Pilocarpine in the management of allergic rhinosinusitis

Background : This retrospective study addresses the question of inadequate cholinergic output in Allergic Rhinosinusitis (ARS) and the feasibility of treatment with cholinergics. Pilocarpine, a muscarinic-receptor agonist, was administered to patients with refractory obstructive sino-nasal symptoms to improve secretion and clearance. Methods : The 22-item sino-nasal outcome test (SNOT-22) was used to identify patients with recalcitrant obstructive symptoms. Patients were treated with pilocarpine 5 mg tid, bid or qd, and changes of their symptoms scores were compared to those of patients who were not treated with pilocarpine. SNOT-22 was administered on presentation and at follow-up at 3 and 6 months. At 6 months of treatment, pilocarpine was discontinued. At 12-15 months the SNOT-22 was administered again to assess sustainability. Results : Based on SNOT-22 score on presentation, 48 patients were identified as severe obstructive-type ARS cases. Nineteen received pilocarpine; two discontinued treatment due to side effects. Eight subjects required dosing adjustment. SNOT-22 scores were lower in the pilocarpine-treated group at 6 months of treatment and at 6 months after discontinuation (p < 0.05 for both). Longitudinal group-specific SNOT-22 improvement was pronounced in the pilocarpine tid-treated sub-group, both at 6 months of treatment, and at 6-9 months after discontinuation (p < 0.05 and < 0.01 respectively). Significance of SNOT-22 decline was also reached at p < 0.1 for subjects on pilocarpine qd, but was not sustained upon discontinuation. Conclusions : Pilocarpine can be useful in the treatment of refractory sino-nasal blockage. Adverse effects are frequent at 5 mg tid, but lower dosing can be effective.