Clinical effects of topical antifungal therapy in chronic rhinosinusitis: a randomized, double-blind, placebo-controlled trial of intranasal fluconazole

The efficacy of itraconazole, fluticasone and doxycycline in chronic rhinosinusitis

BACKGROUND

Different treatment strategies for chronic rhinosinusitis (CRS) have been evaluated. Here we aimed to investigate the effects of fluticasone spray alone and in combination with itraconazole or doxycycline.

METHODS

This is an open-label clinical trial performed in 2020-2021 in Isfahan on patients with CRS. This survey's Iranian Registry of Clinical Trials (IRCT) code was IRCT20200825048515N50 (https://en.irct.ir/trial/60826). Demographic data of all patients including age and gender and duration of CRS, were obtained. The SNOT-22 and Lund-Kennedy questionnaires were evaluated and recorded for the symptomatology of CRS. Patients were randomly assigned to the treatment groups to receive 100 mg of doxycycline with intranasal fluticasone spray, intranasal fluticasone spray alone, or itraconazole 100 mg capsules with intranasal fluticasone spray. After one month of treatment, the scores and patient satisfaction were evaluated and compared.

RESULTS

Data of 104 patients was analyzed. Patients had improvements in their symptoms and SNOTT-22 scores. The mean SNOTT-22 score was 55.36±8.36 in all patients. During the study, patients had improvements in their symptoms and SNOTT-22 scores. The mean final SNOTT-22 score was 47.77±7.36 at the end of the survey (P=0.02). Our data also demonstrated significant improvements in the Lund-Kennedy score in all patients during the study (P<0.05).

CONCLUSION

There were no significant differences between the clinical condition of patients receiving intranasal fluticasone, intranasal fluticasone in combination with doxycycline or itraconazole.

Current Perspective on Nasal Delivery Systems for Chronic Rhinosinusitis

Chronic rhinosinusitis is an upper respiratory disease during which topical drug treatment via the nasal cavity is the most actively utilized therapeutic strategy. In addition to steroids, antibiotics, and antifungal agents, which are widely used in clinical practice, research on novel topical agents to improve the bacterial biofilm or mucociliary clearance remains ongoing. Moreover, owing to the complex structure of the nasal cavity, the effects of nasal drug delivery vary depending on factors related to delivery fluid dynamics, including device, volume, and compounds. In this article, we review methods and compounds that have been applied to chronic rhinosinusitis management and introduce recent advances and future perspectives in nasal drug delivery for upper respiratory diseases.

Topical and systemic antifungal therapy for chronic rhinosinusitis

BACKGROUND

This review adds to a series of reviews looking at primary medical management options for patients with chronic rhinosinusitis.Chronic rhinosinusitis is common and characterised by inflammation of the lining of the nose and paranasal sinuses leading to nasal blockage, nasal discharge, facial pressure/pain and loss of sense of smell. The condition can occur with or without nasal polyps. Antifungals have been suggested as a treatment for chronic rhinosinusitis.

OBJECTIVES

To assess the effects of systemic and topical antifungal agents in patients with chronic rhinosinusitis, including those with allergic fungal rhinosinusitis (AFRS) and, if possible, AFRS exclusively.

SEARCH METHODS

The Cochrane ENT Information Specialist searched the Cochrane ENT Trials Register; Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE; Ovid Embase; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 17 November 2017.

SELECTION CRITERIA

Randomised controlled trials (RCTs) with at least a two-week follow-up period comparing topical or systemic antifungals with (a) placebo, (b) no treatment, (c) other pharmacological interventions or (d) a different antifungal agent. We did not include post-surgical antifungal use.

DATA COLLECTION AND ANALYSIS

We used the standard Cochrane methodological procedures. Our primary outcomes were disease-specific health-related quality of life (HRQL), patient-reported disease severity and the significant adverse effects of hepatic toxicity (systemic antifungals). Secondary outcomes included general HRQL, endoscopic nasal polyp score, computerised tomography (CT) scan score and the adverse effects of gastrointestinal disturbance (systemic antifungals) and epistaxis, headache or local discomfort (topical antifungals). We used GRADE to assess the quality of the evidence for each outcome; this is indicated in italics.

