Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

mild to moderate polyposis (VAS 0-7)

1st line – intranasal corticosteroid

Back
ACUTE
|
mild to moderate polyposis (VAS 0-7)
1st line – 

intranasal corticosteroid

For patients with mild to moderate symptoms (visual analog scale score 0-7), the initial treatment is a 3-month course of intranasal corticosteroid spray, such as fluticasone or mometasone. There is insufficient evidence to suggest one type of corticosteroid over another.[2]

Intranasal corticosteroids improve symptoms, improve quality of life, reduce polyp size, and prevent polyp recurrence after surgery.[2][4]​​

The patient is re-evaluated at 3 months and if there has been satisfactory improvement, the patient may continue to use the intranasal corticosteroid spray, at the lowest effective dose, with review every 6 months.

Primary options

fluticasone propionate nasal: (93 micrograms/spray) 93-186 micrograms (1-2 sprays) in each nostril twice daily

OR

mometasone nasal: (50 micrograms/spray) 100 micrograms (2 sprays) in each nostril once or twice daily

Consider – nasal saline irrigation

Back
ACUTE
|
mild to moderate polyposis (VAS 0-7)
Consider – 

nasal saline irrigation

Treatment recommended for SOME patients in selected patient group

Nasal saline irrigation with isotonic saline or Ringer lactate can be beneficial.[2][40] Adding xylitol, sodium hyaluronate, and xyloglucan to nasal saline irrigation may have a positive effect.[2]

Consider – doxycycline

Back
ACUTE
|
mild to moderate polyposis (VAS 0-7)
Consider – 

doxycycline

Treatment recommended for SOME patients in selected patient group

May have a modest effect in addition to intranasal corticosteroids when used for 3-12 weeks.​[38][39]

Primary options

doxycycline: 200 mg orally on the first day, followed by 100 mg once daily

2nd line – surgical polypectomy

Back
ACUTE
|
mild to moderate polyposis (VAS 0-7)
2nd line – 

surgical polypectomy

If there is no or minimal improvement in symptoms after the initial 3 months of medical treatment, many clinicians suggest surgery to remove the polyps.

The evidence relating to the effectiveness of different types of surgery versus medical treatment for adults with chronic rhinosinusitis and nasal polyps is of very low quality. The evidence thus far does not show that one treatment is better than another in terms of patient-reported symptom scores and quality-of-life measurements.[44]

Patients with chronic rhinosinusitis with nasal polyps and comorbid asthma are at a higher risk of undergoing revision surgery, and many of these patients experience poor symptom control, the need for repeated systemic steroids and multiple surgeries.[45]

Plus – postoperative nasal saline irrigation

Back
ACUTE
|
mild to moderate polyposis (VAS 0-7)
Plus – 

postoperative nasal saline irrigation

Treatment recommended for ALL patients in selected patient group

Whichever surgical technique is employed, patients usually carry out daily saline douching for 1 month after the surgery.

Plus – postoperative oral antibiotic

Back
ACUTE
|
mild to moderate polyposis (VAS 0-7)
Plus – 

postoperative oral antibiotic

Treatment recommended for ALL patients in selected patient group

Doxycycline for 3 weeks or 12 weeks may have a beneficial effect.[38][39]

Clinicians may also use a macrolide antibiotic.

Primary options

doxycycline: 200 mg orally on the first day, followed by 100 mg once daily for 3-12 weeks

OR

clarithromycin: 250 mg orally twice daily for 8-12 weeks

OR

azithromycin: 500 mg orally three times weekly for up to 12 weeks

Plus – ongoing intranasal corticosteroid

Back
ACUTE
|
mild to moderate polyposis (VAS 0-7)
Plus – 

ongoing intranasal corticosteroid

Treatment recommended for ALL patients in selected patient group

Postoperatively, patients should continue with intranasal corticosteroid spray to help reduce regrowth of polyps.[43]

