Intranasal corticosteroids show variable efficacy for chronic rhinosinusitis with nasal polyps

August 19, 2022

4 minute read


Disclosures: Chu does not report any relevant financial information. Please see the study for relevant financial information from all other authors.

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Key points to remember:

  • Sinusitis-related quality of life may improve with intranasal corticosteroid flushing and exhalation systems compared to placebo.
  • Administration of a stent/bandage and intranasal corticosteroid spray will likely improve symptoms of nasal obstruction compared to placebo.
  • The interventions examined had no significant differences in adverse events.

According to a review published in The Journal of Allergy and Clinical Immunology.

Based on this review, stent, spray, and exhale (EDS) delivery systems appear beneficial for the widest range of important patient outcomes, Derek K. Chu, MD, PhD, assistant professor in the department of medicine at McMaster University, Hamilton, Ontario, Canada, and colleagues wrote.

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“Chronic rhinosinusitis with nasal polyposis is an inflammatory disease of the nasal mucosa and paranasal sinuses lasting a minimum of 12 weeks. It affects approximately 2% to 4% of people in the United States and Europe with symptoms including nasal obstruction, impaired sense of smell, nasal drainage, and facial pain and pressure,” Chu told Healio .

To treat CRSwNP, topical intranasal corticosteroids (INCS) are applied directly to the nasal and sinus mucosa using sprays, rinses, drops, EDS, stents and dressings, nebulization, injections local and high-dose sprays.

Derek K Chu

“However, it remains unclear which route of administration should be preferred – for example, spray or rinse – as well as how and when they should be used versus other therapies and what outcomes benefit from their use,” said Chu.

The authors prepared this systematic review and network meta-analysis to inform an update of the clinical practice guidelines of the American College of Allergy, Asthma & Immunology and the American Academy of Allergy, Asthma & Immunology’s Joint Task Force for Allergy-Immunology Practice Parameters (JTFAIPP).

Exam design, results

The authors reviewed 61 unique randomized controlled trials (RCTs) published up to September 2021 including 7176 participants studying eight modalities of using INCS to treat CRSwNP.

The trials had a median number of 70 participants (range, 18-748; mean age, 46.1 years; range of means, 31-54; mean percentage of women, 40%). The interventions had a median duration of 12 weeks (range, 2-260).

In addition, 91.3% of trials included patients who had only CRSwNP, and the remainder included populations with mixed patients. In addition, 31.9% had asthma, although only 40.1% reported data on this.

Fourteen RCTs (n=950) compared the effect of spray, rinse, stent/bandage, high-dose spray, EDS, and placebo on patient-specific quality of life (QoL). disease, concluding with low-certainty evidence that only flushing (mean difference [MD], –6.83; 95% CI, -11.94 to -1.71) and EDS (MD, -7.86; 95% CI, -14.64 to -1.08) may lead to improvements. The other interventions had no clear effect.

Then 31 RCTs (n = 4539) compared these same routes of administration plus drops on symptoms of nasal obstruction. Spray (MD, -0.51; 95% CI, -0.61 to -0.41; high certainty), stent/dressing (MD, -0.31; 95% CI, -0.54 to – 0.08; moderate certainty) and EDS (MD, -0.35; 95% CI, -0.51 to -0.18; moderate certainty) improvement in symptoms. Additionally, high-dose spraying ( MD , -0.51; 95% CI , -0.85 to -0.16; very low certainty) may produce improvements. Rinse and drops had no clear difference.

Eight trials (n=1306) found that EDS (difference in risk [RD], –4.3%; 95% CI, -6.9% to -0.9%; certainty), stent/dressing (RD, -10.3%; 95% CI, -12.9 to -0.2%; low certainty) and spray (RD, -10.7%; 95% CI , -13 to -2.1%; very low certainty) reduced the rates of life-saving surgeries needed compared with placebo, although the drops had no clear benefit and no particular treatment was superior to another in direct comparisons.

In 25 studies (n=4036), the INCS stent improved sense of smell with moderate certainty ( MD 3.81; 95% CI 1.22-6.39). With low certainty, researchers also found that spray (MD, 3.24; 95% CI, 2.05-4.42), EDS (MD, 4.1; 95% CI, 1 .69-6.52) and drops (MD, 5.03; 95% CI, 1.89-8.18) might improve odor, but rinsing does not clearly affect odor.

Nasal polyp scores were measured in 24 trials (n = 3668). Spraying (MD, -0.64; 95% CI, -0.85 to -0.43; high certainty) and EDS (MD, -0.56; 95% CI, -0.97 to -0.14; moderate certainty) reduced the size of nasal polyps, but other interventions did not have a clear effect compared with placebo, with very low to low certainty evidence.

Five RCTs (n=397) found that stent/dressing, spray, rinse, drops, and nebulizer had no clear effect on imaging scores, based on the Lund Mackay scale , with very low to low certainty evidence.

Finally, 10 trials (n=595) found that stent/dressing, spray, rinse, nebulizers and high-dose spray had no clear effect on improving endoscopy scores measured on the Lund-Kennedy scale versus placebo, with very low certainty.

An analysis of adverse events showed no important difference between routes of administration of INCS and placebo, with moderate certainty for INCS spray and very low to low certainty for other routes of administration.

Conclusions, next steps

“The comparative efficacy and safety of different INCS approaches were different depending on the results,” Chu said.

“Multiple administration forms of INCS are viable treatment options for CRSwNP, resulting in improved patient-important outcomes. INCS via stent, spray, and EDS appears to be beneficial across the widest range of outcomes considered. “, he continued.

Overall, EDS administration was most beneficial in five of the nine outcomes analyzed by the authors, with the spray being the most beneficial in four of the outcomes and the stent the most beneficial in three.

The researchers further concluded that each delivery method delivers sufficient corticosteroids to the targeted mucosa with significant patient benefits, although they noted that further research should focus on additional interventions. Additionally, future RCTs should more robustly address patient-important outcomes and reduce imprecision with larger and more diverse sample sizes in multicenter studies, Chu said.

In the meantime, the authors expect the JTFAIPP to publish the associated guideline soon. Along with the task force’s previous research, the authors said, it will inform physicians on how to achieve optimal outcomes for patients with CRSwNP.

“Physicians can use this study and its associated guidelines to inform shared decision-making with patients with CRSwNP regarding whether or not to use INCS and, if so, which approach might be most consistent with their values. and individual preferences,” Chu said.


For more information:

Derek K. Chu, MD, PhD, can be reached at [email protected]

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