Is an intranasal corticosteroid (INCS) effective monotherapy for treatment of acute rhinosinusitis?
Explore this issue:July 2010
Background: Acute rhinosinusitis is often treated with antibiotics as if it were a bacterial infection; however, estimates suggest that approximately 98 percent of cases may be of viral etiology. The natural history of acute sinusitis, even in cases of bacterial disease, is spontaneous resolution in the majority of cases. Given this fact, the routine use of antibiotics is sometimes questioned, and further questions have been raised regarding the potential role of interventions that might speed the rate of symptom resolution.
Study design: Case report and systematic review.
Synopsis: The authors discuss the results of their review within the framework of a clinical example describing a patient who has suffered fatigue, nasal discharge, obstruction, hyposmia and maxillary pain for a period of 10 days. Acknowledging overutilization of antibiotics for a disease that is largely self-limiting, while appreciating the significant impact that the disease has upon quality of life and function, the following question was posed as the basis of this systematic review: Does treatment with an INCS alone reduce the time to recovery in adults with acute, non-complicated rhinosinusitis?
Using a broad filter, search terms were chosen to select for patients with acute rhinosinusitis whose sole therapy had been INCS. This search yielded 811 articles that were further screened to four articles specifically addressing their focused clinical question. Full review of these four articles resulted in only two articles that satisfied the authors’ domain, determinant and outcomes.
The two studies were designed as randomized, prospective, double-blind, double-dummy placebo-controlled trials assessing the effectiveness of an INCS versus that of combinations of amoxicillin, combined therapy and placebo. Each of the studies differed with respect to specific INCS and methods of outcome assessment. Williamson and colleagues compared regular-strength budesonide to placebo, amoxicillin and combined therapy and showed neither difference in total symptom score nor proportion of cured patients attributable to the use of budesonide in any group at treatment day 10 (aRD: 0 percent [95 percent CI:-12.6 percent to 12.7 percent]). Meltzer and colleagues compared amoxicillin to once-daily (200mg) mometasone, twice-daily (400mg) mometasone and placebo and demonstrated a statistically significant dose-dependent improvement for those patients treated with single-dose (p<0.018) and double-dose (p<0.001) mometasone when compared to placebo. It may be of interest that, within the Meltzer study, double-dose mometasone also showed statistical superiority over amoxicillin (p=0.002).
The authors ultimately conclude that there are insufficient data to recommend the use of an INCS as monotherapy for the patient presented within their clinical example. Interestingly, the conclusion of the authors in this systematic review offers an example of the variability that can accompany individual authors’ interpretation as a component of systematic review of the literature. As an example of this variability, Cochrane recently conducted a similar systematic review of the literature involving the same two articles but arrived at the opposite conclusion.1