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

504

International consensus statement on rhinosinusitis

ficient evidence to make a recommendation regarding this therapy.

Oral Non-Macrolide Antibiotics for > 3Weeks forCRSwNP Aggregate Grade of Evidence: D (Level 3: 1 study, Level 4: 2 studies; Table X-23). Benefit: Potential symptom relief. Harm: Adverse effects of antibiotics include skin rash, gastrointestinal upset, and anaphylaxis; delay in more effective therapy (see Table II-1). Cost: Variable depending on the antibiotic. Benefits-Harm Assessment: Balance of benefit and harm. Value Judgments: A lack of evidence and known adverse effects may outweigh the possible benefit. Policy Level: No recommendation. Intervention: Practitioners should weight the risks and benefits of extended courses ( > 3 weeks) of non-macrolide antibiotics for CRSwNP and know that the literature is sparse. X.D.5.c. Antibiotics for CRSwNP: Macrolide Antibiotics Macrolide antibiotics have both anti-inflammatory and immunomodulatory properties, in which they demon strate reduction in pro-inflammatory cytokines, especially IL-8, the primary cytokine involved in the recruitment of neutrophils, and TNF- α . 1105,1628 Due to this effect on the primarily neutrophilic rather than eosinophilic com ponent of the inflammatory response, macrolide antibi otics have been found to be most effective specifically in Th1-mediated non-eosinophilic CRS in long durations and low doses. 1,31,1628,1629 Of the 2 common phenotypes of CRS, CRSsNP, and CRSwNP, 1,31,1105,1628 CRSwNP generally responds well to corticosteroids due to its pathophysiol ogy being driven more by excessive T-helper2 inflamma tion and eosinophilic infiltration. 1,1628,1630 However, there is a subset of CRSwNP characterized by its corticosteroid resistance, which has been found to have a predomi nantly neutrophilic or mixed histopathology, rather than eosinophilic, and has shown benefit from long-term, low dose macrolide therapy. 1628 In 2014, Peric et al. evaluated the clinical effects of pre operative long-term, low-dose clarithromycin administra tion in patients with nasal polyposis. They found preop erative clarithromycin administration delays nasal polyp relapse after ESS. 1631 Varvyanskaya et al. assessed the efficacy of long-term macrolide therapy adjunct to the

TABLE X-23 Evidence for CRSwNP management with non-macrolide oral antibiotics for ≥ 3weeks Study Year LOE Study Design Study Groups Clinical Endpoint Conclusions Sreenath 1622 2015 3 Prospective, randomized cohort 3 weeks of antibiotics 6 weeks of antibiotics Recommendation for surgery RSDI score LMCTscore No difference in recommendation for surgery. Bezerra 1625,1626 2014 4 Prospective cohort INCS INCS + doxycycline SNOT-20 score NOSEscore LK endoscopy score Statistical improvement in all endpoints with addition of doxycycline. Hoza 1627 2013 4 Case-series Erdosteine Erdosteine with INCS spray SNOT-22 score Reduction in symptom score. Better response seen without INCS.