Evidence for Twice-Daily Nasal Steroids Versus Once Daily for Treatment of Chronic Rhinosinusitis with Nasal Polyps

Nasal steroids are first-line treatment for chronic rhinosinusitis (CRS), with nasal polyps. Some physicians prescribe once-daily (QD) regimens and some twice-daily (BID). This literature review compares once- vs twice-daily dosing. We reviewed select reasonably sized randomized controlled trials (RCTs) testing the efficacy of QD or BID nasal steroids vs placebo in reducing polyp burden. Six RCTs exposing a total of 1,712 patients to conventional nasal steroid sprays or placebo were identified. In addition, two RCTs using a novel exhalation delivery system with fluticasone (EDS-FLU) were identified (N=643). In four RCTs (N=142, 310, 354, 748), mean total bilateral polyp grade (polyp grade) was significantly reduced with BID nasal steroid vs placebo. In contrast, three RCTs (N’s=104, 142, 310) found that polyp grade improvement was not significantly better with QD nasal steroid compared to placebo. Only one large RCT (N=354) showed significant reduction in polyp grade with QD treatment, while one additional very small RCT (N=54) reported reduction in polyp volume with a nonstandard scale. Notably, efficacy with mometasone nasal spray using BID dosing was replicated in 2 independent registration studies, but not with QD dosing. Both RCTs with EDS-FLU (NAVIGATE I/II) studied BID showed significant symptom reduction of comparatively large magnitude and statistically significant polyp grade reduction vs placebo. Evidence suggests that twice-daily treatment with topical corticosteroid is likely to offer more reliable efficacy than once-daily treatment for patients with moderate-to-severe CRS with nasal polyps.