Primary options

fluticasone propionate nasal: (93 micrograms/spray) 93-186 micrograms (1-2 sprays) in each nostril twice daily

OR

mometasone nasal: (50 micrograms/spray) 100 micrograms (2 sprays) in each nostril once or twice daily

3rd line – biologic

Back
ACUTE
|
mild to moderate polyposis (VAS 0-7)
3rd line – 

biologic

Biologics (e.g., dupilumab, mepolizumab, omalizumab) target-specific inflammatory pathways which are important in disease pathophysiology. As most patients with chronic rhinosinusitis with nasal polyps (CRSwNP) have type 2 inflammation, biologics for managing CRSwNP are designed to modify the type 2 inflammatory response.[4]

The American Academy of Allergy, Asthma & Immunology/American College of Allergy, Asthma & Immunology Joint Task Force guideline panel suggests using biologics over no biologics, depending on the preferences of patients and/or their carers for individual outcomes, disease severity, and availability of other treatment options.[4]

Consider biologics in patients on intranasal corticosteroids for at least 4 weeks who do not show symptom improvement.[4] Biologics may be preferred over other therapies in patients with high disease severity at presentation.[4]

Dosing for biologics for CRSwNP varies based on the type of biologic and may depend on patient’s weight, laboratory tests, or severity of disease.[4]

Do not use biologics in patients in whom symptoms improve with intranasal corticosteroids, surgery, or aspirin therapy after desensitization.[4]

Individuals with symptoms impairing quality of life despite regular use of intranasal corticosteroids may be considered for treatment, while taking additional factors into consideration (e.g., previous sinus surgery, need for oral corticosteroids, comorbid asthma).[41]

Biologics are recommended in patients with bilateral polyps who have had sinus surgery or are not fit for surgery and who have three of the following characteristics: evidence of type 2 hypersensitivity (tissue eosinophils ≥10/high-power field or blood eosinophils ≥250 cells/microliter or total IgE ≥100 IU/mL); contraindication to systemic corticosteroids, need for systemic corticosteroids or continuous use of systemic corticosteroids (≥2 courses per year or long term [>3 months] low-dose corticosteroids); significantly impaired quality of life (SNOT-22 score ≥40); anosmic on smell test, and/or a diagnosis of comorbid asthma needing regular inhaled corticosteroids.[2]

Dupilumab is directed against the interleukin-4 receptor alpha subunit, thereby blocking the activity of interleukin-4 and interleukin-13. It has been shown to reduce polyp size and improve symptoms, computed tomography appearances, and sense of smell in patients already on an intranasal corticosteroid.[22] Dupilumab is approved in the US as add-on maintenance treatment in adults with inadequately controlled CRSwNP. It is also approved in Europe as an add-on therapy with intranasal corticosteroids for adults with severe CRSwNP for whom therapy with systemic corticosteroids and/or surgery do not provide adequate disease control. Ocular adverse reactions have been reported; healthcare professionals should review new onset or worsening ocular symptoms and refer patients for ophthalmologic exam as appropriate.[42]

Mepolizumab blocks the activity of the pro-eosinophilic cytokine interleukin-5.[20] It has been shown to reduce the need for repeat surgery in those already taking an intranasal corticosteroid.[21] Mepolizumab is approved in the US and Europe for four eosinophil-driven diseases, including CRSwNP.[22] 

Omalizumab inhibits IgE binding to the high-affinity IgE receptor on mast cells and basophils. It is approved in the US as add-on maintenance treatment for CRSwNP in adults with an inadequate response to intranasal corticosteroids, and in Europe as add-on therapy with intranasal corticosteroids for adults with severe CRSwNP in whom intranasal corticosteroids do not provide adequate disease control.

