2016 Section 5 Green Book

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Oral corticosteroids in the management of chronic
rhinosinusitis with and without nasal polyps: Risks and
benefits
David M. Poetker, M.D., M.A.
ABSTRACT
Background: Oral steroids are synthetic mimics of adrenal cortex hormones and are considered a staple in the management of chronic rhinosinusitis due
to their anti-inflammatory effects. Despite their common use, many providers are not familiar with the potential risks of the drugs.
Methods: Literature review.
Results: An overview of the existing data on the risks of oral steroids is presented as well as a review of the malpractice lawsuits with regard to oral steroid
use and a discussion of the data that support the use of oral steroids in patients with chronic rhinosinusitis with and those without nasal polyps.
Conclusion: It is essential for providers to be aware of the potential complications of a medication, the medical jurisprudence of the drugs, and the data
that support their use.
(Am J Rhinol Allergy 29, 339–342, 2015; doi: 10.2500/ajra.2015.29.4223)
Oral steroids are a mainstay of treatment in the management of
sinonasal inflammatory disease, are commonly used, and are
considered by many rhinologists to constitute a key component of
“maximal” medical therapy.1 Their anti-inflammatory effects to treat
the inflammation associated with chronic rhinosinusitis (CRS) as well
as their antifibroblast effects to reduce postoperative scar formation
are the most common reasons for their widespread use.2 Despite their
common use, many providers are not familiar with the potential risks
of the drugs.
The objectives of this review were to present an overview of the
existing data on the risks of oral steroids. This was not intended to be
an exhaustive review because other articles exist that specifically
outline those risks.3 We plan to discuss what is known about specific
risks, review the lawsuits regarding oral steroid use, and finally,
discuss the data that support the use of oral steroids in patients with
CRS, with and without nasal polyps.
COMPLICATIONS OF STEROID USE
Morphologic Changes
Redistribution of adipose tissue, a common effect associated with
prolonged oral steroids, is known as “corticosteroid-induced lipodys-
trophy” or “cushingoid” changes, and includes truncal obesity, facial
adipose tissue (moon facies), and dorsocervical adipose tissue (buf-
falo hump). 4 The rate and incidence is variable but has been reported
to occur in 15% of patients in 3 months, with daily doses equivalent
to 10–30 mg of prednisone. 4 Higher doses and longer durations of
corticosteroids seem to increase the frequency of adipose tissue re-
distribution. 5 The risk is reportedly higher in women, patients 50
years of age, and patients with either a high initial body mass index
or a high calorie intake.5
Hyperglycemia
Steroids increase blood sugars by stimulating proteolysis, promot-
ing gluconeogenesis, and inhibiting glucose uptake.6 In addition,
steroids cause an insulin resistance by decreasing the ability of adi-
pocytes and hepatocytes to bind insulin. This effect can occur within
hours of beginning therapy but seems to decrease with prolonged
use. 6 Synthetic steroids are many times more potent than natural
steroids at decreasing carbohydrate tolerance.6 Upon cessation of the
steroids, the inhibition of glucose uptake and metabolism usually
returns to normal. 6 Despite their common use, the degree of hyper-
glycemia caused by steroids has not been clearly established.
Infection
Although steroids increase circulating neutrophils by enhanced
release from bone marrow and reduced migration from blood vessels,
the number of lymphocytes, monocytes, basophils, and eosinophils
decrease due to a migration from the vascular bed to lymphoid
tissue.7 Steroids can impair neutrophil function by reducing their
adherence to vascular endothelium and their bactericidal activity;
inhibit antigen-presenting cells by limiting chemotaxis, phagocytosis,
and the release of cytokines; decrease the expression of inflammatory
mediators; and may inhibit B-cell production of immunoglobulins.7,8
Interestingly, steroid administration on an alternate day schedule has
been shown to reduce their negative impact on leukocyte function. 8
Two large meta-analyses found that the rate of infections were
significantly higher in patients treated with steroids.9,10 Further re-
view found that patients who received a daily dose of 10 mg per
day or a cumulative dose of 700 mg of prednisone did not have an
increased rate of infectious complications. 10 Although the disease
processes for which the patients are being treated may themselves be
independent risk factors for infection, close review of the included
studies identified few patients with diseases known to increase risk
for infection.9,10 Additional studies demonstrated that patients treated
with glucocorticoids are at increased risk for developing invasive
fungal infections, pneumocystosis, and viral infections, especially in
patients who have undergone bone marrow transplantation.4,11–15
Wound Healing
Steroids inhibit the natural wound healing process by decreasing
the influx of macrophages, which may decrease phagocytosis as well
as growth factor and/or cytokine production.16–19 Steroids can also
delay reepithelialization, decrease the fibroblast response, slow cap-
illary proliferation, and inhibit collagen synthesis and wound matu-
ration.16,18,20
From the Division of Otolaryngology, Department of Surgery, Zablocki VA Medical
Center, Milwaukee, Wisconsin
D. Poetker is a speaker for Intersect ENT and a consultant for GlaxoSmithKline
Presented at the North American Rhinology and Allergy Conference, Boca Raton,
Florida, February 7, 2015
Address correspondence to David M. Poetker, M.D., Division of Rhinology and Sinus
Surgery, Department of Otolaryngology and Communication Sciences, Medical College
of Wisconsin, 9200 W Wisconsin Avenue, Milwaukee, WI 53226
E-mail address:
Copyright © 2015, OceanSide Publications, Inc., U.S.A.
American Journal of Rhinology & Allergy
Reprinted by permission of Am J Rhinol Allergy. 2015; 29(5):339-342.
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