Intranasal Steroid

Aka: Intranasal Steroid, Intranasal Corticosteroid, Corticosteroid Intranasal

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II. Efficacy

  1. Significantly reduces allergic symptoms
    1. Reduces nasal obstruction
    2. Reduces Rhinorrhea, sneezing, and nasal itching
    3. More effective than Antihistamines
    4. Small effect on impaired smell
  2. References
    1. Bronsky (1996) J Allergy Clin Immunol 97:915-21 [PubMed]
    2. Yanez (2002) Ann Allergy Asthma Immunol 89(5): 479-84 [PubMed]

III. Safety

  1. Pregnancy Category: C (except Budesonide which is pregnancy category B)
  2. Systemic absorption is minimal
  3. Appears safe in children as young as age 2 years
    1. No hypothalamic-pituitary-adrenal axis suppression
    2. Galant (2003) Pediatrics 112:96-100 [PubMed]

IV. Pharmacokinetics

  1. Onset of action within hours, but maximal effect requires 2-4 weeks of continuous use

V. Adverse Effects

  1. Bitter aftertaste
  2. Candidiasis
  3. Nasal irritation
  4. Pharyngitis or Dry Mouth
  5. Nasal septum perforation (rare)
  6. Epistaxis
    1. Reduced by spraying away from septum
    2. Use left hand when spraying right nostril
    3. Use right hand when spraying left nostril
    4. (2004) Prescribers Letter 11(1):2 [PubMed]

VI. General

  1. Aqueous Preparations: Better for dry nose, winter
    1. Moisturizing: Nasarel (Flunisolide)
    2. Moisture neutral: Nasocort AQ and Rhinocort AQ
    3. Drying agents (Alcohol): most AQ agents
  2. Non-Aqueous: Better for "wet", watery nose

VII. Preparations: By Age Restriction

  1. All agents are pregnancy category C (except Budesonide which is pregnancy category B)
  2. Age 2 years and older
    1. Intranasal Fluticasone furoate (Veramyst, Flonase sensimist)
    2. Intranasal Mometasone (Nosonex)
    3. Intranasal Triamcinolone (Nasocort)
  3. Age 4 years and older
    1. Intranasal Fluticasone Propionate (Flonase)
  4. Age 6 years and older
    1. Intranasal Beclomethasone (Beconase, Qnasl, Pregnancy category B)
    2. Intranasal Budesonide (Rhinocort)
    3. Intranasal Ciclesonide (Omnaris)
    4. Intranasal Flunisolide

VIII. Preparations: Low potency agents (especially in children)

  1. Intranasal Triamcinolone acetonide (Nasacort)
    1. As of 2014, available as OTC ($20 per 120 spray bottle)
    2. Relative potency: 1
    3. Dose (age 2 years and older)
      1. Child: 1 sprays per nostril daily
      2. Adult: 2 sprays per nostril daily (then taper to 1 spray per nostril daily as able)
  2. Intranasal Mometasone (Nasonex)
    1. Dose (2 years and older): 1 spray each nostril daily (adults should use 2 sprays each nostril)
    2. Relative potency: 1
    3. OTC in 2022

IX. Preparations: Medium potency agents

  1. Intranasal Flunisolide (Nasalide)
    1. Dose: 2 sprays per nostril twice daily
    2. Relative potency: 3
    3. Age 6 years and older
  2. Intranasal Beclomethasone (Beclovent)
    1. Dose (age 6 and older): 1-2 sprays per nostril twice daily
    2. Relative potency: 5
    3. Pregnancy Category C

X. Preparations: Higher potency agents

  1. Intranasal Budesonide (Rhinocort)
    1. As of 2016, over-ther-counter without a prescription
    2. Dose (age 6 to older): 1-2 sprays each nostril daily
    3. Adults may bolus start with 4 sprays/nostril daily for 1 week then use standard dose (1-2 sprays)
    4. Relative potency: 10
    5. Pregnancy Category B
  2. Intranasal Fluticasone Propionate (Flonase)
    1. As of 2015, over-ther-counter without a prescription
    2. Dose (age 4 years and older): 1-2 sprays per nostril daily
    3. Relative potency: 10
  3. Intranasal Qvar 80 mg (use oral Inhaler with baby bottle nipple as nasal adapter)
    1. Dose: 1-2 sprays each nostril daily
  4. Intranasal Ciclesonide (Omnaris, Zetonna)
    1. May be less irritating then other Intranasal Corticosteroids
    2. Omnaris (aqueous nasal spray)
    3. Zetonna (dry aerosol version)

XI. Preparations: Miscellaneous

  1. Combination Agents
    1. Fluticasone with Azelastine (Dymista)
      1. Expensive (up to $200/month) and add little to benefit of generic nasal Corticosteroids alone
      2. Alternatively, use OTC Azelastine (Astepro) and a generic generic nasal Corticosteroid
      3. (2022) Presc Lett 29(5): 25-6
  2. Xhance (fluticasone nose and mouth device, for Nasal Polyps)
    1. Patient blows into mouth piece while activating device 93 mcg bid
    2. Theoretically penetrates more deeply into nose (hence reaching Nasal Polyps)
    3. Unproven benefit and expensive ($425/month in 2018)
    4. Similar effect likely with Nasal Saline pre-treatment and 2 standard fluticasone sprays bid
    5. (2018) Presc Lett 25(7): 41

XII. Drug Interactions

  1. Ritonavir or Cobicistat
    1. Raise levels of CYP3A4 metabolized steroid Inhalers (Fluticasone, Budesonide, Mometasone)

XIII. References

  1. Wallace (2008) J Allergy Clin Immunol 122(2 suppl):S21 [PubMed]

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