Primary options

dupilumab: 300 mg subcutaneous every 2 weeks

OR

mepolizumab: 100 mg subcutaneously every 4 weeks

OR

omalizumab: 75-600 mg subcutaneously every 2-4 weeks, individualize dose based on IgE levels and body weight, maximum 150 mg/injection site

Plus – ongoing intranasal corticosteroid

Back
ACUTE
|
mild to moderate polyposis (VAS 0-7)
Plus – 

ongoing intranasal corticosteroid

Treatment recommended for ALL patients in selected patient group

Intranasal corticosteroid therapy should be continued in patients when biologics are introduced. If the biologic is sufficiently effective and symptoms become almost negligible/very mild, corticosteroid dose could be reduced and even stopped.

Primary options

fluticasone propionate nasal: (93 micrograms/spray) 93-186 micrograms (1-2 sprays) in each nostril twice daily

OR

mometasone nasal: (50 micrograms/spray) 100 micrograms (2 sprays) in each nostril once or twice daily

3rd line – aspirin therapy after desensitization (ATAD) (patients with NERD)

Back
ACUTE
|
mild to moderate polyposis (VAS 0-7)
3rd line – 

aspirin therapy after desensitization (ATAD) (patients with NERD)

ATAD can be considered in patients with chronic rhinosinusitis with nasal polyps (CRSwNP) with a convincing history of a respiratory reaction to aspirin/nonsteroidal anti-inflammatory drugs (NSAIDs), as judged by the clinician, or the development of respiratory symptoms during an aspirin challenge.[2][4]​​​ ATAD has been recommended for treating patients with CRSwNP and NSAID-exacerbated respiratory disease (NERD) who agree to comply with the therapy.[2]

The American Academy of Allergy, Asthma & Immunology/American College of Allergy, Asthma & Immunology Joint Task Force guideline panel suggests using ATAD over no ATAD in patients with NERD but not in those without NERD.[4]​​ ATAD is preferred in patients who are unable to tolerate NSAIDs but need them for other indications such as cardiovascular disease.[4]​​ In patients with NERD who do not require NSAIDs to manage other conditions and who wish to avoid the desensitization procedure, biologics are preferred over ATAD.[4]

ATAD involves desensitizing patients with NERD to aspirin, followed by daily aspirin therapy. Desensitization itself does not provide immediate clinical benefit for patients with NERD but is necessary to allow patients to take aspirin daily, which in turn may lead to improvement in chronic rhinosinusitis symptoms. Oral ATAD is effective in improving quality of life and total nasal symptom score in patients with NERD.[2]

Appropriate preventive measures (i.e., Helicobacter pylori eradication, proton-pump inhibitors, H2 antagonists) should be introduced and continued during ATAD to prevent adverse effects following aspirin treatment.[2]

Several oral and nasal aspirin desensitization protocols have been developed. Consult a specialist for further guidance on the choice of regimen and how to administer the regimen.

Plus – ongoing intranasal corticosteroid

Back
ACUTE
|
mild to moderate polyposis (VAS 0-7)
Plus – 

ongoing intranasal corticosteroid

Treatment recommended for ALL patients in selected patient group

Intranasal corticosteroid therapy should be continued in patients when aspirin therapy after desensitization (ATAD) is introduced. If ATAD is sufficiently effective and symptoms become almost negligible/very mild, corticosteroid dose could be reduced and even stopped.

Primary options

fluticasone propionate nasal: (93 micrograms/spray) 93-186 micrograms (1-2 sprays) in each nostril twice daily

OR

mometasone nasal: (50 micrograms/spray) 100 micrograms (2 sprays) in each nostril once or twice daily

severe polyposis (VAS >7)

1st line – intranasal corticosteroid

Back
ACUTE
|
severe polyposis (VAS >7)
1st line – 

intranasal corticosteroid

For patients with severe symptoms (visual analog scale score >7-10), the first-line treatment is an intranasal corticosteroid spray, plus consideration of a short course of an oral corticosteroid.[2][36][37] [ Cochrane Clinical Answers logo ]

There is insufficient evidence to suggest one type of intranasal corticosteroid over another.

