xRead - Olfactory Disorders (September 2023)

20426984, 2022, 4, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/alr.22929, Wiley Online Library on [04/09/2023]. 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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INTERNATIONAL CONSENSUS ON OLFACTION

enrolled in clinical trials and frequent use of combination therapy with topical intranasal steroids being used as a maintenance medication in the majority of studies. In patients with CRSsNP, data on treatment of OD is more limited and no clear benefit has been demonstrated in a randomized manner. Topical steroids and oral steroids are potential treatment options, and the decision to treat OD with these medications should be individualized. Data on macrolide therapy is limited and the available literature is conflicting. 1363–1366 Therefore, no recommendation can be made regarding macrolide therapy for OD in patients with CRSsNP refractory to more conservative therapy. In patients with AR, there are few randomized con trolled clinical trials investigating olfactory outcomes. Top ical intranasal steroids are recommended for treatment of OD in patients with AR, with some randomized clini cal trials demonstrating benefit in objective and subjective assessments of olfaction. 231,236,1367–1370 The literature on immunotherapy primarily consists of case series and one RCT, which together demonstrate improvement in sub jective and objective olfactory outcomes. 1371–1375 Therefore, immunotherapy may be considered a treatment option. Available randomized clinical trials have demonstrated no clear benefit of antihistamines over topical nasal steroids for OD related to AR. However, some studies demonstrate improvement in subjective olfaction scores and therefore antihistamines may be considered as an option to treat OD in patients with AR. OD is more common and more severe in patients with CRSwNP compared with patients with CRSsNP or AR. 225,1358 Currently, there is strong evidence in the form of both subjective and psychophysical measures support ing use of oral steroids, dupiliumab, and omalizumab for OD in patients with CRSwNP. There is also support for the use of regular sustained topical steroid use for OD in patients with CRSwNP, but this data are largely in the form of subjective outcomes. Oral steroids are generally used for short durations ranging from 1 to 3 weeks and topical intranasal steroids are used for sustained longer term use. Biologics are used for prolonged periods at reg ular intervals (every 1 to 4 weeks), they do not all have the same effect on OD, and olfactory benefit is unknown once the medication is stopped. These medications are recom mended for the treatment of OD in patients with CRSwNP in the appropriate clinical circumstances. Further high level studies investigating use of medical therapy for treat ment of OD are needed, especially in patients with CRSsNP or AR. (Tables IX.3-17) Oral corticosteroids for OD in patients with CRSwNP. Aggregate Quality of Evidence : A (Level 1: one study; Level 2: 11 studies).

Benefit : Significant short-term improvements in sub jective and objective measures of olfaction in patients with CRSwNP. Duration of improvement with systemic corti costeroid alone may last 2 to 4 weeks, but this benefit may be lengthened with concurrent use of topical intranasal corticosteroids. Harm : Corticosteroid risks include gastrointesti nal (GI) upset, hyperglycemia, rare severe reactions, cataracts, increased risk of infection, transient adrenal suppression, insomnia, and increased bone turnover, among others. Risks are greater with higher cumulative doses. Cost : Direct: Low monetary cost. Indirect: Minimal. Benefits-harm assessment : Preponderance of benefit over harm with short, infrequent treatment courses. Value judgments : Weighing the potential benefits against the possible harms should be done as part of a shared decision-making process. Policy level : Strong recommendation for short-term use. Intervention : Strong recommendation for the use of oral corticosteroids in the short-term management of OD in CRSwNP as part of a shared decision-making approach. Longer-term use of oral steroids for OD in CRSwNP has not been studied and carries increased risk of harm to the patient. Intranasal topical corticosteroids for OD in patients with CRSwNP. Aggregate grade of evidence : A (Level 1: two studies; Level 2: 26 studies; Level 3: one study). Benefit : Significant improvements in subjective and objective measures of olfaction in patients with CRSwNP. With regular use, benefits can be maintained. Harm : Relatively low with epistaxis, nasal irritation, headache possible side effects. Cost : Direct: Low to moderate monetary cost depending on formulation. Indirect: Minimal. Benefits-harm assessment : Preponderance of benefit overharm. Value judgments : Increasing dosage of topical intranasal corticosteroid should be considered if the magnitude of observed clinical benefit is partial/limited. Policy level : Strong recommendation for daily use of topical intranasal corticosteroid spray for the management of OD in patients with CRSwNP. Intervention : The use of topical nasal corticosteroids for OD in patients with CRSwNP is strongly recommended both before and after sinus surgery.