HealthDay News — For patients with acute sinusitis, inhaled corticosteroids provide a small benefit over placebo but only after several weeks, results of a meta-analysis suggest.
The treatment worked best at higher doses and longer durations, Gail Hayward, MBBChir, DPhil, of Oxford University in England, and colleagues reported in Annals of Family Medicine.
Overall, symptoms improved or resolved completely about 7% more often in patients who used inhaled corticosteroids compared with those on placebo, with the most consistently significant benefits observed for facial pain and congestion.
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“This systematic review demonstrates that intranasal corticosteroids offer a small but significant symptomatic benefit in acute sinusitis,” the researchers wrote.
The meta-analysis involved six studies and 2,495 patients aged 12 to 18 years with suspected acute sinusitis or rhinosinusitis, who were treated with intranasal corticosteroids or placebo in outpatient otorhinolaryngology clinics, emergency departments and general practice clinics.
Three trials evaluated mometasone furoate (Nasonex), two evaluated budesonide and one evaluated fluticasone propionate (Flonase). Antibiotics were also prescribed in five of the studies.
After 14 to 21 days, 66% of patients taking placebo experienced symptom improvement or resolution. This proportion increased 7% among patients taking the inhaled corticosteriods, which the researchers equated to a number needed to treat (NNT) of 13.
Although intranasal steriods are widely used to treat upper respiratory infections, there is minimal high-level evidence to support their use, the researchers noted.
Primary outcomes in five of the studies included in the metanalysis was improvement or resolution of symptoms within 14 to 21 days. For this outcome inhaled corticosteroids showed a combined risk difference (RD) of 0.08 in favor of steroid treatment (P=0.004), which persisted after two lower-quality studies were excluded (RD 0.07, P=0.02).
In the three studies that evaluated outcomes after 14 to 15 days, the researchers observed no differences between treatment with inhaled corticosteriods and placebo (RD 0.05, P=0.13). Similarly, no significant difference was observed in two studies that reported outcomes after 10 days.
In the three trials examined the effect of mometasone furoate, the researchers observed a significant dose-response relationship. An overall significant benefit was observed with doses ranging from 200 to 800 µg/d for 15 to 21 days (RD 0.08, P=0.02). Higher doses produced greater differences from placebo — the NNT was 8 for 800 µg/d (RD 0.12, P=0.0002), and 14 for 400 µg/d (RD 0.07, P=0.001).
In the three trials that involved mometasone, patients randomized to inhaled corticosteriods had significantly greater improvement in facial pain, congestion, rhinorrhea, headache and postnasal drip (P<0.05).
Overall, no differences were observed in adverse events between patients taking inhaled corticosteriods and those on placebo.
In an accompanying editorial, John Hickner, MD, MSc, from the Cleveland Clinic, pointed out that the modest benefits observed in the meta-analysis do not necessarily translate into clinical practice.
“Most patients want to get better in a few days, not three weeks,” Hicker wrote. “Nasal steroids are not the answer for most patients.”
With a cost of about $61 for a bottle of fluticasone propionate nasal spray, most patients will opt to take cheaper medications such as pseudoephedrine and ibuprofen “for similar relief at a fraction of the cost,” he noted.
However, patients with allergic rhinitis are an exception to this rule. “I would not hesitate to prescribe nasal steroids for these patients when they have acute sinusitis,” Hickner wrote.
Hayward G. Ann Fam Med. 2012;10:241-249;doi:10.1370/afm.1338.
Hickner J. Ann Fam Med. 2012;10:196-197;doi:10.1037/afm.1395.
