Oral Prednisolone Might Not Improve Acute Rhinosinusitis Symptoms

DynaMed Weekly Update - Volume 7, Issue 43

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Oral corticosteroids are sometimes prescribed for symptom relief in patients with acute rhinosinusitis. In a Cochrane review (Cochrane Database Syst Rev 2011 Dec 7;(12):CD008115) steroids were associated with some symptom improvement, but most of the patients in the included trials had been referred for specialist care and had radiologic assessment as part of diagnostic testing. The benefit of corticosteroids in primary care management of sinusitis remains unclear. A recent randomized trial evaluated oral prednisolone in 185 adults with uncomplicated acute rhinosinusitis who visited their primary care physician.

Patients (mean age 43 years) with sinusitis symptoms for at least 5 days were randomized to prednisolone 30 mg/day orally vs. placebo for 7 days. All patients had either nasal discharge or congestion and had facial pain or pressure (or pain when chewing). They were allowed to take acetaminophen as needed. Participating physicians were allowed to prescribe antibiotics or nasal corticosteroids, but were asked to refrain from doing so for the first 7 days whenever possible. Patients were asked to fill out a symptom diary for 14 days.

In analysis of 94% of the randomized patients, there were no significant differences in symptom outcomes (level 2 [mid-level] evidence). In the prednisolone group, 62.5% had complete resolution of facial pain or pressure at 7 days compared to 55.8% in the placebo group. The median duration of facial pain was 4.5 days with prednisolone vs. 5 days with placebo. The rates of total symptom resolution at 7 days were 32.9% with prednisolone vs. 25.3% with placebo. There were no significant differences in health related quality of life or adverse events at 7 or 14 days or in symptoms in long-term follow-up at 8 weeks (CMAJ 2012 Oct 2;184(14):E751).

The trial was powered to detect a 20% difference in the rates of pain resolution at 7 days, but the observed difference was only 6.7%, and the trial was underpowered to establish this degree of difference as statistically significant. Whether a difference of this magnitude would warrant the use of corticosteroids involves considerations of both the patient’s and clinician’s values and preferences. This clinical decision-making may depend on the severity of the symptoms, the patient-specific risks associated with corticosteroids, and the alternative options considered.

For more information, see the Acute sinusitis topic in DynaMed.