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Corticosteroides orales de corta duración como tratamiento adyuvante para la rinosinusitis crónica

Appendices

Appendix 1. Search strategies

CENTRAL

Ovid MEDLINE

#1 MeSH descriptor: [Sinusitis] explode all trees

#2 MeSH descriptor: [Rhinitis] this term only

#3 MeSH descriptor: [Rhinitis, Atrophic] this term only

#4 MeSH descriptor: [Rhinitis, Vasomotor] this term only

#5 MeSH descriptor: [Paranasal Sinus Diseases] this term only

#6 MeSH descriptor: [Paranasal Sinuses] explode all trees

#7 rhinosinusitis or nasosinusitis or pansinusitis or ethmoiditis or sphenoiditis

#8 kartagener* near syndrome*

#9 inflamm* near sinus*

#10 (maxilla* or frontal*) near sinus*

#11 #1 or #2 or #3 or #4 or #5 or #6 or #7 or #8 or #9 or #10

#12 MeSH descriptor: [Chronic Disease] explode all trees

#13 MeSH descriptor: [Recurrence] explode all trees

#14 chronic or persis* or recurrent*

#15 #12 or #13 or #14

#16 #11 and #15

#17 CRSsNP

#18 (sinusitis or rhinitis) near (chronic or persis* or recurrent*)

#19 #16 or #17 or #18

#20 MeSH descriptor: [Nasal Polyps] explode all trees

#21 MeSH descriptor: [Nose] explode all trees

#22 MeSH descriptor: [Nose Diseases] explode all trees

#23 #21 or #22

#24 MeSH descriptor: [Polyps] explode all trees

#25 #23 and #24

#26 (nose or nasal or rhino* or rhinitis or sinus* or sinonasal) near (papilloma* or polyp*)

#27 rhinopolyp* or CRSwNP

#28 #19 or #20 or #25 or #26 or #27

#29 MeSH descriptor: [Steroids] explode all trees

#30 MeSH descriptor: [Adrenal Cortex Hormones] explode all trees

#31 MeSH descriptor: [Glucocorticoids] explode all trees

#32 MeSH descriptor: [Anti‐Inflammatory Agents] explode all trees

#33 MeSH descriptor: [Anti‐Inflammatory Agents, Non‐Steroidal] explode all trees

#34 #32 not #33

#35 steroid* or glucocorticoid* or corticosteroid* or glucosteroid* or cyclocosteroid*

#36 beclomethasone or beclometasone or beclamet or beclocort or becotide

#37 betamethasone or betadexamethasone or flubenisolone or celeston* or cellestoderm or betnelan or oradexon

#38 dexamethasoneor dexameth or dexone or dexametasone or decadron or dexasone or hexadecadron or hexadrol or methylfluorprednisolone or millicorten

#39 flunisolide or fluticasone or hydrocortisone or cortisol or cortifair or cortril or hyrocortone or cortef or epicortisol or efcortesol or Cortisone

#40 methylprednisolone or medrol or metripred or urbason

#41 mometasone or prednisolone or precortisyl or deltacortril or deltastab or prednesol or deltasone or prednisone or cortan or liquid next pred or meticorten

#42 paramethasone or triamcinolone or aristocort or volon or atolone or kenacort or orasone or panasol or prednicen

#43 corticoid* or betamethason* or betamethasone or hydrocortison* or celesto* or dexamethason* or hexadecadrol or budesonid* or horacort or pulmicort or rhinocort or methylfluorprednisolone or flunisolid* or nasalide or fluticason* or flonase or flounce or mometason* or nasonex or triamclinolon* or nasacort or tri next nasal or aristocort or Ciclesonide

#44 #29 or #30 or #31 or #34 or #35 or #36 or #37 or #38 or #39 or #40 or #41 or #42 or #43

#45 #28 and #44

1 exp Sinusitis/

2 paranasal sinus diseases/ or rhinitis/ or rhinitis, atrophic/ or rhinitis, vasomotor/

3 exp Paranasal Sinuses/

4 (rhinosinusitis or nasosinusitis or pansinusitis or ethmoiditis or sphenoiditis).ab,ti.

5 (kartagener* adj3 syndrome*).ab,ti.

6 (inflamm* adj5 sinus*).ab,ti.

7 ((maxilla* or frontal*) adj3 sinus*).ab,ti.

8 1 or 2 or 3 or 4 or 5 or 6 or 7

9 exp chronic disease/

10 exp Recurrence/

11 (chronic or persis* or recurrent*).ab,ti.

12 9 or 10 or 11

13 8 and 12

14 CRSsNP.ab,ti.

15 ((sinusitis or rhinitis) adj3 (chronic or persis* or recurrent*)).ab,ti.