The patient is reviewed at 1 month and, if there has been satisfactory improvement, the patient should continue on the intranasal corticosteroid spray, with review at 3 months.

Primary options

fluticasone propionate nasal: (93 micrograms/spray) 93-186 micrograms (1-2 sprays) in each nostril twice daily

OR

mometasone nasal: (50 micrograms/spray) 100 micrograms (2 sprays) in each nostril once or twice daily

Plus – consider short course of oral corticosteroid

Back
ACUTE
|
severe polyposis (VAS >7)
Plus – 

consider short course of oral corticosteroid

Treatment recommended for ALL patients in selected patient group

For patients with severe symptoms (visual analog scale score >7-10), the first-line treatment is an intranasal corticosteroid, plus consideration of a short course of an oral corticosteroid.[2][36][37] [ Cochrane Clinical Answers logo ]

A short course (7-21 days) of a systemic corticosteroid, with or without local corticosteroid treatment, results in a significant reduction in total symptom score and nasal polyp score in patients with chronic rhinosinusitis with nasal polyps.[2] One to two courses of systemic corticosteroids can be given every year along with intranasal corticosteroid treatment in patients with partial or uncontrolled disease.

Following completion of the oral corticosteroid course, the patient then continues on the intranasal corticosteroid. The patient is reviewed at 1 month and, if there has been satisfactory improvement, the patient should continue on the intranasal corticosteroid, with review at 3 months.

Primary options

prednisone: 0.5 mg/kg orally once daily in the morning for 7-14 days, maximum 40 mg/day

Consider – nasal saline irrigation

Back
ACUTE
|
severe polyposis (VAS >7)
Consider – 

nasal saline irrigation

Treatment recommended for SOME patients in selected patient group

Nasal saline irrigation with isotonic saline or Ringer lactate can be beneficial.[2][40] Adding xylitol, sodium hyaluronate, and xyloglucan to nasal saline irrigation may have a positive effect.[2]​​

Consider – doxycycline

Back
ACUTE
|
severe polyposis (VAS >7)
Consider – 

doxycycline

Treatment recommended for SOME patients in selected patient group

May have a modest effect in addition to intranasal corticosteroids when used for 3-12 weeks.​[38][39]

Primary options

doxycycline: 200 mg orally on the first day, followed by 100 mg once daily

2nd line – surgical polypectomy

Back
ACUTE
|
severe polyposis (VAS >7)
2nd line – 

surgical polypectomy

If there is no or minimal improvement in symptoms after the initial 1 month of medical treatment, many clinicians suggest surgery to remove the polyps.

The evidence relating to the effectiveness of different types of surgery versus medical treatment for adults with chronic rhinosinusitis and nasal polyps is of very low quality. The evidence thus far does not show that one treatment is better than another in terms of patient-reported symptom scores and quality-of-life measurements.[44]

Patients with chronic rhinosinusitis with nasal polyps and comorbid asthma are at a higher risk of undergoing revision surgery, and many of these patients experience poor symptom control, the need for repeated systemic steroids and multiple surgeries.[45]

Plus – postoperative nasal saline irrigation

Back
ACUTE
|
severe polyposis (VAS >7)
Plus – 

postoperative nasal saline irrigation

Treatment recommended for ALL patients in selected patient group

Whichever surgical technique is employed, patients usually carry out daily saline douching for 1 month after the surgery.

Plus – postoperative oral antibiotic

Back
ACUTE
|
severe polyposis (VAS >7)
Plus – 

postoperative oral antibiotic

Treatment recommended for ALL patients in selected patient group

Doxycycline for 3 weeks or 12 weeks may have a beneficial effect.[38][39]

Clinicians may also use a macrolide antibiotic.

