Hopkins C, Surda P, Walker A, Wolf A, Speth M, Jacques T, et al. EPOS 4 patients. Rhinology. 2021 Suppl. 30: 1-57.

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Corticosteroids

What are corticosteroids?

Corticosteroids are hormones that are naturally produced in the body. They play an important role in the everyday processes in your body like growth, repair, and responding to stress. Corticosteroids can be given as medication by using a man- made version of these naturally occurring hormones and may be given to patients for many different conditions. They may be given as tablets (“oral”), injection into the bloodstream (“intravenous”), or by sprays and creams (“topical”).

 

Why you have been prescribed this medication?

Your physician has prescribed this treatment because you either suffer from a severe type of rhinosinusitis that does not respond well to other therapies or because you will undergo sinus surgery. Chronic rhinosinusitis is an inflammatory disease of the nose and sinuses and steroids are amongst the most effective anti- inflammatory drugs available. In case of failure of other drugs such as nasal sprays, drops and rinsing, oral steroids can some- times be used to bring you added relief. This is particularly true if you suffer from nasal polyps and if you suffer from smell problems or severe nasal obstruction.

In some cases where you are due to undergo sinus surgery with your doctor, corticosteroids may be used in the immediate few days prior to your operation as the reducing inflammation in your sinuses can help the operation be more straightforward, although this is not needed in most cases.

 

How it works

Oral steroids have a strong action in reducing inflammation. They reduce swelling and the fluid that accumulates in unhealthy tissue and can help to soothe the vicious cycle of inflammation that can sometimes occur when the immune system is activated incorrectly. Through this action, they can reduce the size of your nasal polyps (if present) and improve your nasal breathing and sense of smell within days. Unfortunately, this change is not permanent and some patients will experience a relapse of some symptoms after steroid treatment has ended.

 

How, when and for how long you should use it.

The tablet form of corticosteroids that are given to you by your doctor will come with a written prescription of how many tablets you should take, and how long you should take them for. It is important that you follow the treatment scheme exactly as prescribed by your physician. It is recommended to take the tablet(s) in the morning during breakfast.

 

Your treatment consists of tablets that, in some people needs to be reduced slowly over a certain number of days, usually only after long-term courses. This is because corticosteroids tablets can reduce the need to produce your own naturally occurring hormone levels; when the course of tablets is due to end then you may need to give your body a chance to start producing its own corticosteroids again. This slow reduction in tablet dosing is called a “taper” and if it is required, will be clearly written on your prescription. It is usually unnecessary after a short course.

 

Side effects (and what to do if they occur)

Steroid hormones are active in almost every part of the body, and equally, their potential side-effects can be found in almost every part of the body. However, they do not occur in all patients and some people will be more bothered by them than others. Because of the potential harmful side-effects of the steroids, your physician will aim to strike a balance by prescribing you the shortest course possible that will still have a beneficial effect on your disease. The duration of this course can alter according to the type of rhinosinusitis you suffer from.

 

Steroid hormones have a stimulating effect on your body, with possible side-effects of agitation, palpitations and trouble falling asleep. For this reason, it is recommended to take steroid tablets in the morning so the effect will have faded by the time you have to go to bed. One of the most common side-effects of a short course of oral steroids is stomach upset, and some patients suffer heartburn or a feeling of acid reflux. Therefore, it is recommended to take your medication together with break- fast. If you have a history of stomach problems, your physician

may prescribe an additional treatment to protect your stomach.

 

Oral steroids increase blood sugar levels and if you are diabetic, you must take extra care to monitor your blood sugar more closely than normal whilst you take oral corticosteroids.

 

These tablets also have an effect on your mood and you should inform your physician if you have any current or previous mental health problems. Some patients report that their mood can be altered during the time they take steroids, with some feeling high or excited and others feeling flat and depressed. If you suffer these extremes of mood, please do make sure you talk to your doctor about whether you should continue taking this medication.

 

More rare side effects include problems with the blood supply to bones and heart problems.

 

If you have a history of diabetes, high blood pressure, heart disease, psychiatric disease, stomach problems or insomnia you should mention this to your physician before starting this therapy. Equally, if you have concerns about the risks of side effects then please talk to your doctor who will be able to offer information that is specific to your own personal health history.

 

In case you feel you react badly to the treatment, do not stop it abruptly, but contact your physician instead to discuss whether a change in dose or early stopping is indicated.

 

Because of its positive effects on growth and metabolism, oral steroids are considered doping by the World Anti-Doping Association (WADA) and if you are a competitive athlete, you should inform your sports physician about this.

 

Potential interactions

Oral steroids can interact with other medications you may be taking and increase the risk of side effects of those drugs. You should let your doctor know about any medications you are taking prior to starting oral corticosteroids.

