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Journal Reading

Does Oral Prednisolone Increase
The Efficacy of Subsequent Nasal
Steroids in Treating Nasal
Polyposis?
Presented by:
Cindy Dewinta S 11 2013 254
Melissa Trixiana 11 2013 249
Margareth S.Pereira 11 2013 259
Ricardo C. Amalo 11 2013 314

Backgrou
nd

Conclusi
on

Discussi
on

Methods

Results

Background
• To evaluate whether oral prednisolone
produces any additive effects on
subsequent nasal steroid therapy
• To evaluate if any clinical variables can
predict therapeutic outcome

but some patients do not respond • Systemic steroid is well known for reduction the symptoms and polyp size • Long term used side effects • The optimum usage without side effects important to improve medical treatment • Data to confirm the additive effects of oral steroids on long term efficacy are lacking.Nasal polyposis Chronic inflammatory disesase of the sinonasal mucosa of unknown etiology Nasal steroids are Mainstay treatment. .

.Allergy Sinusitis Multifactori al disease Predisposin g factors Asthma Comorbid disorders Aspirin intolerance Size of polyps Poor response to steroid therapy and higher recurrence rate after surgery Knowledge of the effects of these possibly predicative variables would be useful in treatment planning and identifying patients to benefit from early surgical intervention.

polyps size. nasal airflow Patients with large polyp size and/or mucoid or mucopurulent discharge from the meatus middle and superior were predisposed to a poorer treatment outcome. .Evaluated the efficacy of a 14 day course of 50 mg of oral prednisolone Evaluated the short term effects of systemic steroid at 14 days posttrial in nasal polyposis Showed the positive effects of a short course of corticosteroids on improvement in nasal symptoms.

Inclusion and Exclution Criteria Statistical Analysis METHODS Clinical Assessment Data Collection .

2007 and September 30. Thailand . Songkhla. Department of Otolaryngology.METHODS 117 patients with nasal polyposis at the Allergy and Rhinology Clinic. Prince of Songkla University. Faculty of Medicine between May 1. 2010 Songklanagarind Hospital.

acute infection . immunocompromise d. glaucoma. severe septal deviation. unstable asthma. DM cataract.Inclusio n Exclusi on Benign bilateral nasal polyps diagnosed clinically and confirmed by nasal endoscopy Symptoms or physical signs of renal. hepatic. cardiovascular. cystic fibrosis mucociliary disorders.

Data Collection .

d ss. e ) e whe tightn t night ray.nasal symptom s sex age Medic al Histor y concomit ant diseases medicati on use of y r o hist  ma h t a. a st x che icularly chest l t (par norma a and . or c . s e t A h n n g p e r u s r o y recu zing.

The criteria for diagnosis of rhinosinusitis rhinitis symptom s positive sinus radiograp hy positive meatal discharge .

Skin-prick test ommon Bermuda grass Johnson grass Careless weed Alternaria species Penicillium mix 18 c lergens al aero Acacia Fusarium Dermatophagoides pteronyssinus Positif control Aspergillus mix Candida albicans cat pelt Dog epithelium American cockroach Mixed feathers Dermatophagoides farinae Histamine phosphate 2.75 mg/mL kapok pyrethrum Negative control G Cladosporium sphaerospermum aline s n i r lyce .

t s e t k c i r p n i k S Skin wheal diameters were determined at 20 minutes posit iv e rea ction .

daily for 14 days and were blinded to their treatment regimen. The dosage and duration of prednisolone were selected as the maximum safe dose. respectively.Patients were randomly assigned at a 3:2 ratio to receive 50 mg of prednisolone or placebo. .

At the end of this preliminary stage .

• All patients were instructed to return their remaining drug at the 2-week follow-up visit and then record carefully each nasal steroid dose taken on a diary card. which they would bring at their 7and 12-week follow-up visits. .

hyposmia. sneezing. and sinonasal pain. . postnasal drip. nasal itching. cough. runny nose.Clinical assesment Evaluations of the patients’ symptoms First visit before beginning treatment (week 0) At the end of the oral prednisolone phase (week 2) At the middle of the MFNS treatment phase (week 7) At the end of the MFNS treatment (week 12) blocked nose.

The severity of each individual symptom assesment Score 0 No symptoms Mild symptoms (steady Score 1-2 symptoms but easily tolerable) Score 3-4 Score 5-6 Moderate symptoms (symptoms hard to tolerate. sleep. might interfere with activities of daily living. both) Severeor symptoms (symptoms so bad that the person could not function virtually all the time TNSS .