16 13 or 14 or 15

17 exp Nasal Polyps/

18 exp Nose/ or exp Nose Diseases/

19 exp Polyps/

20 18 and 19

21 ((nose or nasal or rhino* or rhinitis or sinus* or sinonasal) adj3 (papilloma* or polyp*)).ab,ti.

22 (rhinopolyp* or CRSwNP).ab,ti.

23 16 or 17 or 20 or 21 or 22

24 exp Steroids/

25 exp Adrenal Cortex Hormones/

26 exp Glucocorticoids/

27 exp Anti‐Inflammatory Agents/

28 exp Anti‐Inflammatory Agents, Non‐Steroidal/

29 27 not 28

30 (steroid* or glucocorticoid* or corticosteroid* or glucosteroid* or cyclocosteroid* orbeclomethasone or beclometasone or beclamet or beclocort or becotide or betamethasone or betadexamethasone or flubenisolone or celeston* or cellestoderm or betnelan or oradexon or dexamethasone or dexameth or dexone or dexametasone or decadron or dexasone or hexadecadron or hexadrol or methylfluorprednisolone or millicorten or flunisolide or fluticasone or hydrocortisone or cortisol or cortifair or cortril or hyrocortone or cortef or epicortisol or efcortesol or Cortisone or methylprednisolone or medrol or metripred or urbason or mometasone or prednisolone or precortisyl or deltacortril or deltastab or prednesol or deltasone or prednisone or cortan or liquid next pred or meticorten or paramethasone or triamcinolone or aristocort or volon or atolone or kenacort or orasone or panasol or prednicen).ab,ti.

31 (corticoid* or betamethason* or betamethasone or hydrocortison* or celesto* or dexamethason* or hexadecadrol or budesonid* or horacort or pulmicort or rhinocort or methylfluorprednisolone or flunisolid* or nasalide or fluticason* or flonase or flounce or mometason* or nasonex or triamclinolon* or nasacort or (tri adj3 nasal) or aristocort or Ciclesonide).ab,ti.

32 24 or 25 or 26 or 29 or 30 or 31

33 23 and 32

Ovid EMBASE

Trial registries (via CRS)

1 exp sinusitis/ or paranasal sinus disease/

2 atrophic rhinitis/ or chronic rhinitis/ or rhinosinusitis/ or vasomotor rhinitis/

3 exp paranasal sinus/

4 (rhinosinusitis or nasosinusitis or pansinusitis or ethmoiditis or sphenoiditis).tw.

5 (kartagener* adj3 syndrome*).tw.

6 (inflamm* adj5 sinus*).tw.

7 ((maxilla* or frontal*) adj3 sinus*).tw.

8 1 or 2 or 3 or 4 or 5 or 6 or 7

9 exp chronic disease/

10 exp recurrent disease/

11 (chronic or persis* or recurrent*).tw.

12 9 or 10 or 11

13 8 and 12

14 CRSsNP.tw.

15 ((sinusitis or rhinitis) adj3 (chronic or persis* or recurrent*)).tw.

16 13 or 14 or 15

17 exp nose polyp/

18 exp nose disease/ or exp nose/

19 exp polyp/

20 18 and 19

21 ((nose or nasal or rhino* or rhinitis or sinus* or sinonasal) adj3 (papilloma* or polyp*)).tw.

22 (rhinopolyp* or CRSwNP).tw.

23 16 or 17or 20 or 21 or 22

24 exp *corticosteroid/

25 exp steroid/

26 exp antiinflammatory agent/

27 exp nonsteroid antiinflammatory agent/

28 26 not 27

29 (steroid* or glucocorticoid* or corticosteroid* or glucosteroid* or cyclocosteroid* or beclomethasone or beclometasone or beclamet or beclocort or becotide or betamethasone or betadexamethasone or flubenisolone or celeston* or cellestoderm or betnelan or oradexon or dexamethasone or dexameth or dexone or dexametasone or decadron or dexasone or hexadecadron or hexadrol or methylfluorprednisolone or millicorten or flunisolide or fluticasone or hydrocortisone or cortisol or cortifair or cortril or hyrocortone or cortef or epicortisol or efcortesol or Cortisone or methylprednisolone or medrol or metripred or urbason or mometasone or prednisolone or precortisyl or deltacortril or deltastab or prednesol or deltasone or prednisone or cortan or liquid next pred or meticorten or paramethasone or triamcinolone or aristocort or volon or atolone or kenacort or orasone or panasol or prednicen).tw.

