2018 Section 5 - Rhinology and Allergic Disorders

Orlandi et al.

TABLE III-5. Summary of recommendations for CRSwNP management

Benefit-harm assessment

Intervention

LOE

Benefit

Harm

Cost

Policy level

Saline irrigation

A Improved

Local irritation, nasal

Minimal

Preponderance of

Recommended

symptomatic, radiologic, and endoscopic outcomes

burning, headaches, and ear discomfort

benefit over harm

Topical corticosteroids (standard delivery)

A Improved symptoms and endoscopic appearance A Difficult to assess based on current evidence A Significant short-term improvements in subjective and objective measures

Epistaxis, headache

Low to moderate Benefits outweigh harm

Recommended

Topical corticosteroids (nonstandard delivery)

Possible systemic absorption

Moderate

Balance of benefit and harm

Option

Oral corticosteroids

GI symptoms, transient adrenal suppression,

Low

Preponderance of

Recommendation for

benefit to harm in small, short-term follow-up and with use less than once every 2 years

short-term management. Longer-term or frequent use is not supported by the literature and carries an increased risk of harm

insomnia, and increased bone turnover. All established corticosteroid risks exist, particularly with prolonged treatment

Antibiotics: oral nonmacrolide Antibiotics: oral macrolide

N/A

Insufficient evidence for a recommendation

B Reduction in

Significant potential for

Low

Benefits appear to outweigh harm

Option

endoscopy scores and some symptoms; benefit may be transient

medication interactions. Rare adverse events

Antibiotics:

C Possible symptom improvement

Thrombophlebitis,

High

Risks outweigh benefits

Recommendation against

intravenous

neutropenia, sepsis, deep vein thrombosis, elevated liver enzymes, drug adverse events, rash, bleeding Local irritation, possible systemic absorption

Antibiotics: topical

B None demonstrated in randomized trials A None demonstrated in randomized trials (may have some benefit in AFRS)

Moderate to high Harm outweighs benefits

Recommended against

Antifungals: topical

Local irritation (rare)

Moderate

Harm outweighs benefits

Recommended against

Surfactants, Manuka honey, xylitol

N/A

Insufficient evidence for a recommendation

Colloidal silver

N/A

Significant safety concerns

Recommended against

Antileukotrienes

A Improvement in symptoms

Limited risks

Moderate

Balance of benefit and harm

Option

Aspirin desensitization (for AERD patients)

B Reduced polyp

Bleeding, gastrointestinal upset

High initial cost for desensitization

Benefit outweighs harm

Recommended for AERD patients

re-formation after surgery

AERD = aspirin-exacerbated respiratory disease; AFRS = allergic fungal rhinosinusitis; CRSwNP = chronic rhinosinusitis without nasal polyps; GI = gastrointestinal; N/A = not applicable.

International Forum of Allergy & Rhinology, Vol. 6, No. S1, February 2016

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