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Tamene S, Dalhoff K, Schwarz P, Backer V, Aanaes K. Systemic corticosteroids in treatment of chronic rhinosinusitis-A systematic review. Eur Clin Respir J 2023; 10:2240511. [PMID: 37554567 PMCID: PMC10405757 DOI: 10.1080/20018525.2023.2240511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Accepted: 07/20/2023] [Indexed: 08/10/2023] Open
Abstract
Purpose When first-line chronic rhinosinusitis (CRS) treatment fails, patients can either be treated with oral or injected systemic corticosteroids. Although the EPOS and international guidelines for CRS do not mention injected corticosteroids, it is commonly used by ear, nose, and throat specialists. While the risks of systemic corticosteroids, in general, are known, the pros and cons of injected and oral corticosteroids (OCS) in CRS treatment are unclear. Methods A systematic review of studies that report the effects and/or side effects of injected and oral corticosteroids in the treatment of CRS was made according to the PRISMA guidelines. Results Altogether, 48 studies were included, only five studies reported on injected corticosteroids, and five attended with side effects. Three studies found beneficial effects of OCS perioperatively on sinus surgery, while four articles found no effect. Nineteen articles reported that OCS resulted in an improvement in symptoms. Two articles presented a longer-lasting effect of injected corticosteroids than OCS. Three studies reported adverse side effects of systemic corticosteroids, while two studies showed no adverse side effects. One study showed less adrenal suppression after injected corticosteroids compared to OCS. The evidence is not strong but shows a positive effect of systemic corticosteroids that lasts longer with injections. Conclusion Although systemic corticosteroids are widely used to treat CRS, there is a lack of studies comparing the OCS and injected corticosteroids. The evidence is sparse, however, injected steroids show longer effects with fewer side effects. An RCT study is needed to compare OCS and injected corticosteroids.
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Affiliation(s)
- Sarah Tamene
- Department of Otorhinolaryngology, Head & Neck Surgery and Audiology, Rigshospitalet and Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Kim Dalhoff
- Department of Clinical Pharmacology, Bispebjerg and Frederiksberg University Hospital, Copenhagen, Denmark
| | - Peter Schwarz
- Department of Endocrinology, Rigshospitalet and Faculty of Health Sciences, University of Copenhagen, Denmark, Copenhagen
| | - Vibeke Backer
- Department of Otorhinolaryngology, Head & Neck Surgery and Audiology, Rigshospitalet and Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Center of Physical Activity Research (CFAS), Rigshospitalet, University Hospital, Copenhagen, Denmark
| | - Kasper Aanaes
- Department of Otorhinolaryngology, Head & Neck Surgery and Audiology, Rigshospitalet and Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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2
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Ramkumar SP, Lal D, Miglani A. Considerations for shared decision-making in treatment of chronic rhinosinusitis with nasal polyps. FRONTIERS IN ALLERGY 2023; 4:1137907. [PMID: 36970067 PMCID: PMC10036764 DOI: 10.3389/falgy.2023.1137907] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 02/13/2023] [Indexed: 03/12/2023] Open
Abstract
Shared decision-making is an approach where physicians and patients work together to determine a personalized treatment course. Such an approach is integral to patient-centered care in chronic rhinosinusitis with nasal polyps (CRSwNP). CRSwNP is a chronic inflammatory condition of the sinonasal cavity that can severely impact physical health, smell, and quality of life (QOL). Traditional standard-of-care treatment options include topical (i.e. sprays) and oral corticosteroids and endoscopic sinus surgery, but more recently, novel corticosteroid delivery methods (i.e. high volume irrigations, recently-approved exhalation breath-powered delivering devices, and drug-eluting steroid implants) and 3 new FDA approved biologics directed against type II immunomodulators have become available. The availability of these therapeutics offers exciting new opportunities in CRSwNP management but requires personalized and shared-decision making as each modality has variable impacts on CRSwNP and related comorbid conditions. Studies have published treatment algorithms, but the practical use of these lean guidelines is heavily influenced by the lens of the treating physician, the most common being otolaryngologists and allergy immunologists. Clinical equipoise occurs when there is no basis for one intervention to be regarded as “better” than another. While most guidelines, in general, support the use of topical corticosteroids with or without oral corticosteroids followed by ESS for the majority of unoperated CRSwNP patients, there are situations of clinical equipoise that arise particularly in CRSwNP who have failed surgery or those with severe comorbid conditions. In the shared decision-making process, clinicians and patients must consider symptomatology, goals, comfort, compliance, treatment efficacy, and treatment cost when determining the initial choice of therapy and escalation of therapy with the potential use of multiple modalities for recalcitrant CRSwNP. A summary of salient considerations that might constitute shared decision-making is presented in this summary.
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Affiliation(s)
- Shreya P. Ramkumar
- Department of Otolaryngology – Head and Neck Surgery, Mayo Clinic Hospital, Phoenix, AZ, United States
- Saint Louis University School of Medicine, Saint Louis, MO, United States
| | - Devyani Lal
- Department of Otolaryngology – Head and Neck Surgery, Mayo Clinic Hospital, Phoenix, AZ, United States
| | - Amar Miglani
- Department of Otolaryngology – Head and Neck Surgery, Mayo Clinic Hospital, Phoenix, AZ, United States
- Correspondence: Amar Miglani
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3
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Sanchez-Collado I, Mora T, Munoz-Cano R, Ribo P, Mullol J, Valero A. Prevalence of Chronic Rhinosinusitis with Nasal Polyps in Catalonia (Spain): a retrospective, large-scale population-based study. Rhinology 2022; 60:384-396. [DOI: 10.4193/rhin21.364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Background: Studies on the prevalence of chronic rhinosinusitis (CRS) with nasal polyps (NP) in general-based populations are scarce in Europe and worldwide. We performed a retrospective population-based observational cohort study of 30,189 adult patients diagnosed with NP in Catalonia (Spain). Methodology: Adult individuals (≥18 years old) with a diagnosis of NP established by medical records at different health care levels (primary, hospital, and emergency) from the Catalan Health System (CHS) were included. Socio-demographic characteristics, prevalence, overall and by age and gender, disease severity, multi-morbidities, and biomarkers of type-2 inflammation were evaluated, together with appropriate medical treatment (AMT) and Endoscopic Sinus Surgery (ESS). Results: In general population and severity sub-populations, the overall diagnosed NP prevalence was 0.49% and higher for males than females (0.60% vs 0.39%, p less than 0.0016). The prevalence for the severe NP population was 0.12%. The NP prevalence increased with age, the highest being at ≥ 60 years old for both gender and severity groups. Asthma (40.1%), acute rhinosinusitis (41.1%), and allergic rhinitis (32.1%) were among the most frequent comorbid respiratory diseases. ESS was performed in 15.4% of NP patients. Type 2 inflammation was present in 83.8% of the NP population and was more frequent in severe than non-severe (87.1% vs 82.7%, p less than 0.0001) patients and in those with respiratory multi-morbidities (91%). Conclusions: This is the first large-scale population-based NP epidemiology study conducted in Spain, including severity based on undergoing medical and surgical treatment and type 2 inflammation. Although the prevalence data are lower than in previous European studies, the large NP cohort studied represents an essential strength of the results.
