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Medical Treatments for Sinusitis and Nasal Polyp Removal
Quynh-Chi Dang • Aug 4, 2021 • 70 hits
Sinusitis is a condition that refers to the swelling of the sinuses and usually causes the growth of nasal polyps. In general, medical treatments for sinusitis and nasal polyps should be explored before nasal polyps surgery. Dr. Patricia Loftus explains her approach to medical treatments for sinusitis and nasal polyp removal on the BackTable ENT Podcast.
We’ve provided the highlight reel in this article, but you can listen to the full podcast below.
The BackTable ENT Brief
• Because an overactive inflammatory response is a common cause of sinusitis and nasal polyps, prescribing corticosteroids like Flonase, budesonide, and prednisone for sinusitis and nasal polyps is recommended.
• Dr. Loftus recommends following a steroid taper of 40 pills over 16 days if oral prednisone for sinusitis and nasal polyps is prescribed.
• Steroid medication should only be prescribed to diabetic patients if they are able to control their blood glucose levels. Primary care physicians should be notified about the medication and participate in blood glucose monitoring.
• Dupixent, a biologic that inhibits the interleukin inflammatory response, was first used to treat atopic dermatitis and asthma. In recent years, it has been used to treat nasal polyps. Dr. Loftus sees Dupixent as a last option after nasal polyp removal surgery because of its high cost and there is a lack of research around using this medication for nasal polyps.
Table of Contents
(1) Steroid Regimen for Sinusitis & Nasal Polyps: Prednisone, Budesonide, and Flonase
(2) Prescribing Steroids for Sinusitis in the Diabetic Patient
(3) Biologics for Nasal Polyps: Dupixent
Steroid Regimen for Sinusitis & Nasal Polyps: Prednisone, Budesonide, and Flonase
Dr. Loftus recommends exploring medical treatments for nasal polyps before transitioning to surgical options. Prednisone is an oral corticosteroid that reduces swelling and allergy symptoms. Dr. Loftus usually prescribes prednisone for sinusitis; she recommends tapering of 40 pills over 16 days to first-time nasal polyps patients. She does not recommend prescribing more than 40 prednisone pills, as side effects from overmedication may be harmful.
Budesonide and Flonase, other corticosteroids, can also be used instead of prednisone for sinusitis. However, both are commonly prescribed in the form of a nasal spray for polyps. These intranasal sprays can also be combined with post-operative nasal rinses for a more efficient recovery.
[Dr. Ashley Agan]
When patients walk into your clinic and you see that they have polyps, what happens after that? I assume if they haven't had a scan, they probably get a CT scan and you probably send them out on some topical therapies--maybe prednisone. What does that look like?
[Dr. Patricia Loftus]
Yeah. Like you said, we always try medical management first, and for chronic rhinosinusitis with nasal polyps, this is a disease where prednisone is actually recommended. We have guidelines that give us different options. However, patients with polyps, which are eosinophilia-driven, tend to do well with prednisone because they respond well to steroids. So, this is something that's recommended if the patient doesn't have any contraindications to it. In a patient who is treatment-naive and can take prednisone, I will do a steroid taper.
There's no specific taper that you should do. What I like to do is 40 milligrams for four days, 30 for four days, 20 for four days, 10 for four days. So, it's 40 pills over a 16 day taper. I would say that most rhinologists tend to not go higher than 40. From what I read, someone looked into it and found that the dosage that you hit had side effects and might've created lawsuits, or something along that line. They kind of found that 40 was okay to go up to. That's what most of us do. Also, I will definitely tell them to do saltwater rinses.
[Dr. Patricia Loftus]
We know there's a recommendation for intranasal corticosteroids. Intranasal corticosteroids that are FDA approved are Flonase or the other sprays. But as you guys know, we do tend to add our steroids to rinses. I use budesonide for that. It is off-label technically. There's not robust data and I think mostly because it is off-label, but we know that it does work. What's nice about adding the budesonide is that with the rinse, it's higher volume, can kind of get into the nose and sinus cavities a little bit better.
I think pre-operatively, the budesonide and the rinse doesn't matter as much just because you don't have that open space yet. I think it's very important post-operatively. My patient who hasn't had surgery yet, I’ll prescribe a steroid taper, a saline rinse, an intranasal corticosteroid--whether it's Flonase or whether you add it into the rinse. I won't do a CAT scan unless there is something concerning to me, just because there are some people who respond really well and can keep their polyps under control on topical steroids.
If they feel good, we might just have them come back in a couple months and see if the polyps have come back or if they're still doing okay on the topical medication. If they quickly come back, that's when we'll potentially discuss surgery and that's when I would get a CAT scan.
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Prescribing Steroids for Sinusitis in the Diabetic Patient
Because steroids cause the liver to release stored glucose, diabetics must monitor their blood sugar closely when using Flonase, budesonide, or prednisone for sinusitis and nasal polyps. Before prescribing oral or intranasal steroids to a diabetic patient, Dr. Loftus assesses the patient's A1C levels and their ability to manage their blood sugar. If the patient is able to control his blood sugar on a daily basis, she will prescribe steroids and notify their primary care provider about the medication.
[Dr. Gopi Shah]
Do you do any steroids for your patients that are diabetics? Do you get in touch with endocrine or is that just not an option? Do you talk to the endocrinologist about budesonide rinses? Can those patients take that?
