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).