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Ranford D, Hopkins C. Safety review of current systemic treatments for severe chronic rhinosinusitis with nasal polyps and future directions. Expert Opin Drug Saf 2021; 20:1177-1189. [PMID: 33957840 DOI: 10.1080/14740338.2021.1926981] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: Chronic rhinosinusitis is a common condition characterized by inflammation of the nasal and sinus linings, rhinorrhea, nasal blockage, facial pain, and loss of sense of smell for longer than 12 weeks. CRS can occur with or without nasal polyps.Areas covered: First-line treatment in chronic rhinosinusitis with nasal polyps is long-term intranasal corticosteroids, which have few adverse events associated with their use, as second-generation intranasal corticosteroids having a bioavailability of <0.5%. Systemic corticosteroids are used when intranasal steroids fail to achieve symptom control. However, the repeated use of oral corticosteroids is associated with numerous adverse events and the benefit from a course of oral corticosteroids is lost within three to six months.Expert opinion: Antibiotics are commonly prescribed in nasal polyposis although there is also very little evidence for their use outside of acute infection. Macrolide antibiotics are also associated with a transient increase in the risk of arrhythmias. Biologics offer a steroid-sparing alternative to the treatment of severe nasal polyposis. They have shown to be relatively well tolerated in studies to date; however, studies suggest that there is no disease modifying effect and that any benefit is lost within weeks of finishing treatment.
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Affiliation(s)
- David Ranford
- ENT Department, Guy's and St Thomas NHS Foundation Trust, London, UK
| | - Claire Hopkins
- ENT Department, Guy's and St Thomas NHS Foundation Trust, London, UK
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5
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Sousa JC, Etchbehere RM, Alves EAR, Stark LM, Murta EFC, Michelin MA. Interferon-α action in cytokine profile in eosinophilic nasal polyp cultures. Braz J Otorhinolaryngol 2021; 87:260-268. [PMID: 31870738 PMCID: PMC9422409 DOI: 10.1016/j.bjorl.2019.08.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 03/01/2019] [Accepted: 08/28/2019] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Chronic rhinosinusitis is currently classified into two types: chronic rhinosinusitis without nasal polyps and chronic rhinosinusitis with nasal polyps. In the West, approximately 80% of chronic rhinosinusitis with nasal polyps cases are characterized by a predominantly eosinophilic cell infiltrate and a Th2 cytokine pattern. OBJECTIVE To evaluate the effect of Interferon-α on cytokine levels of the eosinophilic nasal polyp cell culture supernatant. METHODS Cell cultures were performed based on nasal polypoid tissue samples collected from 13 patients with eosinophilic chronic rhinosinusitis with nasal polyps. Polyps were considered eosinophilic according to the histopathological examination. Cell cultures were stimulated with 3000 IU of interferon-α. Before and after the stimulus, concentrations of Interferon-γ, tumor necrosis factor αand IL 2, 4, 6 and 10, using cytometric bead array, were assessed. RESULTS Cell samples from eosinophilic nasal polyps from 13 patients were included in the study. Twenty-four hours after interferon-α stimulation, eosinophilic nasal polyp culture supernatants showed significantly decreased IL-4 concentrations and increase in interferon-γ, IL-10 and IL-6 concentrations compared to controls. There were no significant differences in tumor necrosis factor -α and IL-2 concentrations. CONCLUSION We demonstrated that interferon-α in vitro alters the pattern of cytokines in cell cultures of eosinophilic nasal polyps. Analysis of these alterations suggests that interferon-α promotes a rebalancing of inflammatory profiles in cell cultures, favoring the expression of Th1 and regulatory cytokines over Th2 cytokines.
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Affiliation(s)
- Júlio Cláudio Sousa
- Universidade Federal do Triângulo Mineiro (UFTM), Faculdade de Medicina, Disciplina de Otorrinolaringologia, Uberaba, MG, Brazil.
| | - Renata Margarida Etchbehere
- Universidade Federal do Triângulo Mineiro (UFTM), Faculdade de Medicina, Disciplina de Patologia Especial, Uberaba, MG, Brazil
| | - Eduardo Arthur Rodovalho Alves
- Universidade Federal do Triângulo Mineiro (UFTM), Faculdade de Medicina, Instituto de Pesquisa em Oncologia (IPON), Uberaba, MG, Brazil
| | - Letícia Montes Stark
- Universidade Federal do Triângulo Mineiro (UFTM), Faculdade de Medicina, Instituto de Pesquisa em Oncologia (IPON), Uberaba, MG, Brazil
| | - Eddie Fernando Cândido Murta
- Universidade Federal do Triângulo Mineiro (UFTM), Faculdade de Medicina, Instituto de Pesquisa em Oncologia (IPON), Uberaba, MG, Brazil
| | - Márcia Antoniazi Michelin
- Universidade Federal do Triângulo Mineiro (UFTM), Faculdade de Medicina, Instituto de Pesquisa em Oncologia (IPON), Uberaba, MG, Brazil
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Hox V, Lourijsen E, Jordens A, Aasbjerg K, Agache I, Alobid I, Bachert C, Boussery K, Campo P, Fokkens W, Hellings P, Hopkins C, Klimek L, Mäkelä M, Mösges R, Mullol J, Pujols L, Rondon C, Rudenko M, Toppila-Salmi S, Scadding G, Scheire S, Tomazic PV, Van Zele T, Wagemann M, van Boven JFM, Gevaert P. Benefits and harm of systemic steroids for short- and long-term use in rhinitis and rhinosinusitis: an EAACI position paper. Clin Transl Allergy 2020; 10:1. [PMID: 31908763 PMCID: PMC6941282 DOI: 10.1186/s13601-019-0303-6] [Citation(s) in RCA: 100] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Accepted: 12/02/2019] [Indexed: 02/05/2023] Open
Abstract
Because of the inflammatory mechanisms of most chronic upper airway diseases such as rhinitis and chronic rhinosinusitis, systemic steroids have been used for their treatment for decades. However, it has been very well documented that—potentially severe—side-effects can occur with the accumulation of systemic steroid courses over the years. A consensus document summarizing the benefits of systemic steroids for each upper airway disease type, as well as highlighting the potential harms of this treatment is currently lacking. Therefore, a panel of international experts in the field of Rhinology reviewed the available literature with the aim of providing recommendations for the use of systemic steroids in treating upper airway disease.
