Side effects of corticosteroids
The Anti-inflammatory effects of corticosteroids cannot be separated from their metabolic effects, as all cells use the same glucocorticoid receptor; therefore when corticosteroids are prescribed measures should be taken to minimize their side effects. Clearly, the chance of significant side effects increases with the dose and duration of treatment and so the minimum dose necessary to control the disease should be given.
The safety of nasal and oral corticosteroids has been the subject of concern in medical literature since many patients with chronic sinus disease are prescribed these drugs due to their efficacy. Suppression of the hypothalamic-pituitary-adrenal axis, osteoporosis or changes in bone mineral density, growth retardation in children, cataracts and glaucoma have been reported to be the main adverse effects of corticosteroid treatment (6). In relation to adverse effects of corticosteroids, it is obvious that a clear distinction needs to be made between nasal (topical) and oral corticosteroids.
Nasal corticosteroid treatment represents one of the long-term treatment modalities in patients with chronic sinus disease. It is well established that absorption into the systemic circulation takes place after nasal administration of corticosteroids. However, several factors influence the systemic absorption, like the molecular characteristics of the corticosteroid, the prescribed dose, the mode of delivery and the severity of the underlying disease (4)
There is insufficient evidence from the literature to relate the use of nasal corticosteroids at licensed doses to changes in bone mineral biology, cataract and glaucoma. Adrenal suppression may occur with some nasal corticosteroids at licensed doses, but the clinical relevance remains uncertain. Overuse of nasal corticosteroids may be responsible for adrenal insufficiency and decrease in bone mineral density. Of note, inhaled corticosteroids are the mainstay of treatment for children and adults with asthma and are more often associated with systemic side effects than the nasal route of treatment for rhinosinusitis. Intranasal administration of corticosteroids is associated with minor nose bleeding in a small proportion of recipients. This effect has been attributed to the vasoconstrictor activity of the corticosteroid molecules, and is considered to account for the very rare occurrence of nasal septal perforation (5) although it is also hypothesized that it could be related to repeated traumas on the nasal mucosa and septal cartilage by the nasal device, to the underlying nasal disorder for which corticosteroids were prescribed. However, it should be remembered that minor nosebleeds are common in the population.
Nasal biopsy studies do not show any detrimental structural effects within the nasal mucosa with long-term administration of intranasal corticosteroids (6).
Short treatment with oral corticosteroids is effective in chronic rhinosinusitis with nasal polyps. It is obvious that repeated or prolonged use of oral corticosteroids is associated with a significantly enhanced risk of the above-mentioned side effects.
In summary, intranasal corticosteroids are highly effective in cases of NP; nevertheless, they are not completely devoid of systemic effects. Thus, care has to be taken, especially in children, when long-term treatments are prescribed.