[Dr. Patricia Loftus]
Yeah, that's a great question. I think that what I really like about having an EMR now, is that it's really easy to send a quick message to these patients’ PCPs. For anybody who has diabetes, I'll usually check if their A1C isn't too bad. They seem pretty controlled. Usually, these patients are actually fine to take prednisone, but I'll always send a message to the PCP and just kind of ask them to check on how they're doing in a week or two. I pretty much always get the go-ahead from the PCPs when the patients are pretty controlled.
I think it's the patients that are not controlled. You know those patients, you kind of know the patients that you see that it’s not a good idea to give them a steroid. There are patients that can’t take prednisone. I will still give them topical because we do know that there's not great systemic absorption and we don't really have anything to show that there's bad systemic side effects from doing the topical. Patients with diabetes who can't take oral, I will definitely give them topical. But they potentially might be someone who doesn't respond that well and would be going to surgery a little bit sooner.
Biologics for Nasal Polyps: Dupixent
Biologics are a class of drugs that are produced from or contain elements of living organisms. Oftentimes, when administered to patients, they are able to change intracellular processes.
Dupixent is a biologic that inhibits the interleukin inflammatory response, thus mitigating a hyperactive immune system. Although the use of Dupixent has been studied in the context of atopic dermatitis and asthma, its side effects and efficacy has not been widely studied in nasal polyp patients. Dr. Loftus prefers performing nasal polyp surgery on patients before prescribing Dupixent for sinusitis and nasal polyps because of the lack of research and high costs associated with this medication. However, she notes that she has seen Dupixent improve patients’ lives in some cases and is excited to see more research about its use in nasal polyps cases.
[Dr. Patricia Loftus]
These are all options that I would talk about with the patient. Biologics is a very new thing that we've been trying to do. We, as ENTs, have only been able to prescribe Dupixent since June of last year. It has not been that long that we've even been able to prescribe these biologics. There was a meeting with the NIH where everybody kind of met and they said, “Okay, when do we use these?” Because they are very expensive. It's like 38 grand a year to be on this medication. So, it's not something that you just kind of throw at anybody.
We feel that you really should fail all of the other stuff that we have. Definitely surgery first. Of course, there are those patients that may not be surgical candidates ever, and they could potentially be someone who can start on Dupixent without having surgery, but your typical patient, you want them to have had full surgery--meaning give them a revision surgery if there's ethmoid septations left or give them a revision surgery if they haven't had a Draf III. Try all the topical stuff, whether it's budesonide rinses, XHANCE, or stents with a steroid on them. So, try all that stuff, and if they are refractory to all of that, I have seen Dupixent work wonders.
Dupixent it's an IL-4 receptor medication that works on IL-4 and IL-13 since they share a receptor. That's what's really interesting about biologics in general. What we're trying to figure out is how we can work sort of downstream before polyp formation even happens. We used to just kind of just call sinusitis either, without polyps, right? But we know that it's so much more than that. We know there's TH1 inflammation where the cytokines tend to be IL-2 and tumor necrosis factor beta and interferon, and then TH2, which is polyp, which is your IL-4, 5 and 13.
We're trying to look at these cytokines and see if we can intervene at that portion of development of polyps. That's what Dupixent does. It works on these cytokines that you see in TH2 inflammation. I have seen it work wonders. It doesn't work for everyone, and there's still a lot of questions about it. For instance, how long do you give it a try until you decide it hasn't worked? Right now, we're kind of going off the asthma literature, because in asthma, they've had biologics for a much longer time for allergic asthma and atopic dermatitis. They've been dealing with biologics a lot longer than us, so we kind of look to them.
They usually do about four months or 16 weeks, and if there's been no change, we don't think it's going to work. But then there's also things like: how long do you leave the patients on for it? What we know so far is that, once the patients come off, the polyps tend to come back. So, is this a lifelong thing? So, you have to talk about that with the patients. Like, if we start you on this, this is going to be a shot every two weeks for what we think will be the rest of your life. That's a big deal, and then also, are there markers to decide who's going to respond and who isn't? Going back to one of your other questions, Ashley, was like, what things do you test for?
People will ask me, “Oh, do you test for IgE, and do you test for some of this eosinophilia?” These types of markers would be a biologic candidate in the future. Actually, currently, those things are not necessary to prescribe it. You really just have to show that they've tried other things, they failed, and that this is severely affecting their quality of life, and that you have polyps on endoscopy. So, quality of life would be smell loss and that kind of thing. You don't need to actually check those things to go on Dupixent. I don't usually check those early on, but if they were to see allergy or immunology, they might check them. There's still a lot that we don't know about Dupixent, but it is something that we should know about as ENTs treating polyps because there are those patients that will benefit from it.
Dr. Patricia Loftus
Dr. Patricia Loftus is Assistant Professor in the Rhinology & Skull Base Surgery division in the Department of Otolaryngology – Head and Neck Surgery (OHNS) at the University of California, San Francisco.
Dr. Ashley Agan
Dr. Ashley Agan is a practicing ENT and assistant professor at UT Southwestern Medical Center in Dallas, TX.
Dr. Gopi Shah
Dr. Gopi Shah is a practicing ENT at UT Southwestern Medical Center in Dallas, TX.
Cite This Podcast
BackTable, LLC (Producer). (2021, January 1). Ep. 13 – Treatment of Nasal Polyps [Audio podcast]. Retrieved from https://www.backtable.com
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