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Affiliation(s)
- Valerie Hox
- 1Cliniques Universitaires Saint-Luc Brussels, Av. Hippocrate 10, 1200 Brussels, Belgium
| | - Evelijn Lourijsen
- 2Department of Otorhinolaryngology, Amsterdam University Medical Centres, AMC, Amsterdam, The Netherlands
| | - Arnout Jordens
- 3Upper Airway Research Laboratory, Dep. of Otorhinolaryngology, Ghent University Hospital, Ghent, Belgium
| | | | - Ioana Agache
- Faculty of Medicine, Transsylvania University, Brasov, Romania
| | - Isam Alobid
- 6Hospital Clínic, IDIBAPS, CEBERES Universitat de Barcelona, Catalonia, Spain.,7Centro Medico Teknon, Barcelona, Spain
| | - Claus Bachert
- 3Upper Airway Research Laboratory, Dep. of Otorhinolaryngology, Ghent University Hospital, Ghent, Belgium.,8Department of Ear, Nose and Throat Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Koen Boussery
- 9Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
| | - Paloma Campo
- 10Allergy Unit, Hospital Regional Universitario of Málaga, IBIMA, ARADyAL, Malaga, Spain
| | - Wytske Fokkens
- 2Department of Otorhinolaryngology, Amsterdam University Medical Centres, AMC, Amsterdam, The Netherlands
| | - Peter Hellings
- 11Department of Ear, Nose and Throat Disease, University Hospitals, Louvain, Belgium
| | - Claire Hopkins
- 12ENT Department, Guy's & St Thomas' Hospital, London, UK
| | - Ludger Klimek
- Center of Rhinology and Allergology, Wiesbaden, Germany
| | - Mika Mäkelä
- 14Skin and Allergy Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | | | - Joaquim Mullol
- 6Hospital Clínic, IDIBAPS, CEBERES Universitat de Barcelona, Catalonia, Spain
| | - Laura Pujols
- 6Hospital Clínic, IDIBAPS, CEBERES Universitat de Barcelona, Catalonia, Spain
| | - Carmen Rondon
- 10Allergy Unit, Hospital Regional Universitario of Málaga, IBIMA, ARADyAL, Malaga, Spain
| | | | - Sanna Toppila-Salmi
- 14Skin and Allergy Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | | | - Sophie Scheire
- 9Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
| | | | - Thibaut Van Zele
- 3Upper Airway Research Laboratory, Dep. of Otorhinolaryngology, Ghent University Hospital, Ghent, Belgium
| | | | - Job F M van Boven
- 20Department of Clinical Pharmacy & Pharmacology, University Medical Center Groningen, Groningen Research Institute for Asthma and COPD (GRIAC), University of Groningen, Groningen, The Netherlands
| | - Philippe Gevaert
- 3Upper Airway Research Laboratory, Dep. of Otorhinolaryngology, Ghent University Hospital, Ghent, Belgium
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7
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Sahlstrand-Johnson P, Holmström M, Ehnhage A. Does the oral steroid treatment of patients with nasal polyposis cause osteopenia or osteoporosis? Clin Otolaryngol 2019; 44:1011-1016. [PMID: 31529761 DOI: 10.1111/coa.13431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Revised: 08/19/2019] [Accepted: 09/13/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVES We aimed to investigate the bone mineral density (BMD) in a group of Swedish patients with chronic rhinosinusitis with nasal polyposis (CRSwNP) with or without asthma, as well as to evaluate whether the treatment of this patient group is in accordance with the EPOS recommendations. DESIGN, SETTINGS AND PARTICIPANTS Adult patients with a diagnosis of CRSwNP, and a history of at least two courses of oral corticosteroids (OCS) during the last year, were consecutively included in this study at five centres. MAIN OUTCOME MEASURES The BMD of the patients was measured by Dual-energy X-ray absorptiometry (DXA), which is the only technology for classifying BMD according to the criteria established by WHO. RESULTS A total of 51 patients, with an average number of 7 years with OCS treatment, were enrolled. During the last 12 months, the mean number of OCS courses was 2.76, and the total mean intake was 891 mg of Prednisone equivalents. According to the T-scores, 17 patients were measured to have ≤-1 SD T-score lumbar spine, which is considered to be osteopenia, and five patients had <-2.5 SD T-score, considered as osteoporosis. However, when taking age and gender into account and analysing the Z-scores, only 2 patients had a reduced density of the spine and none in the hip, which is no difference compared to a matched Swedish population. CONCLUSIONS This prospective study shows that 2-3 moderate courses of OCS annually may be used without high risk of causing osteopenia/osteoporosis in patients with CRSwNP.
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Affiliation(s)
| | - Mats Holmström
- Department of Clinical Sciences, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Anders Ehnhage
- Department of Clinical Sciences, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
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8
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Grammatopoulou V, Praveena CV, Sunkaraneni VS. Optimising Medical Management in CRS. CURRENT OTORHINOLARYNGOLOGY REPORTS 2019. [DOI: 10.1007/s40136-019-00232-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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9
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Risks and management of long-term corticosteroid use in chronic rhinosinusitis. Curr Opin Otolaryngol Head Neck Surg 2018; 26:1-7. [PMID: 29059082 DOI: 10.1097/moo.0000000000000421] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to provide an update on the use and risks of long-term corticosteroids in the management of chronic rhinosinusitis (CRS). RECENT FINDINGS Long-term use of systemic corticosteroids is not indicated in the management of CRS due to the associated side effects and potential complications. Therefore, recent research has focused on the safety and efficacy of topical corticosteroid, particularly second-generation corticosteroids, and their modes of administration. Second-generation corticosteroids are more potent and have less systemic bioavailability than their first-generation counterparts. However, caution must be taken with concomitant use of more than two types of corticosteroids (topical, systemic, inhaled etc.) and also with their dosage and frequency of administration to avoid adrenal suppression, growth suppression in children, elevated intraocular pressure or epistaxis. Research is ongoing into therapies that may reduce corticosteroid resistance which has been demonstrated in some nasal polyps. SUMMARY Corticosteroids play an essential role in the management of CRS; however, use must be tailored to the patient-specific disease and requires ongoing review and regular reevaluation by their physician.
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10
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Complications of Short-Course Oral Corticosteroids for Eosinophilic Chronic Rhinosinusitis during Long-Term Follow-Up. SINUSITIS 2018. [DOI: 10.3390/sinusitis3020005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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11
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Bachert C, Gevaert P, Hellings P. Biotherapeutics in Chronic Rhinosinusitis with and without Nasal Polyps. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 5:1512-1516. [DOI: 10.1016/j.jaip.2017.04.024] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/04/2017] [Revised: 04/11/2017] [Accepted: 04/13/2017] [Indexed: 12/31/2022]
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12
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Bachert C, Sousa AR, Lund VJ, Scadding GK, Gevaert P, Nasser S, Durham SR, Cornet ME, Kariyawasam HH, Gilbert J, Austin D, Maxwell AC, Marshall RP, Fokkens WJ. Reduced need for surgery in severe nasal polyposis with mepolizumab: Randomized trial. J Allergy Clin Immunol 2017; 140:1024-1031.e14. [PMID: 28687232 DOI: 10.1016/j.jaci.2017.05.044] [Citation(s) in RCA: 326] [Impact Index Per Article: 46.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Revised: 05/19/2017] [Accepted: 05/31/2017] [Indexed: 01/19/2023]
Abstract
BACKGROUND Patients with eosinophilic nasal polyposis frequently require surgery, and recurrence rates are high. OBJECTIVE We sought to assess the efficacy and safety of mepolizumab versus placebo for severe bilateral nasal polyposis. METHODS This randomized, double-blind, placebo-controlled trial recruited patients aged 18 to 70 years with recurrent nasal polyposis requiring surgery. Patients received 750 mg of intravenous mepolizumab or placebo every 4 weeks for a total of 6 doses in addition to daily topical corticosteroid treatment. The primary end point was the number of patients no longer requiring surgery at Week 25 based on a composite end point of endoscopic nasal polyp score and nasal polyposis severity visual analog scale (VAS) score. Secondary end points included change in nasal polyposis severity VAS score, endoscopic nasal polyp score, improvement in individual VAS symptoms (rhinorrhea, mucus in throat, nasal blockage, and sense of smell), patient-reported outcomes, and safety. RESULTS One hundred five patients received mepolizumab (n = 54) or placebo (n = 51). A significantly greater proportion of patients in the mepolizumab group compared with the placebo group no longer required surgery at Week 25 (16 [30%] vs 5 [10%], respectively; P = .006). There was a significant improvement in nasal polyposis severity VAS score, endoscopic nasal polyp score, all individual VAS symptom scores, and Sino-Nasal Outcome Test patient-reported outcome score in the mepolizumab compared with placebo groups. Mepolizumab's safety profile was comparable with that of placebo. CONCLUSION In patients with recurrent nasal polyposis receiving topical corticosteroids who required surgery, mepolizumab treatment led to a greater reduction in the need for surgery and a greater improvement in symptoms than placebo.