 

If one or more of the medicines described below are prescribed to take at the same time as oral corticosteroids, your doctor may change the dose or how often you use one or both of the medicines:

  • Increased risk of tendon rupture when taken with antibiotics of the quinolone family.

  • Increased risk of stomach ulcers when taken with anti- inflammatory drugs of the non-steroidal family (NSAIDs)

    • e.g. Ibuprofen, Naproxen, Diclofenac

  • Increased effect of certain drugs that thin the blood (warfarin) when steroids are taken in high dosages.

  • Difficulties of regulating the blood sugar levels with certain anti-diabetes medication.

  • Increased risk of low potassium levels in the blood when taken with drugs that interfere with the potassium levels such as certain diuretics or ‘water pills’ (e.g. Furosemide).

 

Always read the leaflet that comes with any other medication you take to check for any other rare interactions.

 

Patient’s experience with oral steroids

Patient 1 reports:

“Because of my problem of chronic sinusitis, I use a nasal spray that my doctor prescribed, on a daily base. Despite this treatment, every year (mostly during winter) I suffer from an acute sinusitis. My main complaints are headache, a blocked nose, secretions dripping down my throat and blocked ears with hearing loss. As a treatment, I always start with a nasal decongestant (never more than 1 week) and daily nasal saline washings.

 

However often, it takes 3 to 4 weeks for these symptoms to resolve. When they do not resolve by themselves, I ask my doctor to prescribe a course of oral corticoids like Medrol (especially when the hearing loss is annoying me). I take it for 12 days in a tapering dose: 4 days 16 mg a day, 4 days 8 mg a day, 4 days 4 mg a day. I take them in the morning, after my breakfast. Mostly, but not always, I start to notice a difference after 2 to 3 days. Besides the very bitter taste of the tablets, side effects that bother me, are a slightly nervous feeling and difficulties to fall asleep.”

 

Patient 2 reports:

“Suffering from a chronic rhinosinusitis with nasal polyps for 8 years, was prescribed several courses of oral corticosteroids in my life to relieve the pain caused by this disease. It is true that my first steroid treatment relieved the feeling of obstruction, allowed my sense of smell to reappear and helped me sleep better over a period of 3 months. However, the symptoms subsequently reappeared. I could see that each new course of oral steroids relieved me over a shorter and shorter period. Therefore, taking Medrol today is less worth the effort than in the past. In addition, my last Medrol cure also had a significant impact on my morale, generating frequent changes in emotions.”

 

Frequently asked questions

Do oral steroids make you put on weight?

One of the best-known side-effects of oral steroids among the general public and often the most feared one by patients is weight gain. It is true that the long-term use of oral steroids is linked to increased body weight when patients are taking this medication for several months to years, depending on the dose they receive, partly as steroids can increase the appetite. However, no weight gain has been shown with treatments shorter than 8 weeks, which is usually the case when treating rhinosinusitis. Some patients on short courses may report temporary water retention which will settle soon after the course has been completed.

 

How many courses can you have in a year without risks of side effects?

Oral steroids can have both early and late side effects. The early side effects, such as agitation, palpitation, insomnia and stomach disturbances can occur during an initial course. Others, such as diabetes, osteoporosis or cataract, occur only after several or long-term courses. There is not much known about how many courses will induce these long-term side effects and it will mostly dependent on your age, the dose of the steroids prescribed and other underlying diseases that you might suffer from. One study suggests that more than 2.5 courses per year (for any disease) should be avoided, and that the total life-time dose should also be carefully considered.

Isn’t it safer to have steroids rather than surgery?

This is a difficult question that is not so easy to answer. As mentioned before, long-term side effects of oral steroids can be serious and it will be difficult to predict who will develop these side effects and after how many courses. Sinus surgery is also linked to certain complications that may depend on the extent of your disease as well as the type of surgery that is planned. But when surgery is performed by an experienced surgeon using appropriate equipment, serious surgical complications are very rare and manageable. Therefore, it is accepted that sinus surgery is indicated for those patients at risk for developing steroid side effects, those that are not responsive to oral steroids or in whom multiple courses are needed to control their disease. One study suggests that in patients requiring more than 2 courses per year, the risks versus benefits shift towards surgery being the better option.

 

Do oral steroids make me more likely to get sinus infections?

Several studies have shown that the use of long-term or high dose oral steroids (more than 700mg total dose) can increase the general risk of infection, because of their effect on the immune system. Also, asthma patients that take a substantial dose of oral steroids, have an increased risk of developing pneumonia. Although not properly studied, studies on short-term courses of oral steroids do not show an increased risk of developing acute sinus infections. So far, nothing is known about the use of long-term oral steroids and the risk of sinus infections.