Pilocarpine in the Management of Allergic Rhinosinusitis

This retrospective study addresses the question of inadequate cholinergic output in Allergic Rhinosinusitis (ARS) and the feasibility of its treatment with cholinergics. Pilocarpine, a muscarinic-receptor agonist, was administered to patients with refractory obstructive sino-nasal symptoms to improve secretion and clearance.

The 22-item sino-nasal outcome test (SNOT-22) was used to identify patients with recalcitrant obstructive symptoms. Patients with SNOT-22 scores greater than 16 were treated with pilocarpine 5 mg three times a day (tid), twice a day (bid), or once a day (qd); changes of their 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. Six to nine months post-discontinuation the SNOT-22 was re-administered to assess sustainability.

Severe obstructive-type ARS was identified in 48 patients over a four-year period. Nineteen patients received pilocarpine; two discontinued treatment due to side effects; eight required dosing adjustment. SNOT-22 scores were lower in the pilocarpine-treated group at 6 months of treatment and at 6-9 months after discontinuation (p < 0.05 for both). Longitudinal SNOT-22 scores improved in the pilocarpine tid-treated sub-group at 6 months of treatment and at 6-9 months after discontinuation (p < 0.05 and < 0.01 respectively). Significant SNOT-22 decline was also reached at p < 0.1 for subjects on pilocarpine qd, but was not sustained upon discontinuation.

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.