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Affiliation(s)
- Claus Bachert
- Upper Airways Research Laboratory and Department of Oto-Rhino-Laryngology, Ghent University and Ghent University Hospital, Ghent, Belgium; Division of ENT Diseases, CLINTEC, Karolinska Institute, University of Stockholm, Stockholm, Sweden.
| | - Ana R Sousa
- Respiratory Therapy Unit, GlaxoSmithKline, Stockley Park, Uxbridge, United Kingdom
| | - Valerie J Lund
- Royal National Throat, Nose and Ear Hospital, UCLH London, London, United Kingdom
| | - Glenis K Scadding
- Royal National Throat, Nose and Ear Hospital, UCLH London, London, United Kingdom
| | - Philippe Gevaert
- Upper Airways Research Laboratory and Department of Oto-Rhino-Laryngology, Ghent University and Ghent University Hospital, Ghent, Belgium
| | - Shuaib Nasser
- Department of Allergy, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Stephen R Durham
- Allergy and Clinical Immunology, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Marjolein E Cornet
- Department of Otorhinolaryngology, Academic Medical Center, Amsterdam, The Netherlands
| | - Harsha H Kariyawasam
- Royal National Throat, Nose and Ear Hospital, UCLH London, London, United Kingdom
| | - Jane Gilbert
- Clinical Statistics, GlaxoSmithKline, Stockley Park, Uxbridge, United Kingdom
| | - Daren Austin
- Respiratory Therapy Unit, GlaxoSmithKline, Stockley Park, Uxbridge, United Kingdom
| | - Aoife C Maxwell
- Respiratory Clinical Sciences & Operations, GlaxoSmithKline, Stockley Park, Uxbridge, United Kingdom
| | - Richard P Marshall
- Respiratory Therapy Unit, GlaxoSmithKline, Stockley Park, Uxbridge, United Kingdom
| | - Wytske J Fokkens
- Department of Otorhinolaryngology, Academic Medical Center, Amsterdam, The Netherlands
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13
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Management of Respiratory Symptoms Induced by Non-Steroidal Anti-Inflammatory Drugs. CURRENT TREATMENT OPTIONS IN ALLERGY 2017. [DOI: 10.1007/s40521-017-0129-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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14
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Rombaux P, Huart C, Levie P, Cingi C, Hummel T. Olfaction in Chronic Rhinosinusitis. Curr Allergy Asthma Rep 2016; 16:41. [PMID: 27131498 DOI: 10.1007/s11882-016-0617-6] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Olfactory dysfunction is a frequent complaint in chronic rhinosinusitis patients and has a significant impact on quality of life. Therefore, it is essential that clinicians are aware of the importance of olfactory dysfunction in chronic rhinosinusitis (CRS) patients and know how to deal with it. Notably, the evaluation of olfactory function (i.e., using psychophysical testing) and imagery of olfactory bulb play an important role in the evaluation of patients and give essential information about the "baseline" olfactory function. Because the high impact of olfactory function on quality of life and medical and/or surgical treatment should be proposed to patients. However, it remains difficult to predict the outcome of treatment as well as long-term efficacy. The first section of this review is dedicated to the assessment of olfactory function. Secondly, we will discuss the etiopathology of olfactory dysfunction in CRS with and without nasal polyps. Finally, we will review literature findings about the efficacy of different treatments on olfactory function.
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Affiliation(s)
- Philippe Rombaux
- Department of Otorhinolaryngology, Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Av Hippocrate, 10, 1200, Brussels, Belgium. .,Institute of Neurosciences, Université Catholique de Louvain, Brussels, Belgium.
| | - C Huart
- Department of Otorhinolaryngology, Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Av Hippocrate, 10, 1200, Brussels, Belgium.,Institute of Neurosciences, Université Catholique de Louvain, Brussels, Belgium
| | - P Levie
- Department of Otorhinolaryngology, Clinique Sainte-Anne, Brussels, Belgium
| | - C Cingi
- ENT Department, Medical Faculty, Eskisehir Osmangazi University, Eskisehir, Turkey
| | - T Hummel
- Interdisciplinary Center "Smell & Taste", Department of Otorhinolaryngology, TU Dresden, Dresden, Germany
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15
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Head K, Chong LY, Hopkins C, Philpott C, Burton MJ, Schilder AGM. Short-course oral steroids alone for chronic rhinosinusitis. Cochrane Database Syst Rev 2016; 4:CD011991. [PMID: 27113367 PMCID: PMC8504433 DOI: 10.1002/14651858.cd011991.pub2] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND This review is one of a suite of six Cochrane reviews looking at the primary medical management options for patients with chronic rhinosinusitis.Chronic rhinosinusitis is a common condition involving inflammation of the lining of the nose and paranasal sinuses. It is characterised by nasal blockage and nasal discharge, facial pressure/pain and loss of sense of smell. The condition can occur with or without nasal polyps. Oral corticosteroids are used to control the inflammatory response and improve symptoms. OBJECTIVES To assess the effects of oral corticosteroids compared with placebo/no intervention or other pharmacological interventions (intranasal corticosteroids, antibiotics, antifungals) for chronic rhinosinusitis. SEARCH METHODS The Cochrane ENT Information Specialist searched the ENT Trials Register; Central Register of Controlled Trials (CENTRAL 2015, Issue 7); MEDLINE; EMBASE; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 11 August 2015. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing a short course (up to 21 days) of oral corticosteroids with placebo or no treatment or compared with other pharmacological interventions. DATA COLLECTION AND ANALYSIS We used the standard methodological procedures expected by Cochrane. Our primary outcomes were disease-specific health-related quality of life (HRQL), patient-reported disease severity, and the adverse event of mood or behavioural disturbances. Secondary outcomes included general HRQL, endoscopic nasal polyp score, computerised tomography (CT) scan score and the adverse events of insomnia, gastrointestinal disturbances and osteoporosis. We used GRADE to assess the quality of the evidence for each outcome; this is indicated in italics. MAIN RESULTS We included eight RCTs (474 randomised participants), which compared oral corticosteroids with placebo or no intervention. All trials only recruited adults with chronic rhinosinusitis with nasal polyps. All trials reported outcomes at two to three weeks, at the end of the short-course oral steroid treatment period. Three trials additionally reported outcomes at three to six months. Two of these studies prescribed intranasal steroids to patients in both arms of the trial at the end of the oral steroid treatment period. Oral steroids versus placebo or no intervention Disease-specific health-related quality of life was reported by one study. This study reported improved quality of life after treatment (two to three weeks) in the group receiving oral steroids compared with the group who received placebo (standardised mean difference (SMD) -1.24, 95% confidence interval (CI) -1.92 to -0.56, 40 participants, modified RSOM-31), which corresponds to a large effect size. We assessed the evidence to be low quality (we are uncertain about the effect estimate; the true effect may be substantially different from the estimate of the effect). Disease severity as measured by patient-reported symptom scores was reported by two studies, which allowed the four key symptoms used to define chronic rhinosinusitis (nasal blockage, nasal discharge, facial pressure, hyposmia) to be combined into one score. The results at the end of treatment (two to three weeks) showed an improvement in patients receiving oral steroids compared to placebo, both when presented as a mean final value (SMD -2.84, 95% CI -4.09 to -1.59, 22 participants) and as a change from baseline (SMD -2.28, 95% CI -2.76 to -1.80, 114 participants). These correspond to large effect sizes but we assessed the evidence to be low quality.One study (114 participants) followed patients for 10 weeks after the two-week treatment