Primary options

doxycycline: 200 mg orally on the first day, followed by 100 mg once daily for 3-12 weeks

OR

clarithromycin: 250 mg orally twice daily for 8-12 weeks

OR

azithromycin: 500 mg orally three times weekly for up to 12 weeks

Plus – ongoing intranasal corticosteroid

Back
ACUTE
|
severe polyposis (VAS >7)
Plus – 

ongoing intranasal corticosteroid

Treatment recommended for ALL patients in selected patient group

Postoperatively, patients continue with intranasal topical corticosteroid spray to help reduce regrowth of polyps.[43]

Primary options

fluticasone propionate nasal: (93 micrograms/spray) 93-186 micrograms (1-2 sprays) in each nostril twice daily

OR

mometasone nasal: (50 micrograms/spray) 100 micrograms (2 sprays) in each nostril once or twice daily

3rd line – biologic

Back
ACUTE
|
severe polyposis (VAS >7)
3rd line – 

biologic

​Biologics (e.g., dupilumab, mepolizumab, omalizumab) target-specific inflammatory pathways which are important in disease pathophysiology. As most patients with chronic rhinosinusitis with nasal polyps (CRSwNP) have type 2 inflammation, biologics for managing CRSwNP are designed to modify the type 2 inflammatory response.[4]

The American Academy of Allergy, Asthma & Immunology/American College of Allergy, Asthma & Immunology Joint Task Force guideline panel suggests using biologics over no biologics, depending on the preferences of patients and/or their carers for individual outcomes, disease severity, and availability of other treatment options.[4]

Do not use biologics in patients in whom symptoms improve with intranasal corticosteroids, surgery, or aspirin therapy after desensitization (ATAD).[4] Consider biologics in patients on intranasal corticosteroids for at least 4 weeks who do not show symptom improvement.[4] Biologics may be preferred over other therapies in patients with high disease severity at presentation.[4]

Dosing for biologics for CRSwNP varies based on the type of biologic and may depend on patient’s weight, laboratory tests, or severity of disease.[4]

Individuals with symptoms impairing quality of life despite regular use of intranasal corticosteroids may be considered for treatment, while taking additional factors into consideration (e.g., previous sinus surgery, need for oral corticosteroids, comorbid asthma).[41]

Biologics are recommended in patients with bilateral polyps who have had sinus surgery or are not fit for surgery and who have three of the following characteristics: evidence of type 2 hypersensitivity (tissue eosinophils ≥10/high-power field or blood eosinophils ≥250 cells/microliter or total IgE ≥100 IU/mL); contraindication to systemic corticosteroids, need for systemic corticosteroids or continuous use of systemic corticosteroids (≥2 courses per year or long term [>3 months] low-dose corticosteroids); significantly impaired quality of life (SNOT-22 score ≥40); anosmic on smell test, and/or a diagnosis of comorbid asthma needing regular inhaled corticosteroids.[2]

Dupilumab is directed against the interleukin-4 receptor alpha subunit, thereby blocking the activity of interleukin-4 and interleukin-13. It has been shown to reduce polyp size and improve symptoms, computed tomography appearances, and sense of smell in patients already on an intranasal corticosteroid.[22]​ Dupilumab is approved in the US as add-on maintenance treatment in adults with inadequately controlled CRSwNP. It is also approved in Europe as an add-on therapy with intranasal corticosteroids for adults with severe CRSwNP for whom therapy with systemic corticosteroids and/or surgery do not provide adequate disease control. Ocular adverse reactions have been reported; healthcare professionals should review new onset or worsening ocular symptoms and refer patients for ophthalmologic exam as appropriate.[42]

Mepolizumab blocks the activity of the pro-eosinophilic cytokine interleukin-5.[20]​ It has been shown to reduce the need for repeat surgery in those already taking an intranasal corticosteroid.[21]​ Mepolizumab is approved in the US and Europe for four eosinophil-driven diseases, including CRSwNP.[22]

Omalizumab inhibits IgE binding to the high-affinity IgE receptor on mast cells and basophils. It is approved in the US as add-on maintenance treatment for CRSwNP in adults with an inadequate response to intranasal corticosteroids, and in Europe as add-on therapy with intranasal corticosteroids for adults with severe CRSwNP in whom intranasal corticosteroids do not provide adequate disease control.