30 24 or 28 or 29

31 23 and 30

ClinicalTrials.gov

Condition: rhinitis OR sinusitis OR rhinosinusitis OR (nose AND polyp*) OR (nasal AND polyp*) OR CRSsNP OR CRSwNP OR CRS

ICTRP

Title: rhinitis OR sinusitis OR rhinosinusitis OR CRSsNP OR CRSwNP OR CR

OR

All: (nose AND polyp*) OR (nasal AND polyp*)

NB These searches were run from 1 March 2015 to 11 August 2015, when these terms were last searched to populate the Cochrane ENT trials register in CRS

Appendix 2. Data extraction form

REF ID:

Study title:

Date of extraction:

Extracted by:

General comments/notes (internal for discussion):

Flow chart of trial

Group A (Intervention)

Group B (Comparison)

No. of people screened

No. of participants randomised ‐ all

No. randomised to each group

No. receiving treatment as allocated

No. not receiving treatment as allocated

‐ Reason 1

‐ Reason 2

No. dropped out

(no follow‐up data for any outcome available)

No. excluded from analysis1 (for all outcomes)

‐ Reason 1

‐ Reason 2

1This should be the people who received the treatment and were therefore not considered 'drop‐outs' but were excluded from all analyses (e.g. because the data could not be interpreted or the outcome was not recorded for some reason).

Information to go into 'Characteristics of included studies' table

Methods

X arm, double/single/non‐blinded, [multicentre] parallel‐group/cross‐over/cluster‐RCT, with x duration of treatment and x duration of follow‐up

Participants

Location: country, no of sites etc.

Setting of recruitment and treatment:

Sample size:

  • Number randomised: x in intervention, y in comparison

  • Number completed: x in intervention, y in comparison

Participant (baseline) characteristics:

  • Age:

  • Gender:

  • Main diagnosis: [as stated in paper]

  • Polyps status: x % with polyps/no information [add info on mean polyps score if available]

  • Previous sinus surgery status: [x% with previous surgery]

  • Previous courses of steroids: [add info on mean number of courses if available]

  • Other important effect modifiers, if applicable (e.g. aspirin sensitivity, comorbidities of asthma):

Inclusion criteria:[state diagnostic criteria used for CRS, polyps score if available]
Exclusion criteria:

Interventions

Intervention (n = x): drug name, method of administration, dose per day/frequency of administration, duration of treatment

Comparator group (n = y):

Use of additional interventions (common to both treatment arms):

Outcomes

Outcomes of interest in the review:

Primary outcomes:

  • Health‐related quality of life, disease‐specific

  • Disease severity symptom score

  • Significant adverse effects: [review specific]

Secondary outcomes:

  • Health‐related quality of life, generic

  • [Other review specific, pre‐specified adverse events]

  • [Other review specific, pre‐specified adverse events]

  • Endoscopy (polyps size or overall score)

  • CT scan

Other outcomes reported by the study:

  • [List outcomes reported but not of interest to the review]

Funding sources

'No information provided'/'None declared'/State source of funding

Declarations of interest

'No information provided'/'None declared'/State conflict

Notes

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Quote: "…"

Comment:

Allocation concealment (selection bias)

Quote: "…"

Comment:

Blinding of participants and personnel (performance bias)

Quote: "…"

Comment:

Blinding of outcome assessment (detection bias)

Quote: "…"

Comment:

Incomplete outcome data (attrition bias)

Quote: "…"

Comment:

Selective reporting (reporting bias)

Quote: "…"

Comment:

Other bias (see section 8.15)

Insensitive/non‐validated instrument?

Quote: "…"

Comment:

Other bias (see section 8.15)

Quote: "…"

Comment:

Findings of study: continuous outcomes

Results (continuous data table)

Outcome

Group A

Group B

Other summary stats/Notes

Mean

SD

N

Mean

SD

N

Mean difference (95% CI), P values etc.

Disease‐specific HRQL

(instrument name/range)

Time point:

Generic HRQL

(instrument name/range)

Time point:

Symptom score (overall)

(instrument name/range)

Time point:

Added total ‐ if scores reported separately for each symptom (range)

Time point:

Nasal blockage/obstruction/congestion

(instrument name/range)

Nasal discharge

(instrument name/range)

Facial pain/pressure

(instrument name/range)

Smell (reduction)

(instrument name/range)

Headache

(instrument name/range)

Cough (in children)

(instrument name/range)

Polyp size

(instrument name/range)

CT score

(instrument name/range)

Comments:

Results (dichotomous data table)

Outcome

Applicable review/intervention

Group A

Group B

Other summary stats/notes

No. of people with events

No. of people analysed

No. of people with events

No. of people analysed

P values, RR (95% CI), OR (95% CI)