period. All patients in both arms received intranasal steroids at the end of the oral steroid treatment period. The results showed that the initial results after treatment were not sustained (SMD -0.22, 95% CI -0.59 to 0.15, 114 participants, percentage improvement from baseline). This corresponds to a small effect size and we assessed the evidence to be low quality.There was an increase in adverse events in people receiving orals steroids compared with placebo for gastrointestinal disturbances (risk ratio (RR) 3.45, 95% CI 1.11 to 10.78; 187 participants; three studies) and insomnia (RR 3.63, 95% CI 1.10 to 11.95; 187 participants; three studies). There was no significant impact of oral steroids on mood disturbances at the dosage used in the included study (risk ratio (RR) 2.50, 95% CI 0.55 to 11.41; 40 participants; one study). We assessed the evidence to be low quality due to the lack of definitions of the adverse events and the small number of events or sample size, or both). Other comparisons No studies that compared short-course oral steroids with other treatment for chronic rhinosinusitis met the inclusion criteria. AUTHORS' CONCLUSIONS At the end of the treatment course (two to three weeks) there is an improvement in health-related quality of life and symptom severity in patients with chronic rhinosinusitis with nasal polyps taking oral corticosteroids compared with placebo or no treatment. The quality of the evidence supporting this finding is low. At three to six months after the end of the oral steroid treatment period, there is little or no improvement in health-related quality of life or symptom severity for patients taking an initial course of oral steroids compared with placebo or no treatment.The data on the adverse effects associated with short courses of oral corticosteroids indicate that there may be an increase in insomnia and gastrointestinal disturbances but it is not clear whether there is an increase in mood disturbances. All of the adverse events results are based on low quality evidence.More research in this area, particularly research evaluating patients with chronic rhinosinusitis without nasal polyps, longer-term outcomes and adverse effects, is required.There is no evidence for oral steroids compared with other treatments.
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Affiliation(s)
- Karen Head
- UK Cochrane CentreSummertown Pavilion18 ‐ 24 Middle WayOxfordUK
| | - Lee Yee Chong
- UK Cochrane CentreSummertown Pavilion18 ‐ 24 Middle WayOxfordUK
| | - Claire Hopkins
- Guy's HospitalENT DepartmentGerat Maze PondLondonUKSE1 9RT
| | - Carl Philpott
- Norwich Medical School, University of East AngliaDepartment of MedicineNorwichUKNR4 7TJ
| | - Martin J Burton
- UK Cochrane CentreSummertown Pavilion18 ‐ 24 Middle WayOxfordUK
| | - Anne GM Schilder
- Faculty of Brain Sciences, University College LondonevidENT, Ear Institute330 Grays Inn RoadLondonUKWC1X 8DA
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Head K, Chong LY, Hopkins C, Philpott C, Schilder AGM, Burton MJ. Short-course oral steroids as an adjunct therapy for chronic rhinosinusitis. Cochrane Database Syst Rev 2016; 4:CD011992. [PMID: 27115214 PMCID: PMC8763342 DOI: 10.1002/14651858.cd011992.pub2] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND This review is one of a suite of six Cochrane reviews looking at the primary medical management options for patients with chronic rhinosinusitis.Chronic rhinosinusitis is a common condition involving inflammation of the lining of the nose and paranasal sinuses. It is characterised by nasal blockage and nasal discharge, facial pressure/pain and loss of sense of smell. The condition can occur with or without nasal polyps. Oral corticosteroids are used to control the inflammatory response and improve symptoms. OBJECTIVES To assess the effects of a short course of oral corticosteroids as an adjunct ('add-on') therapy in people with chronic rhinosinusitis who are already on standard treatments. SEARCH METHODS The Cochrane ENT Information Specialist searched the Cochrane ENT Trials Register; Central Register of Controlled Trials (CENTRAL 2015, Issue 7); MEDLINE; EMBASE; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 11 August 2015. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing a short course (up to 21 days) of oral corticosteroids to placebo or no treatment, where all patients were also receiving pharmacological treatment for chronic rhinosinusitis. DATA COLLECTION AND ANALYSIS We used the standard methodological procedures expected by Cochrane. Our primary outcomes were disease-specific health-related quality of life (HRQL), patient-reported disease severity, and the adverse event of mood or behavioural disturbances. Secondary outcomes included general HRQL, endoscopic nasal polyp score, computerised tomography (CT) scan score, and the adverse events of insomnia, gastrointestinal disturbances and osteoporosis. We used GRADE to assess the quality of the evidence for each outcome; this is indicated in italics. MAIN RESULTS Two trials with a total of 78 participants met the inclusion criteria. Both the populations and the 'standard' treatments differed in the two studies. Oral steroids as an adjunct to intranasal corticosteroids One trial in adults with nasal polyps included 30 participants. All participants used intranasal corticosteroids and were randomised to either short-course oral steroids (oral methylprednisolone, 1 mg/kg and reduced progressively over a 21-day treatment course) or no additional treatment. None of the primary outcome measures of interest in this review were reported by the study. There may have been an important reduction in the size of the polyps (measured by the nasal polyps score, a secondary outcome measure) in patients receiving oral steroids and intranasal corticosteroids, compared to intranasal corticosteroids alone (mean difference (MD) -0.46, 95% confidence interval (CI) -0.87 to -0.05; 30 participants; scale 1 to 4) at the end of treatment (21 days). This corresponds to a large effect size, but we are very uncertain about this estimate as we judged the study to be at high risk of bias. Moreover, longer-term data were not available and the other outcomes of interest were not reported. Oral steroids as an adjunct to antibiotics One trial in children (mean age of eight years) without nasal polyps included 48 participants. The trial compared oral corticosteroids (oral methylprednisolone, 1 mg/kg and reduced progressively over a 15-day treatment course) with placebo in participants who also received a 30-day course of antibiotics. This study addressed one of the primary outcome measures (disease severity) and one secondary outcome (CT score). For disease severity the four key symptoms used to define chronic rhinosinusitis in children (nasal blockage, nasal discharge, facial pressure, cough) were combined into one score. There was a greater improvement in symptom severity 30 days after the start of treatment in patients who received oral steroids and antibiotics compared with placebo and antibiotics (MD -7.10, 95% CI -9.59 to -4.61; 45 participants; scale 0 to 40). The observed mean difference corresponds to a large effect size. At the same time point there was a difference in CT scan score (MD -2.90, 95% CI -4.91 to -0.89; 45 participants; scale 0 to 24). We assessed the quality of the evidence to be low.There were no data available for the longer term (three months). AUTHORS' CONCLUSIONS There might be an improvement in symptom severity, polyps size and condition of the sinuses when assessed using CT scans in patients taking oral corticosteroids when these are used as an adjunct therapy to antibiotics or intranasal corticosteroids, but the quality of the evidence supporting this is low or very low (we are uncertain about the effect estimate; the true effect may be substantially different from the estimate of the effect). It is unclear whether the benefits of oral corticosteroids as an adjunct therapy are sustained beyond the short follow-up period reported (up to 30 days), as no longer-term data were available.There were no data in this review about the adverse effects associated with short courses of oral corticosteroids as an adjunct therapy.More research in this area, particularly research evaluating longer-term outcomes and adverse effects, is required.
