Different types of intranasal corticosteroid molecules for chronic rhinosinusitis

Patient or population: chronic rhinosinusitis (all studies recruited patients with bilateral polyps)
Setting: Europe/North America about 20 years ago, in secondary care settings
Intervention: fluticasone propionate
Comparison: beclomethasone dipropionate or mometasone furoate

Disease‐specific health‐related quality of life

Impact unknown

Disease severity ‐ overall symptoms

• Study 1: 37 participants

• Study 2: 19 participants

• Study 3: 100 participants

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VERY LOW ^{1 2 3}

No differences observed but evidence was too low quality to draw a conclusion

Adverse events: epistaxis

• Study 1: 37 participants

• Study 2: 19 participants

• Study 3: 100 participants

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VERY LOW ^{1 2 3}

Unclear whether the risk of epistaxis varies for different types of steroid molecules

*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

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

High‐dose versus low‐dose intranasal corticosteroids for chronic rhinosinusitis

Patient or population: chronic rhinosinusitis (all studies recruited patients with bilateral polyps)
Setting: studies mostly conducted in Europe/North America about 10 years ago, in secondary care settings
Intervention: high‐dose intranasal corticosteroids
Comparison: low‐dose intranasal corticosteroids

Disease‐specific health‐related quality of life

Impact unknown

Disease severity ‐ overall symptoms, measured as average change from baseline at 4 months

All 4 EPOS domains

3 domains (nasal blockage, rhinorrhoea, loss of sense of smell) Range 0 to 3, lower score = less severe

№ of participants: 237
(1 RCT)

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MD 0.13 points lower (0.37 lower to 0.11 more) than low‐dose group

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LOW ^{1 2 3}

The average score for 3 types of symptoms seems to be similar between the high‐dose and low‐dose groups.

(2 domains: nasal blockage, rhinorrhoea)
Range 0 to 3, lower score = less severe

№ of participants: 441
(2 RCTs)

—

MD 0.19 points lower (0.36 lower to 0.02 lower) than low‐dose group

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LOW ^{1 2 3}

The average score for 2 types of symptoms seems to be slightly lower for the high‐dose group. The clinical significance of this reduction is unclear.

Disease severity ‐ measured as average change from baseline at 4 months (range 0 to 3)

• Nasal blockage (lower score = less severe)

№ of participants: 441
(2 RCTs)

—

MD 0.24 points lower (0.39 lower to 0.08 lower) than low‐dose group

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LOW ^{1 2 3}

The nasal blockage score seems to be slightly lower in the high‐dose group. The clinical significance of this reduction is unclear.

• Rhinorrhoea (lower score = less severe)

№ of participants: 441

(2 RCTs)

—

MD 0.15 points lower (0.33 lower to 0.03 higher) than low‐dose group

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LOW ^{1 2 3}

The average score for rhinorrhoea seems to be similar between the high‐dose and low‐dose groups.

• Loss of sense of smell (lower score = less severe)

№ of participants: 237
(1 RCT)

—

MD 0.06 points higher (0.2 lower to 0.32 higher) than low‐dose group

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LOW ^{1 2 3}

The average score for loss of sense of smell seems to be very similar between the high‐dose and low‐dose groups.

Adverse effects: epistaxis

№ of participants: 637
(4 RCTs)

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MODERATE ^{4 5}

The risk of epistaxis is likely to be higher in the higher‐dose groups. However, the studies included very minor nosebleeds, such as blood stains in the mucus, and most of these events are not likely to be severe.

118 per 1000
(69 to 202)

61 more per 1000

(11 more to 145 more)

124 per 1000
(72 to 214)

64 more per 1000

(12 more to 153 more)

Adverse effects: local irritation

№ of participants: 542
(3 RCTs)

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LOW ^{4 6 7}

The risk of local irritation seems to be similar between groups, but the overall risks are underestimated due to the way the data were reported.

18 per 1000
(5 to 62)

10 fewer per 1000

(13 fewer to 43 more)

17 per 1000
(5 to 58)

10 fewer per 1000

(13 fewer to 40 more)

*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; EPOS: European Position Paper on Rhinosinusitis and Nasal Polyps 2012;MD: mean difference; RCT: randomised controlled trial; RR: risk ratio; SD: standard deviation

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