Epistaxis/nose bleed

INCS

Saline irrigation

Local irritation (sore throat, oral thrush, discomfort)

INCS

Saline irrigation

Osteoporosis (minimum 6 months)

INCS

Stunted growth (children, minimum 6 months)

INCS

Can also be measured as average height

Mood disturbances

OCS

Gastrointestinal disturbances

(diarrhoea, nausea, vomiting, stomach irritation)

OCS

Antibiotics

Insomnia

OCS

Osteoporosis (minimum 6 months)

INCS

OCS

Discomfort

Saline irrigation

Suspected allergic reaction (rash or skin irritation

Antibiotics

Anaphylaxis or other serious allergic reactions such as Stevens‐Johnson

Antibiotics

Comments:

Process for sifting search results and selecting studies for inclusion.
Figuras y tablas -
Figure 1

Process for sifting search results and selecting studies for inclusion.

'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.
Figuras y tablas -
Figure 2

'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.

'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
Figuras y tablas -
Figure 3

'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

Comparison 1 Oral corticosteroids versus no treatment (intranasal steroids in both groups), Outcome 1 Nasal polyp grading.
Figuras y tablas -
Analysis 1.1

Comparison 1 Oral corticosteroids versus no treatment (intranasal steroids in both groups), Outcome 1 Nasal polyp grading.

Comparison 2 Oral corticosteroids versus placebo (antibiotics in both arms), Outcome 1 Total symptom score.
Figuras y tablas -
Analysis 2.1

Comparison 2 Oral corticosteroids versus placebo (antibiotics in both arms), Outcome 1 Total symptom score.

Comparison 2 Oral corticosteroids versus placebo (antibiotics in both arms), Outcome 2 Nasal obstruction.
Figuras y tablas -
Analysis 2.2

Comparison 2 Oral corticosteroids versus placebo (antibiotics in both arms), Outcome 2 Nasal obstruction.

Comparison 2 Oral corticosteroids versus placebo (antibiotics in both arms), Outcome 3 Purulent nasal discharge.
Figuras y tablas -
Analysis 2.3

Comparison 2 Oral corticosteroids versus placebo (antibiotics in both arms), Outcome 3 Purulent nasal discharge.

Comparison 2 Oral corticosteroids versus placebo (antibiotics in both arms), Outcome 4 Headache/facial pain.
Figuras y tablas -
Analysis 2.4

Comparison 2 Oral corticosteroids versus placebo (antibiotics in both arms), Outcome 4 Headache/facial pain.

Comparison 2 Oral corticosteroids versus placebo (antibiotics in both arms), Outcome 5 Cough.
Figuras y tablas -
Analysis 2.5

Comparison 2 Oral corticosteroids versus placebo (antibiotics in both arms), Outcome 5 Cough.

Comparison 2 Oral corticosteroids versus placebo (antibiotics in both arms), Outcome 6 CT score.
Figuras y tablas -
Analysis 2.6

Comparison 2 Oral corticosteroids versus placebo (antibiotics in both arms), Outcome 6 CT score.

Summary of findings for the main comparison. Short‐course oral corticosteroids compared to no oral corticosteroid treatment (intranasal steroids in both groups) for chronic rhinosinusitis

Short‐course oral corticosteroids compared to no oral corticosteroid treatment (intranasal steroids in both arms) for chronic rhinosinusitis

Patient or population: chronic rhinosinusitis
Setting: ENT departments
Intervention: short‐course oral steroids and intranasal steroids
Comparison: intranasal steroids alone (no oral steroid treatment)

Outcomes

No. of participants

(studies)

Relative effect (95% CI)

Anticipated absolute effects* (95% CI)

Quality

What happens

Without oral steroids

With oral steroids

Difference

Disease‐specific health‐related quality of life

No RCT reported this outcome

Disease severity ‐ patient‐reported symptom score

No RCT reported this outcome

Adverse effect: mood or behavioural disturbances

No RCT reported this outcome

Health‐related quality of life

No RCT reported this outcome

Adverse effect: insomnia

No RCT reported this outcome

Adverse effect: gastrointestinal disturbances ‐ not measured

No RCT reported this outcome

*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

CI: confidence interval;RCT: randomised controlled trial

GRADE Working Group grades of evidence
High quality: We are very confident that the true effect lies close to that of the estimate of the effect
Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different
Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect
Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect

Figuras y tablas -
Summary of findings for the main comparison. Short‐course oral corticosteroids compared to no oral corticosteroid treatment (intranasal steroids in both groups) for chronic rhinosinusitis
Summary of findings 2. Short‐course oral corticosteroids compared to placebo (antibiotics in both arms) for chronic rhinosinusitis