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Affiliation(s)
- Karen Head
- UK Cochrane CentreSummertown Pavilion18 ‐ 24 Middle WayOxfordUK
| | - Lee Yee Chong
- UK Cochrane CentreSummertown Pavilion18 ‐ 24 Middle WayOxfordUK
| | - Claire Hopkins
- Guy's HospitalENT DepartmentGerat Maze PondLondonUKSE1 9RT
| | - Carl Philpott
- Norwich Medical School, University of East AngliaDepartment of MedicineNorwichUKNR4 7TJ
| | - Anne GM Schilder
- Faculty of Brain Sciences, University College LondonevidENT, Ear Institute330 Grays Inn RoadLondonUKWC1X 8DA
| | - Martin J Burton
- UK Cochrane CentreSummertown Pavilion18 ‐ 24 Middle WayOxfordUK
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Abstract
Review withdrawn from Issue 4, 2016. Replaced by new reviews 'Short‐course oral steroids alone for chronic rhinosinusitis' (Head 2016a) and 'Short‐course oral steroids as an adjunct therapy for chronic rhinosinusitis' (Head 2016b). The editorial group responsible for this previously published document have withdrawn it from publication.
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Affiliation(s)
| | - Shalini Patiar
- Molecular Oncology LaboratoriesCancer Research UKWeatherall Institute of Molecular MedicineJohn Radcliffe HospitalOxfordUKOX3 9DS
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Bachert C, Zhang L, Gevaert P. Current and future treatment options for adult chronic rhinosinusitis: Focus on nasal polyposis. J Allergy Clin Immunol 2015; 136:1431-1440. [DOI: 10.1016/j.jaci.2015.10.010] [Citation(s) in RCA: 168] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Revised: 10/16/2015] [Accepted: 10/21/2015] [Indexed: 01/10/2023]
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Broersen LHA, Pereira AM, Jørgensen JOL, Dekkers OM. Adrenal Insufficiency in Corticosteroids Use: Systematic Review and Meta-Analysis. J Clin Endocrinol Metab 2015; 100:2171-80. [PMID: 25844620 DOI: 10.1210/jc.2015-1218] [Citation(s) in RCA: 259] [Impact Index Per Article: 28.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVE We aimed to estimate pooled percentages of patients with adrenal insufficiency after treatment with corticosteroids for various conditions in a meta-analysis. Secondly, we aimed to stratify the results by route of administration, disease, treatment dose, and duration. METHODS We searched seven electronic databases (PubMed, MEDLINE, EMBASE, COCHRANE, CENTRAL, Web of Science, and CINAHL/Academic Search Premier) in February 2014 to identify potentially relevant studies. Original articles testing adult corticosteroid users for adrenal insufficiency were eligible. RESULTS We included 74 articles with a total of 3753 participants. Stratified by administration form, percentages of patients with adrenal insufficiency ranged from 4.2% for nasal administration (95% confidence interval [CI], 0.5-28.9) to 52.2% for intra-articular administration (95% CI, 40.5-63.6). Stratified by disease, percentages ranged from 6.8% for asthma with inhalation corticosteroids only (95% CI, 3.8-12.0) to 60.0% for hematological malignancies (95% CI, 38.0-78.6). The risk also varied according to dose from 2.4% (95% CI, 0.6-9.3) (low dose) to 21.5% (95% CI, 12.0-35.5) (high dose), and according to treatment duration from 1.4% (95% CI, 0.3-7.4) (<28 d) to 27.4% (95% CI, 17.7-39.8) (>1 year) in asthma patients. CONCLUSIONS 1) Adrenal insufficiency after discontinuation of glucocorticoid occurs frequently; 2) there is no administration form, dosing, treatment duration, or underlying disease for which adrenal insufficiency can be excluded with certainty, although higher dose and longer use give the highest risk; 3) the threshold to test corticosteroid users for adrenal insufficiency should be low in clinical practice, especially for those patients with nonspecific symptoms after cessation.
