp size regression in patients with CRSwNP. Variable drugs, dosing and duration were used in the reviewed literature. The beneficial effects last for a short duration only and potential adverse effects of a single burst or multiple short-term bursts must be consid ered when treating patients. Oral Corticosteroids for CRSwNP Aggregate Quality of Evidence: A (Level 2: 7 stud ies; Table X-21). Benefit: Significant short-term improvements in subjective and objective measures in CRSwNP patients. Duration of improvement may last 8-12 weeks in conjunction with topical intranasal cor ticosteroid use. Harm: More GI symptoms in steroid group, rare severe reactions occur. Transient adrenal suppres sion, insomnia, and increased bone turnover. All known corticosteroid risks exist, particularly with prolonged treatment. See Table II-1. Cost: Low. Benefits-Harm Assessment: Preponderance of benefit to harm with short-term burst with limited, short-term follow-up. Value Judgments: Significant short-term improve ments in subjective and objective measures based on high quality data, low risk and low cost. Policy Level: Strong recommendation for short termuse. Intervention: Strong recommendation for the use of oral corticosteroids in the short-term manage ment of CRSwNP. Longer term use of steroids for CRSwNP is not supported by the literature and car ries and increased risk of harm to the patient. X.D.5 Management of CRSwNP with Antibiotics X.D.5.a. Antibiotics for CRSwNP: Oral Non-Macrolide Antibiotics for < 3Weeks Since ICAR-RS-2016 there has been little change in the literature to support the use of short-term antibiotics for CRSwNP. Most articles are concerned with antibiotic treat ment of AECRS. In an EBRR on antimicrobials in CRS published in 2013, Soler et al. found only 6 studies examining the short-term ( < 3 weeks) use of antibiotics in CRS. 1119 Only 1 of these,