MAIN RESULTS

We included eight studies (490 adult participants). The presence of nasal polyps on examination was an inclusion criterion in three studies, an exclusion criterion in one study and the remaining studies included a mixed population. No studies specifically investigated the effect of antifungals in patients with AFRS.Topical antifungal treatment versus placebo or no interventionWe included seven studies (437 participants) that used amphotericin B (six studies; 383 participants) and one that used fluconazole (54 participants). Different delivery methods, volumes and concentrations were used.Four studies reported disease-specific health-related quality of life using a range of instruments. We did not meta-analyse the results due to differences in the instruments used, and measurement and reporting methods. At the end of treatment (one to six months) none of the studies reported statistically significant differences between the groups (low-quality evidence - we are uncertain about the result).Two studies reported disease severity using patient-reported symptom scores. Meta-analysis was not possible. At the end of treatment (8 to 13 weeks) one study showed no difference and the second found that patients in the placebo group had less severe symptoms (very low-quality evidence - we are very uncertain about the result).In terms of adverse effects, topical antifungals may lead to more local irritation compared with placebo (risk ratio (RR) 2.29, 95% confidence interval (CI) 0.61 to 8.62; 312 participants; 5 studies; low-quality evidence) but little or no difference in epistaxis (RR 0.97, 95% CI 0.14 to 6.63; 225 participants; 4 studies, low-quality evidence) or headache (RR 1.26, 95% CI 0.60 to 2.63; 195 participants; 3 studies; very low-quality evidence).None of the studies found a difference in generic health-related quality of life (one study) or endoscopic score (five studies) between the treatment groups. Three studies investigated CT scan; two found no difference between the groups and one found a significant decrease in the mean percentage of air space occluded, favouring the antifungal group.Systemic antifungal treatment versus placebo or no treatmentOne study (53 participants) comparing terbinafine tablets against placebo reported that there may be little or no difference between the groups in disease-specific health-related quality of life or disease severity score (both low-quality evidence). Systemic antifungals may lead to more hepatic toxicity events (RR 3.35, 95% CI 0.14 to 78.60) but fewer gastrointestinal disturbances (RR 0.37, 95% CI 0.04 to 3.36), compared to placebo, although the evidence was of low quality.This study did not find a difference in CT scan score between the groups. Generic health-related quality of life and endoscopic score were not measured.Other comparisonsWe found no studies that compared antifungal agents against other treatments for chronic rhinosinusitis.

AUTHORS' CONCLUSIONS

Due to the very low quality of the evidence, it is uncertain whether or not the use of topical or systemic antifungals has an impact on patient outcomes in adults with chronic rhinosinusitis compared with placebo or no treatment. Studies including specific subgroups (i.e. AFRS) are lacking.

The role of infection and antibiotics in chronic rhinosinusitis

OBJECTIVE

To review the current understanding of the role of infection and antibiotics in chronic rhinosinusitis.

REVIEW METHODS

PubMed literature search.

RESULTS

Chronic rhinosinusitis (CRS) in adults is an inflammatory condition and the role of infection is unclear. Biofilms are present in both CRS and normal patients so their role in CRS is unknown. Sinus cultures in CRS demonstrate a mixture of aerobic and anaerobic bacteria but may be hard to interpret due to contaminating nasal flora. Staphylococcus aureus is common in CRS patients but also present in 20-30% of nasal cultures in the normal population; eradicating this organism did not lead to symptom improvement versus placebo in a randomized controlled trial (RCT). In CRS patients who develop an episode of acute rhinosinusitis (ARS), bacteria typical of ARS can generally be cultured and require short-course treatment. For CRS, topical antibacterial or antifungal agents have shown no benefit over placebo in RCTs, although RCTs of topical antibacterial agents have been small. Oral macrolides and doxycycline, antibiotics with anti-inflammatory properties, are the only systemic antibiotics that have been evaluated in RCTs. One RCT found 3 weeks of doxycycline beneficial in patients with polyps but follow up was short (<3 months); RCTs of prolonged macrolide therapy have produced mixed results, and most show no benefit after cessation of therapy. Long-term antibiotic therapy may produce side effects and select increasingly resistant flora. The American Academy of Otolaryngology-Head and Neck Surgery guidelines recommend against treatment of CRS with antifungal agents but do not comment on the role of antibacterial treatment.

CONCLUSION

The role of infection in CRS is unknown, and the only well-defined role for antibiotics is for treatment of ARS episodes or their infectious complications.

LEVEL OF EVIDENCE

N/A.