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Affiliation(s)
- Leonie H A Broersen
- Department of Clinical Epidemiology (L.H.A.B., O.M.D.), Leiden University Medical Centre, Leiden 2300RC, The Netherlands; Department of Medicine (L.H.A.B., A.M.P., O.M.D.), Division of Endocrinology, Leiden University Medical Centre, Leiden 2300RC, The Netherlands; Department of Endocrinology (J.O.L.J., O.M.D.), Aarhus University, 8000 Aarhus C, Denmark; and Department of Clinical Epidemiology (O.M.D.), Aarhus University, 8000 Aarhus C, Denmark
| | - Alberto M Pereira
- Department of Clinical Epidemiology (L.H.A.B., O.M.D.), Leiden University Medical Centre, Leiden 2300RC, The Netherlands; Department of Medicine (L.H.A.B., A.M.P., O.M.D.), Division of Endocrinology, Leiden University Medical Centre, Leiden 2300RC, The Netherlands; Department of Endocrinology (J.O.L.J., O.M.D.), Aarhus University, 8000 Aarhus C, Denmark; and Department of Clinical Epidemiology (O.M.D.), Aarhus University, 8000 Aarhus C, Denmark
| | - Jens Otto L Jørgensen
- Department of Clinical Epidemiology (L.H.A.B., O.M.D.), Leiden University Medical Centre, Leiden 2300RC, The Netherlands; Department of Medicine (L.H.A.B., A.M.P., O.M.D.), Division of Endocrinology, Leiden University Medical Centre, Leiden 2300RC, The Netherlands; Department of Endocrinology (J.O.L.J., O.M.D.), Aarhus University, 8000 Aarhus C, Denmark; and Department of Clinical Epidemiology (O.M.D.), Aarhus University, 8000 Aarhus C, Denmark
| | - Olaf M Dekkers
- Department of Clinical Epidemiology (L.H.A.B., O.M.D.), Leiden University Medical Centre, Leiden 2300RC, The Netherlands; Department of Medicine (L.H.A.B., A.M.P., O.M.D.), Division of Endocrinology, Leiden University Medical Centre, Leiden 2300RC, The Netherlands; Department of Endocrinology (J.O.L.J., O.M.D.), Aarhus University, 8000 Aarhus C, Denmark; and Department of Clinical Epidemiology (O.M.D.), Aarhus University, 8000 Aarhus C, Denmark
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Bousquet J, Anto JM, Demoly P, Schünemann HJ, Togias A, Akdis M, Auffray C, Bachert C, Bieber T, Bousquet PJ, Carlsen KH, Casale TB, Cruz AA, Keil T, Lodrup Carlsen KC, Maurer M, Ohta K, Papadopoulos NG, Roman Rodriguez M, Samolinski B, Agache I, Andrianarisoa A, Ang CS, Annesi-Maesano I, Ballester F, Baena-Cagnani CE, Basagaña X, Bateman ED, Bel EH, Bedbrook A, Beghé B, Beji M, Ben Kheder A, Benet M, Bennoor KS, Bergmann KC, Berrissoul F, Bindslev Jensen C, Bleecker ER, Bonini S, Boner AL, Boulet LP, Brightling CE, Brozek JL, Bush A, Busse WW, Camargos PAM, Canonica GW, Carr W, Cesario A, Chen YZ, Chiriac AM, Costa DJ, Cox L, Custovic A, Dahl R, Darsow U, Didi T, Dolen WK, Douagui H, Dubakiene R, El-Meziane A, Fonseca JA, Fokkens WJ, Fthenou E, Gamkrelidze A, Garcia-Aymerich J, Gerth van Wijk R, Gimeno-Santos E, Guerra S, Haahtela T, Haddad H, Hellings PW, Hellquist-Dahl B, Hohmann C, Howarth P, Hourihane JO, Humbert M, Jacquemin B, Just J, Kalayci O, Kaliner MA, Kauffmann F, Kerkhof M, Khayat G, Koffi N'Goran B, Kogevinas M, Koppelman GH, Kowalski ML, Kull I, Kuna P, Larenas D, Lavi I, Le LT, Lieberman P, Lipworth B, Mahboub B, Makela MJ, Martin F, Martinez FD, Marshall GD, Mazon A, Melen E, Meltzer EO, Mihaltan F, Mohammad Y, Mohammadi A, Momas I, Morais-Almeida M, Mullol J, Muraro A, Naclerio R, Nafti S, Namazova-Baranova L, Nawijn MC, Nyembue TD, Oddie S, O'Hehir RE, Okamoto Y, Orru MP, Ozdemir C, Ouedraogo GS, Palkonen S, Panzner P, Passalacqua G, Pawankar R, Pigearias B, Pin I, Pinart M, Pison C, Popov TA, Porta D, Postma DS, Price D, Rabe KF, Ratomaharo J, Reitamo S, Rezagui D, Ring J, Roberts R, Roca J, Rogala B, Romano A, Rosado-Pinto J, Ryan D, Sanchez-Borges M, Scadding GK, Sheikh A, Simons FER, Siroux V, Schmid-Grendelmeier PD, Smit HA, Sooronbaev T, Stein RT, Sterk PJ, Sunyer J, Terreehorst I, Toskala E, Tremblay Y, Valenta R, Valeyre D, Vandenplas O, van Weel C, Vassilaki M, Varraso R, Viegi G, Wang DY, Wickman M, Williams D, Wöhrl S, Wright J, Yorgancioglu A, Yusuf OM, Zar HJ, Zernotti ME, Zidarn M, Zhong N, Zuberbier T. Severe chronic allergic (and related) diseases: a uniform approach--a MeDALL--GA2LEN--ARIA position paper. Int Arch Allergy Immunol 2012; 158:216-31. [PMID: 22382913 DOI: 10.1159/000332924] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Concepts of disease severity, activity, control and responsiveness to treatment are linked but different. Severity refers to the loss of function of the organs induced by the disease process or to the occurrence of severe acute exacerbations. Severity may vary over time and needs regular follow-up. Control is the degree to which therapy goals are currently met. These concepts have evolved over time for asthma in guidelines, task forces or consensus meetings. The aim of this paper is to generalize the approach of the uniform definition of severe asthma presented to WHO for chronic allergic and associated diseases (rhinitis, chronic rhinosinusitis, chronic urticaria and atopic dermatitis) in order to have a uniform definition of severity, control and risk, usable in most situations. It is based on the appropriate diagnosis, availability and accessibility of treatments, treatment responsiveness and associated factors such as comorbidities and risk factors. This uniform definition will allow a better definition of the phenotypes of severe allergic (and related) diseases for clinical practice, research (including epidemiology), public health purposes, education and the discovery of novel therapies.
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Affiliation(s)
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- Centre Hospitalier Universitaire Montpellier, Montpellier Cedex 05, France.
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Abstract
BACKGROUND This is an update of a Cochrane Review first published in The Cochrane Library in Issue 1, 2007.Benign nasal polyps are lesions that arise from the mucosa of the nasal cavity or one or more of the nasal sinuses. The presenting symptoms are nasal obstruction, watery anterior rhinorrhoea (excessive nasal secretions) or mucopurulent postnasal drip (or both), hyposmia and anosmia (reduced or absent sense of smell) with a concomitant alteration in taste and infrequently pain over the dorsum of the nose, forehead and cheeks. The main aim of treatment is to relieve these symptoms. The aetiology of polyps is uncertain, therefore treatment options differ, consisting of a combination of medical and surgical management. Medical therapy is mainly in the form of steroids, administered topically or systemically via the oral route. OBJECTIVES To assess the effects of oral steroids in patients with multiple nasal polyps. SEARCH STRATEGY We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ISRCTN and additional sources for published and unpublished trials. The date of the most recent search was 12 October 2010, following a previous search in April 2006. SELECTION CRITERIA Randomised controlled trials and controlled clinical trials comparing oral steroids with no intervention, or placebo, or comparing doses or schedules of oral steroids in patients with multiple nasal polyps. DATA COLLECTION AND ANALYSIS Two authors independently assessed study quality. We contacted study authors for additional information. MAIN RESULTS Three trials (166 patients) met our inclusion criteria and showed a short-term benefit of a short (two to four-week) course of oral steroids of variable doses and duration when compared to placebo. There was an objective reduction of polyp size and a subjective improvement of nasal symptoms and quality of life. However, due to the moderate to low quality of these trials it was not possible to quantify the overall size of this effect.There was no report of significant adverse effects of treatment with a short course of steroids. AUTHORS' CONCLUSIONS The authors found three randomised controlled trials, albeit of moderate to poor quality, that suggest a short-term benefit of oral steroids in patients with multiple nasal polyps. To address the issue more thoroughly well-designed, prospective, randomised controlled trials are still needed.
