Systemic corticosteroids
The use of short courses of systemic corticosteroids (SCS) is an
important tool in the treatment of severe CRSwNP due to their potent
anti-inflammatory effects. SCS modulate the immune response with
suppression of inflammation. These agents reduce the infiltration of
inflammatory cells, inhibit the release of pro-inflammatory mediators
and attenuate the vasodilation and oedema associated with CRSwNP. The
downregulation of inflammatory mediators results in reducing nasal polyp
size and improving nasal congestion, smell dysfunction and other
sinonasal symptoms (10-12).
SCS are an inexpensive and a globally available treatment, with
effective reduction of nasal polyp size and rapid improvement of major
sinonasal symptoms such as nasal obstruction, loss of smell and nasal
discharge in both short and long-term treatment (11). SCS are often used
in the management of acute exacerbations or as a short-term burst
therapy because they can quickly reduce nasal polyp size and alleviate
sinonasal symptoms but evidence, including the optimal dose, is lacking.
They are also commonly used for the management of asthma exacerbations
in acute care settings, where usually doses of /1 mg/kg prednisolone
equivalent to q maximum of 50 mg for 2-7 days are advised (13);Banoth,
2022 #94;Normansell, 2016 #95}. Comorbid patients with severe asthma
(SA) and CRSwNP usually receive SCS more frequently as they work on both
upper and lower airway symptoms, but local (intranasal and inhaled)
long-term CS should be preferred.
Unfortunately, the effects of SCS wane shortly after ending treatment
(14). In view of significant systemic side effects observed with
repeated short or long-term courses such as osteoporosis, glaucoma,
diabetes, cataract, hypertension, anxiety, insomnia, agitation, risk of
adrenal suppression, increased appetite and reflux (10, 15) they are not
recommended for maintenance treatment (11). The EPOS 2020 criteria
advise not to prescribe more than two courses of SCS per year because of
the cumulative side-effects (1). Moreover, the willingness of the
patient to use SCS should be considered, as some patients might fear the
adverse effects (16). The use of SCS should be considered extra
carefully and weighed against the induced risks in patients suffering
from certain conditions such as diabetes, glaucoma, or osteoporosis(11).
In routine clinical practice there is a significant heterogeneity in
prescribing systemic steroids by clinicians in terms of type, dosage,
and treatment duration, partially explained by the lack of universally
accepted modes of prescribing of systemic steroids over the years (6,
15, 17, 18).