xRead - Nasal Obstruction (September 2024) Full Articles

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a difference. 1631–1633 Regarding endoscopic scores, Peric et al. and Varvyanskarya et al. both reported better endo scopic scores in the clarithromycin group when given both preoperatively 1631 and postoperatively. 1632 It is also pro posed that the efficacy of anti-inflammatory medications may differ among CRS patients with and without sur gical interventions due to the varied inflammatory load and sinus anatomy amongst postoperative patients. 1068,1636 More placebo-controlled studies are needed to determine the exact efficacy of macrolides across clearly defined CRS subtypes. These subtypes should be classified based on phenotype as well as endotype. In summary, there are 5 meta-analyses and 3 RCTs assessing macrolides in CRSwNP. Most RCTs and some cohort studies revealed significant improvement of certain clinical parameters in patients treated with macrolides, while other studies showed no differences. Further RCT studies are needed in the future. Risks of adverse events should be considered so that potential benefits are bal anced with potential harms. Macrolide Antibiotics for CRSwNP Aggregate Grade of Evidence: B for CRS overall with limited evidence regarding CRSwNP specif ically (Level 1: 5 studies; level 2: 3 studies; level 3: 5 studies; Table X-24). Benefit: Macrolides may improve symptom scores and endoscopic scores in CRSwNP patients. But results are mixed among 3 RCTs. Harm: Significant potential for medication inter actions. Rare mild adverse events, such as gas trointestinal side effects, ototoxicity, hepatotoxic ity, cardiotoxicity. See Table II-1. Cost: Low. Benefits-Harm Assessment: Unclear benefit-to harm ratio in CRSwNP patients. Benefits of treatment over placebo, and benefits of adding macrolides to other treatment were seen in some studies but not others. Value Judgments: Optimal drug, dosage, and dura tion of therapy are not known. Policy Level: Option. Intervention: In CRSwNP, macrolides may be ben eficial, especially in neutrophil-dominant polyps or in those who are unresponsive to corticos teroids.

maintenance therapy with nasal corticosteroids in the recurrence-prevention of nasal polyps after ESS. They con firmed that long-term macrolide therapy had significantly improved almost all parameters they had measured, such as SNOT-20, endoscopic and CT scores, with the exception of acoustic rhinometry and VAS. 1632 In 2014, Korkmaz et al. revealed that the combined administration of long-term low-dose oral macrolides with nasal steroids is effective in eradicating biofilm in CRSwNP. However, in terms of CT and symptom scores, such combined therapy was not any better. 1633 There are several meta-analyses assessing the effect of macrolides on CRS with conflicting conclusions. Pyn nonen et al. concluded that scientific evidence was not strong enough to support the use of long-term macrolides to treat CRS. 1117 Cervin et al. concluded that long-term macrolides were a viable option in the treatment of CRS on selected patients. 1120 Lasso et al. concluded that some positive effects were associated with the use of macrolides for postoperative CRSwNP, but the changes did not reach statistical levels required for a firm conclusion on the use of macrolides for treating CRS patients. 1634 Huang et al. concluded that adding oral clarithromycin to intranasal steroid spray likely achieved better results than intranasal steroid spray alone for both CRSsNP and CRSwNP. 1118 Regarding the characteristics of macrolide responders and factors of success, Oakley et al. conducted a case control study of consecutive CRS patients placed on a 3 month low dose macrolide therapy after failing 3 months of corticosteroid irrigation therapy post-ESS. They con cluded that the CRS phenotype appearing to respond to macrolide therapy had low tissue and serum eosinophilia, and absence of tissue squamous metaplasia. 1123 Seresirika chorn et al. found that low dose macrolides had produced favorable outcomes in patients with CRSsNP compared with CRSwNP, and suggested that a half dose of macrolides should be given for a duration of 24 weeks. 1121 Although macrolide therapy has been shown to be effec tive for CRS patients, there are potential adverse effects to consider, such as cardiovascular risks (prolongation of the QT interval resulting in arrhythmia and myocardial infarc tion), elevated liver enzyme levels, ototoxicity and gas trointestinal side effects. 1635 Bacterial resistance and drug drug interactions are other potential issues. CRS is a heterogeneous disorder comprising differ ent phenotypes and endotypes. Most studies assessing the efficacy of macrolides on CRS patients do not sep arate CRSwNP from CRSsNP, making results harder to interpret. 1111,1114–1116,1539 Only 3 RCTs specifically assessed CRSwNP patients. 1631–1633 Of these, only Varvyanskarya et al. found a significant difference in SNOT-20 scores in CRSwNP patients compared to the control group, whereas other subjective measures did not demonstrate