Doxycycline or oral corticosteroids for nasal polyps
Doxycycline or Oral Corticosteroids for Nasal Polyps
Therapeutic Options Beyond our Pages highlights randomized controlled trials published in other journals of novel therapeuticoptions for the conditions treated by allergist-immunologists. Generally written by Editorial Board members with relevantexpertise, this feature summarizes the methods and results of the study and then provides the author’s perspective regarding thepractical use of the information at this time.
The study by Van Zele et al1 reports positive results for either 20
doxycycline group is similar to that reported after 4 weeks of
days of doxycycline (200 mg the ﬁrst day, followed by 100 mg
daily) or 20 days of a tapering schedule of methylprednisolone
Relative to the secondary outcome of important nasal symptoms,
(32 mg on days 1-5; 16 mg on days 6-10, and 8 mg days 11-20)
the methylprednisolone group had reduction of postnasal drip,
for the treatment of nasal polyps in a randomized, double-blind,
smell loss, and nasal congestion, whereas the doxycycline-treated
placebo-controlled trial. The primary end point was reduction in
group improved only in postnasal drip. Neither group showed
nasal polyp score, which was graded 0 to 4 on each side, resulting
improvement in anterior rhinorrhea. Improvement in both treat-
in a score range of 0 to 8; the score was determined at baseline
ment groups was also seen in the secondary outcome of nasal peak
and weeks 1, 2, 4, 8, and 12. Entry criteria required that the
inspiratory ﬂow, with the methylprednisolone group being better
patient either have recurrent polyps after surgery or massive
than the doxycycline group. Inﬂammatory markers were measured
polyps (grade 3 or 4); the total polyp score in each of the 3groups averaged approximately 6. The patient population in thisstudy was, therefore, at the severe end of the spectrum; results
This trial of 47 patients reported a signiﬁcant
may not be generalizable to patients with milder disease.
reduction in endoscopically graded polyp size in
This trial of 47 patients reported a signiﬁcant reduction in
both the doxycycline- and methylprednisolone-
endoscopically graded polyp size in both the doxycycline- and
treated groups compared with placebo.
methylprednisolone-treated groups compared with placebo. Ashas been reported by others,2 the patients who received a burst ofmethylprednisolone enjoyed a substantive, statistically signiﬁcant
reduction in nasal polyp size (maximum decrease of 2.3 on the
in nasal secretions. Compared with placebo, both groups had
8-point scale); unfortunately, the effect was transient with return
reduced eosinophilic cationic protein (ECP); the methylpredniso-
to baseline score by week 8. In contrast, the doxycycline-treated
lone group had reduced IgE and IL-5, whereas the doxycycline
group had a less impressive but still statistically signiﬁcant
group had reduced myeloperoxidase and matrix metalloproteinase-
reduction (maximum decrease of 0.7) in nasal polyp score that
9. One important aspect of the study design to note is that
persisted through the end of the study, week 12. As the
supplemental antibiotics, nasal steroids, and oral glucocorticoste-
researchers noted, the magnitude of polyp reduction in the
roids were disallowed during the study. Therefore, in some nasalsecretion biomarker comparisons, such as ECP, IL-5, and IgE, thedifferences observed were partly because of increases in the placebogroup that occurred because they discontinued nasal steroids.
The study by Van Zele et al1 provides category I evidence in
This work is supported by the Ernest S Bazley Trust to Northwestern University and
support of an oral glucocorticosteroid burst for improvement in
Conﬂicts of interest: L. C. Grammer has received research and travel support from
the signs and symptoms of nasal polyps. Because of the side effect
the National Institutes of Health, Food Allergy Network, and S&C Electric;
proﬁle of oral glucocorticosteroids, however, the frequency with
has received the Bazley Foundation Grant; has received consultancy fees
which they can be judiciously administered is limited. It should
from Astellas Pharmaceuticals; is employed by Northwestern University and the
be emphasized that this is probably the ﬁrst study to evaluate the
Northwestern Medical Faculty Foundation; has received lecture fees from theAAAAI and Beth Israel Hospital; and receives royalties from Lippincott,
duration of the effect of a short course of oral glucocorticoste-
roids. Unfortunately, the effect is transient, essentially dis-
Received for publication April 16, 2013; accepted for publication April 18, 2013.
appearing by 8 weeks after initiation of therapy. In practice, most
patients prescribed a short course of oral glucocorticosteroids
Cite this article as: Grammer LC. Doxycycline or oral corticosteroids for nasal
would also be using nasal steroids, which was not the case in this
polyps. J Allergy Clin Immunol: In Practice. http://dx.doi.org/10.1016/j.jaip.2013.04.010.
study. It is possible that the effect would have been longer lasting
Corresponding author: Leslie C. Grammer, MD, Northwestern University, 14022
if nasal steroids were concomitantly administered.
Arkes Pavilion; 676 N St Clair St, Chicago, IL 60611. E-mail: [email protected]
This study also provides proof of concept for use of doxycycline
in the treatment of nasal polyps. The researchers speculate that there
is a population of patients whose disease is exacerbated by
Ó 2013 American Academy of Allergy, Asthma & Immunology
lococcus aureus enterotoxin.4 Although doxycycline reduced polyp
patients with nasal polyps would beneﬁt from the addition of
doxycycline, what the best dosage schedule is, and whether there
are additive or synergistic effects with other therapies. Inparticular, although both doxycycline and methylprednisolonedecreased ECP, they had different effects on other inﬂammatory
size and symptoms only modestly, it supports the superantigen
biomarkers, with doxycycline reducing matrix metalloproteinase-
theory of chronic rhinosinusitis with nasal polyposis. The
9 and myeloperoxidase, whereas methylprednisolone reduced IgE
researchers speculate that doxycycline has great potential for
and IL-5. Because the 2 drugs seem to affect different inﬂam-
extended use. Because of the modest effects observed, this trial
matory components, the hypothesis that they could result in
does not support the use of doxycycline as monotherapy for nasal
additive or synergistic effects seems a reasonable one to test.
polyps. It does suggest that, in some patients, it might be anadditive therapy to currently proven treatments such as nasal
steroids.5 Future studies will be needed to determine which
1. Van Zele T, Gevaert P, Holtappels G, Beule A, Wormald PJ, Mayr S, et al. Oral
steroids and doxycycline: two different approaches to treat nasal polyps.
J Allergy Clin Immunol 2010;125:1069-1076.e4.
2. Martinez-Devesa P, Patiar S. Oral steroids for nasal polyps. Cochrane Database
Future studies will be needed to determine
3. Small CB, Hernandez J, Reyes A, Schenkel E, Damiano A, Stryszak P, et al.
which patients with nasal polyps would beneﬁt
Efﬁcacy and safety of mometasone furoate nasal spray in nasal polyposis.
from the addition of doxycycline, what the best
J Allergy Clin Immunol 2005;116:1275-81.
dosage schedule is, and whether there are
4. Conley DB, Tripathi A, Seiberling KA, Suh LA, Harris KE, Paniagua MC, et al.
Superantigens and chronic rhinosinusitis; II, analysis of T-cell receptor V beta
additive or synergistic effects with other
domains in nasal polyps. Am J Rhinol 2006;20:451-5.
5. Kalish L, Snidvongs K, Sivasubramaniam R, Cope D, Harvey RJ. Topical
steroids for nasal polyps. Cochrane Database Syst Rev 2012;12:CD006549.
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