The patient was instructed to keep their lips tightly closed while performing the maximal total expiratory effort through the nose after a maximal inspiration. .

The PEFI was calculated as the nasal PEF divided by the oral PEF to compensate for changes in lung function. with the best of three readings with a variation of 10% considered as the true peak flow. . which was then recorded as the result.Peak flow rate was read from a cursor in liters per minute.

causing total or almost total obstruction) (TNPS) re o c s s p ly o p l a s a The total n the polyps f o m su e th as d te la u was calc scores for each nostril.Nasal polyps size was assessed by nasal endoscopy at each visit scored on a scale of 0– Score No polyps 3 as follows: 0 Score mild polyposis (small polyps. . causing only slight obstruction) 1 Score 2 Scor e3 moderate polyposis (mediumsized polyps. causing troublesome obstruction) severe polyposis (large-sized polyps.

Patient Characteris tic Potentially Predictive Factors on Treatment Outcome Adver se Effect s Resul ts Nasal Sympto ms PEFI and Nasal Polyp Size .

Received allocated intervention (n=48) -Did not receive allocated intervention (n=0) -Lost to follow up (logistical problems) (n=1) -Discontinued intervention (n=0) Analyzed (n=47) -Excluded from analysis (give reasons (n=0) .Other reasons (n=0) Randomized 3:2 ratio (n=117) Allocated to intervention (n=69) .Received allocated intervention (n=69) -Did not receive allocated intervention (n=0) -Lost to follow up (logistical problems) (n=2) .Assesed for eligibility Excluded (n=4) .Discontinued intervention (n=0) Analyzed (n=67) -Excluded from analysis (give reasons) (n=0) Allocated to intervention (n=48) .Declined to participate (n=4) .Not meeting inclusion criteria (n=0) .

Nasal Symptoms Oral Prednisolone  significantly more improvements of all nasal symptoms (Prednisolon Group) Nasal Steroids (MFNS) Maintained improvement in Prednisolone group Continuing improvement in Placebo group End of the Nasal Steroid Phase:  no significant differences in the improvements of most nasal symptoms between the two groups. except in hyposmia .

PEFI AND NASAL POLYP SIZE PEFI scores and nasal polyp size in the prednisolone group were significantly higher than in the placebo group .

dyspepsia (oral steroid) Headache Nasal irritation No patient reported significant adverse symptoms immediately after cessation of oral prednisolone .Throat irritation Adverse Effects Gastrointestinal disturbance.

Adverse Event Gastrointestinal disturbance Dyspepsia Throat irritation Headache Nasal irritation Increased appetite Fatigue Acne Insomnia Prednisol one Group Placebo Group 11 5 4 3 2 1 1 1 1 1 1 3 3 2 0 0 0 0 .

Potentially Predictive Factors on Treatment Outcome Patients with polyp grade 3 positive meatal discharge showed less improvement in all treatment outcomes than patients with polyp grades 1 and 2 and negative meatal discharge In this analysis. both polyp grade and nasal endoscopy were significant predictors of treatment outcome Increasing polyp size or positive meatal discharge predicted poorer therapeutic response .

DISCUSSION .

Effect of initial oral prednisolone administration on subsequent nasal steroid treatment in patient with nasal polyposis The measures is in the subjective assessment and objective This study showed that in subjective and objective have been improved after oral steroid treatment after 2 weeks and maintained with the nasal steroids .

.

Allergy and asthma are frequently associated with nasal polyps.. showed a worse therapeutic response. and inflammation of sinus . and patient with these condition may have poor outcome in treatment And potent antiinflammatory action with the initial oral prednisolone. allergic. might be highly effective in control of asthma. An abnormal sinus radiography could be the result of noninfectious inflammation and/or infection.Other factor beside steroid resistance that can cause poor treatment outcome is chronic sinus inflammation Nasal polyps with positive meatal discharge.

abnormal sinus radiography should be interpreted in the clinical examination. nasal endoscopy A CT Scan is the imaging modality to provide more objective information. however CT imaging is limited by cost and consideration of radiation This study represent an examination of short-term effect of initial oral steroid followed by topical steroid in patient with nasal polyps. and need the longer clinical trials to examine the long-term therapeutic effect and identify reliable clinical predictors.Limitation in this study There is False positive and negative of conventional sinus radiography. .

CONCLUSION .

The main findings of this study Nasal steroid therapy alone effectively improved nasal symptons Combined therapy oral steroid and nasal steroid was more effective than nasal steroid alone in improving hyposmia. Massive polyposis and/or positive meatal discharge can be considered as major risk factors for steroid insensitivity. . polyps size. and nasal airflow.