Short‐course oral corticosteroids compared to placebo (antibiotics in both groups) for chronic rhinosinusitis

Patient or population: chronic rhinosinusitis
Setting: paediatric allergy and ENT department
Intervention: oral corticosteroids and antibiotics
Comparison: placebo and antibiotics

Outcomes

No of participants (studies)

Anticipated absolute effects* (95% CI)

Quality

What happens

Without oral steroids

With oral steroids

Difference

Disease‐specific health‐related quality of life

No RCT reported this outcome

Disease severity ‐ patient‐reported symptom score, assessed with: 4 individual symptoms measured on 0 to 10 visual analogue scale summed to provide a range of 0 to 40
Follow‐up: 30 days 2

No. of participants: 45
(1 RCT)

The mean disease severity score without oral steroids was 15.2

The mean disease severity score with oral steroids was 3.6

The mean disease severity score in the intervention group was 7.10 lower (9.59 lower to 4.61 lower)

⊕⊕⊝⊝
LOW 1

A lower score indicates less severe symptoms. The results relate to a standardised mean difference of 1.61 standard deviations lower (‐2.29 to 0.93 lower), corresponding to a large difference.

Adverse effect: mood or behavioural disturbances

No RCT reported this outcome

Health‐related quality of life

No RCT reported this outcome

Adverse effect: insomnia

No RCT reported this outcome

Adverse effect: gastrointestinal disturbances

No RCT reported this outcome

*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

CI: confidence interval; RCT: randomised controlled trial

GRADE Working Group grades of evidence
High quality: We are very confident that the true effect lies close to that of the estimate of the effect
Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different
Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect
Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect

1Study completed only in children (mean age 8 years old). Study follow‐up time was less than 3 months (1 month). Scales were not validated and were completed by "parents and children".

2Symptoms included in this score were: purulent nasal discharge, nasal obstruction, cough and facial pain/headache.

Figuras y tablas -
Summary of findings 2. Short‐course oral corticosteroids compared to placebo (antibiotics in both arms) for chronic rhinosinusitis
Table 1. Summary of the most commonly reported side effects of systemic steroids

System

Adverse events

Notes

Musculoskeletal

Osteoporosis

Largely limited to long‐term use

Significantly increased risk of fractures with prolonged use

Osteonecrosis

Rare; appears to be dose‐dependent

Endocrine

Hyperglycaemia

Common; dose‐dependent, usually reversible

Cardiovascular

Hypertension

Common; dose‐dependent, usually reversible

Dermatological

Striae, bruising

Dose‐dependent, occurs after > 1 month usage

Ophthalmological

Cataracts

Irreversible; largely related to long‐term usage

Glaucoma

High risk with pre‐existing disease

Gastrointestinal tract

Peptic ulceration

Increased risk largely due to concomitant NSAIDs

Psychological

Psychosis

Common; increased risk with dosages > 40 mg/day

References: Da Silva 2006; Naber 1996; Stanbury 1998

NSAIDs: non‐steroidal anti‐inflammatory drugs

Figuras y tablas -
Table 1. Summary of the most commonly reported side effects of systemic steroids
Comparison 1. Oral corticosteroids versus no treatment (intranasal steroids in both groups)

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Nasal polyp grading Show forest plot

1

30

Mean Difference (IV, Fixed, 95% CI)

‐0.46 [‐0.87, ‐0.05]

Figuras y tablas -
Comparison 1. Oral corticosteroids versus no treatment (intranasal steroids in both groups)
Comparison 2. Oral corticosteroids versus placebo (antibiotics in both arms)

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Total symptom score Show forest plot

1

45

Mean Difference (IV, Fixed, 95% CI)

‐7.10 [‐9.59, ‐4.61]

2 Nasal obstruction Show forest plot

1

45

Mean Difference (IV, Fixed, 95% CI)

‐3.50 [‐4.71, ‐2.29]

3 Purulent nasal discharge Show forest plot

1

45

Mean Difference (IV, Fixed, 95% CI)

‐0.20 [‐1.54, 1.14]

4 Headache/facial pain Show forest plot

1

45

Mean Difference (IV, Fixed, 95% CI)

‐1.3 [‐2.55, ‐0.05]

5 Cough Show forest plot

1

45

Mean Difference (IV, Fixed, 95% CI)

‐2.10 [‐3.35, ‐0.85]

6 CT score Show forest plot

1

45

Mean Difference (IV, Fixed, 95% CI)

‐2.90 [‐4.91, ‐0.89]

Figuras y tablas -
Comparison 2. Oral corticosteroids versus placebo (antibiotics in both arms)