Primary options

dupilumab: 300 mg subcutaneous every 2 weeks

OR

mepolizumab: 100 mg subcutaneously every 4 weeks

OR

omalizumab: 75-600 mg subcutaneously every 2-4 weeks, individualize dose based on IgE levels and body weight, maximum 150 mg/injection site

Plus – ongoing intranasal corticosteroid

Back
ACUTE
|
severe polyposis (VAS >7)
Plus – 

ongoing intranasal corticosteroid

Treatment recommended for ALL patients in selected patient group

Intranasal corticosteroid therapy should be continued in patients when biologics are introduced. If the biologic is sufficiently effective and symptoms become almost negligible/very mild, corticosteroid dose could be reduced and even stopped.

Primary options

fluticasone propionate nasal: (93 micrograms/spray) 93-186 micrograms (1-2 sprays) in each nostril twice daily

OR

mometasone nasal: (50 micrograms/spray) 100 micrograms (2 sprays) in each nostril once or twice daily

3rd line – aspirin therapy after desensitization (ATAD) (patients with NERD)

Back
ACUTE
|
severe polyposis (VAS >7)
3rd line – 

aspirin therapy after desensitization (ATAD) (patients with NERD)

​ATAD can be considered in patients with CRSwNP with a convincing history of a respiratory reaction to aspirin/nonsteroidal anti-inflammatory drugs (NSAIDs), as judged by the clinician, or the development of respiratory symptoms during an aspirin challenge.[2][4]​​​ ATAD has been recommended for treating patients with CRSwNP and NSAID-exacerbated respiratory disease (NERD) who agree to comply with the therapy.[2]

The American Academy of Allergy, Asthma & Immunology/American College of Allergy, Asthma & Immunology Joint Task Force guideline panel suggests using ATAD over no ATAD in patients with NERD but not in those without NERD.[4]​​ ATAD is preferred in patients who are unable to tolerate NSAIDs but need them for other indications such as cardiovascular disease.[4]​​​ In patients with NERD who do not require NSAIDs to manage other conditions and who wish to avoid the desensitization procedure, biologics are preferred over ATAD.[4]

​ATAD involves desensitizing patients with NERD to aspirin, followed by daily aspirin therapy. Desensitization itself does not provide immediate clinical benefit for patients with NERD but is necessary to allow patients to take aspirin daily, which in turn may lead to improvement in chronic rhinosinusitis symptoms. Oral ATAD is effective in improving quality of life and total nasal symptom score in patients with NERD.[2]

Appropriate preventive measures (i.e., Helicobacter pylori eradication, proton-pump inhibitors, H2 antagonists) should be introduced and continued during ATAD to prevent adverse effects following aspirin treatment.[2]

Several oral and nasal aspirin desensitization protocols have been developed. Consult a specialist for further guidance on the choice of regimen and how to administer the regimen.

Plus – ongoing intranasal corticosteroid

Back
ACUTE
|
severe polyposis (VAS >7)
Plus – 

ongoing intranasal corticosteroid

Treatment recommended for ALL patients in selected patient group

Intranasal corticosteroid therapy should be continued in patients when aspirin therapy after desensitization (ATAD) is introduced. If ATAD is sufficiently effective and symptoms become almost negligible/very mild, corticosteroid dose could be reduced and even stopped.

Primary options

fluticasone propionate nasal: (93 micrograms/spray) 93-186 micrograms (1-2 sprays) in each nostril twice daily

OR

mometasone nasal: (50 micrograms/spray) 100 micrograms (2 sprays) in each nostril once or twice daily

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Choose a patient group to see our recommendations

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

Use of this content is subject to our disclaimer