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Affiliation(s)
- Pablo Martinez-Devesa
- ENT Department, John Radcliffe Hospital - West Wing, Headley Way, Oxford, UK, OX3 9DU
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Bachert C. Evidence-based management of nasal polyposis by intranasal corticosteroids: from the cause to the clinic. Int Arch Allergy Immunol 2011; 155:309-21. [PMID: 21346361 DOI: 10.1159/000321406] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Nasal polyposis is an inflammatory disorder involving the mucosa of the nose and paranasal sinuses and affecting approximately 2-4% of the general population. METHODS A literature search of Medline and Embase was conducted to obtain an overview of the epidemiology, pathophysiology, and current treatment of nasal polyposis, focusing on evidence-based efficacy of intranasal corticosteroids (INSs) as primary and postoperative therapy. Recent research on INSs in nasal polyp treatment, along with notable historic findings, was reviewed. RESULTS Nasal polyps are mostly characterized by eosinophil infiltration, a complex inflammation of nasal mucosa, and possibly production of polyclonal IgE. Current treatment modalities include INSs, oral corticosteroids, and surgery; surgery is generally limited to those with an insufficient response to medical treatment. Because of their effects on eosinophil-dominated inflammation, INSs and oral corticosteroids are the primary medical treatment strategies. The very low (≤1%) systemic bioavailability of newer INSs minimizes the systemic adverse effects seen with oral corticosteroids. CONCLUSION Based on randomized, controlled trials, guidelines recommend INSs as first-line therapy for nasal polyps and for care after polypectomy. Clinical data suggest INSs are effective in reducing polyp size and relieving nasal symptoms. INS treatment has also reduced nasal polyp recurrence in patients undergoing functional endoscopic sinus surgery. Treatment with these mainstay options has been found to improve quality of life, which, along with symptom improvement, is a key factor in disease treatment.
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Affiliation(s)
- Claus Bachert
- Department of Otorhinolaryngology, University Hospital Ghent, Ghent, Belgium. claus.bachert @ ugent.be
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Rajasekaran K, Seth R, Abelson A, Batra PS. Prevalence of metabolic bone disease among chronic rhinosinusitis patients treated with oral glucocorticoids. Am J Rhinol Allergy 2010; 24:215-9. [PMID: 20537290 DOI: 10.2500/ajra.2010.24.3445] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND The treatment of chronic rhinosinusitis (CRS) often requires chronic or intermittent oral steroid therapy, which has the potential for adverse skeletal effects, including osteoporosis and increased risk of fragility fractures. The purpose of this study was to determine the prevalence of osteopenia/osteoporosis (OP) or low bone density (LBD) in patients with CRS with/without polyposis treated with oral glucocorticoids. METHODS Retrospective chart analysis was performed at a tertiary-care rhinology practice. Patients with CRS with/without polyposis evaluated between September 2003 and July 2008 were included if they had (1) previous history of oral steroid usage (> or =5 mg daily for at least 3 months) and (2) previous bone mineral density evaluation. RESULTS A total of 197 patients were included with a mean age of 51.1 years (range, 15-79 years). The primary presenting diagnoses included CRS with polyposis in 176 cases (89.3%) and CRS without polyposis in 21 cases (10.7%). Concomitant asthma was present in 161 patients (81.7%). Overall, the prevalence of low bone mass was 38.6%. Among men >50 years of age and postmenopausal women, the prevalence of osteopenia/OP or LBD was 62.5 and 62.2%, respectively. Comparing men >50 years of age and postmenopausal women to their respective younger populations, both had a statistically higher presence of low bone mass (p < 0.0001), with an odds ratio of 10.6 (3.9-28.7) and 34.6 (7.4-161.5), respectively. There was no statistical difference in the presence of bone loss when comparing groups by gender. A multivariable analysis of common comorbidities revealed age to be the only factor associated with increased risk for OP/osteopenia or LBD. CONCLUSION Patients with CRS with/without polyposis treated with oral steroids who underwent bone density testing were found to have a high prevalence of LBD. High index of suspicion is required to identify at-risk patients and to initiate careful evaluation and treatment to prevent additional bone-related complications.
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Affiliation(s)
- Karthik Rajasekaran
- Chicago Medical School, Rosalind Franklin University of Science and Medicine, North Chicago, IL, USA
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Bella Z, Kadocsa E, Kemény L, Koreck A. Narrow-band UVB phototherapy of nasal polyps: results of a pilot study. JOURNAL OF PHOTOCHEMISTRY AND PHOTOBIOLOGY B-BIOLOGY 2010; 100:123-7. [PMID: 20566294 DOI: 10.1016/j.jphotobiol.2010.05.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2010] [Revised: 04/22/2010] [Accepted: 05/26/2010] [Indexed: 10/19/2022]
Abstract
Nasal polyposis (NP) is characterized by high recurrence rate despite medical and/or surgical treatment. The major mechanism of action of ultraviolet B light (UVB) is induction of apoptosis in inflammatory cells. Therefore phototherapy may represent a new therapeutic approach in NP. A pilot feasibility study was performed to assess the tolerability and clinical efficacy of UVB phototherapy in NP. Thirteen subjects with bilateral grade 1-3 NP were enrolled in an open-labeled prospective pilot study. Patients were exposed to gradually increasing doses of UVB light over a 12 week period (3 exposures/week). Subjects rated their nasal obstruction symptom scores weekly on a visual analogue scale from 0 to 6. The NOSE quality of life questionnaire was used at baseline and end of treatment period. Adverse events were monitored by endoscopy. Ten subjects completed the study. Nasal obstruction symptom scores and quality of life (NOSE) improved at end of treatment compared to baseline. Treatments were well tolerated and no device related adverse events were reported. The results suggest that phototherapy may represent a potential new treatment option in nasal polyps.
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Affiliation(s)
- Zsolt Bella
- Department of Otolaryngology, Head and Neck Surgery, University of Szeged, Hungary
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Weale RA. A note on age-related comorbidity. Arch Gerontol Geriatr 2009; 49:93-7. [DOI: 10.1016/j.archger.2008.05.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2007] [Revised: 05/16/2008] [Accepted: 05/28/2008] [Indexed: 10/21/2022]
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Bonfils P, Chatellier G, Malinvaud D, Consoli SM. [Evaluating the knowledge of nasal polyposis in patients, GPs, and ENT specialists]. ACTA ACUST UNITED AC 2007; 124:215-21. [PMID: 17803953 DOI: 10.1016/j.aorl.2007.06.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2006] [Accepted: 06/11/2007] [Indexed: 11/23/2022]
Abstract
OBJECTIVES To evaluate education for adults with nasal polyposis (NP) and compare their knowledge and opinions on NP to those of a group of general practitioners and a group of ENT specialists. MATERIAL AND METHODS Prospective study conducted on 87 consecutive subjects (33 patients with NP, 20 GP, and 34 ENT) using a questionnaire to evaluate the knowledge on NP (general, medical, and surgical information). RESULTS The results obtained from the three groups of subjects (patients, GP, ENT) differed significantly on "overall knowledge of the disease." Patients and GPs showed similar results. The ENT group had significantly better results. CONCLUSION Education in a this type of chronic disease of the upper respiratory tract seems necessary for the management of NP. This study also underscores the need for information transfer on NP from ENT specialists and GPs.
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Affiliation(s)
- P Bonfils
- Service d'ORL et de chirurgie cervicofaciale, CNRS UPRESSA 7060, hôpital européen Georges-Pompidou, faculté de médecine Paris-Descartes, université Paris-V, 20, rue Leblanc, 75015 Paris, France.
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