NEW YORK (Reuters Health) – For patients with chronic rhinosinusitis accompanied by nasal polyps, treatment first with oral steroids followed by topical steroids is more effective than just topical steroid therapy, a Scottish team reports in the Annals of Internal Medicine for March 1.

Dr. Brian Lipworth and colleagues at Ninewells Hospital and University of Dundee, UK note that chronic rhinosinusitis with nasal polyposis is common, affecting 32 million people in the US alone.

The team reasoned that frequent relapse in patients treated with intranasal corticosteroids is partly attributable to polyps blocking penetration of topical therapy, and that a short course of oral steroids to reduce polyp size would improve treatment.

To test this, the team randomly assigned 60 patients with chronic rhinosinusitis and moderate-to-large nasal polyps to receive oral prednisolone 25 mg/d or placebo for 2 weeks. Both groups then were given fluticasone nasal drops 400 mcg BID for 8 weeks followed by fluticasone nasal spray 200 mcg BID for 18 weeks.

From baseline to 2 weeks, polyp grade decreased by 2.1 units in the oral prednisolone group and by 0.1 units in the placebo arm (p<0.001). The difference in polyp grade was still significant at 10 weeks (-1.08 units; p=0.001) but not at 28 weeks (-0.8 units; p=0.11), according to the report. Hyposmia score, measured on a 100-mm scale, declined by 31.12 mm in the first 2 weeks in the prednisolone groups compared with 1.41 mm in the placebo group. Again, the difference between groups remained significant at 10 weeks (-16.06 mm) but not a 28 weeks (-12.13 mm). “We believe these results are an important step in developing robust treatment approaches for this common but relatively understudied condition,” Dr. Lipworth and colleagues conclude. They note that prednisolone therapy was associated with adrenal suppression and increased bone turnover after 2 weeks, but these parameters returned to normal at 10 and 28 weeks. However, an editorial points out that the adverse effects of oral steroid therapy on the HPA axis and bone metabolism are likely greatest among the elderly, postmenopausal women, and those given repeated course of oral therapy. “Thus,” write Drs. Joaquim Mullol and Isam Alobi at Hospital Clinic i Universitari, Barcelona, Spain, “we believe that oral steroid therapy should be initiated only when patients with chronic rhinosinusitis with nasal polyps have an unsatisfactory response to at least 3 months of treatment with intranasal corticosteroids.” Ann Intern Med. 2011;154:293-302,365-367.