Intranasal corticosteroids for allergic rhinitis

Intranasal corticosteroids are particularly useful for moderate to severe allergic rhinitis. They are more effective than oral antihistamines and are especially effective for nasal obstruction. They also reduce ocular symptoms. However, intranasal corticosteroids require good technique and adherence to be effective.

It is important to explain to patients that intranasal corticosteroids do not provide immediate relief of symptoms. Symptom relief usually starts within a few days, but a minimum trial of 4 weeks of consistent use is needed to properly establish efficacy.

For intranasal corticosteroid therapy, use a high dose for 4 weeks, then reduce to a maintenance dose. Available intranasal corticosteroid formulations for allergic rhinitis are summarised in Intranasal corticosteroid formulations for allergic rhinitis. Use:

1 beclometasone 100 micrograms (child 6 years or older: 50 to 100 micrograms) into each nostril, twice daily for 4 weeks, then 50 micrograms twice daily allergic rhinitis beclometasone

1 budesonide (adult or child 6 years or older) 128 micrograms into each nostril, daily (in 1 or 2 divided doses) for 4 weeks, then 32 to 64 micrograms daily allergic rhinitis budesonide

1 ciclesonide (adult or child 6 years or older) 100 micrograms into each nostril, daily¹ allergic rhinitis ciclesonide

1 fluticasone furoate 55 micrograms (child 2 to 11 years: 27.5 to 55 micrograms) into each nostril, daily for 4 weeks, then 27.5 micrograms daily allergic rhinitis fluticasone furoate

1 fluticasone propionate (adult or child 12 years or older) 100 micrograms into each nostril, daily for 4 weeks, then 50 micrograms daily allergic rhinitis fluticasone propionate

1 mometasone 100 micrograms (child 3 to 11 years: 50 micrograms) into each nostril, daily for 4 weeks, then 50 micrograms daily. allergic rhinitis mometasone mometasone furoate mometasone furoate

Table 1. Intranasal corticosteroid formulations for allergic rhinitis
Drug	Dose per spray	Initial dose (for 4 weeks) (into each nostril)	Maintenance dose [NB1] (into each nostril)
beclometasone	50 micrograms	adults: 2 sprays, twice daily children 6 years and older: 1 to 2 sprays twice daily	1 spray twice daily
budesonide	32 micrograms	adults and children 6 years and older: 2 sprays twice daily, or 4 sprays once daily	1 to 2 sprays once daily
budesonide	64 micrograms	adults and children 6 years and older: 1 spray twice daily, or 2 sprays once daily	1 spray once daily
ciclesonide	50 micrograms	adults and children 6 years and older: 2 sprays once daily	2 sprays once daily [NB2]
fluticasone furoate	27.5 micrograms	adults: 2 sprays once daily children 2 to 11 years: 1 to 2 sprays once daily	1 spray once daily
fluticasone propionate	50 micrograms	adults and children 12 years and older: 2 sprays once daily	1 spray once daily
mometasone	50 micrograms	adults: 2 sprays once daily children 3 to 11 years: 1 spray once daily	1 spray once daily
Note: NB1: Maintenance dose is the same for adults and children. NB2: Based on lack of available clinical data, the manufacturer does not recommend decreasing the initial dose of ciclesonide.

Instruct patients on how to use nasal sprays correctly; see Patient instructions for using a nasal spray. Using a crossover technique (right hand to left nostril, left hand to right nostril) reduces deposition of the corticosteroid directly onto the nasal septum, and reduces the likelihood of causing nasal septal perforation.

To reduce the likelihood of systemic adverse effects, reduce to the maintenance dose after 4 weeks of initial therapy and tailor the duration of treatment to the patient’s symptoms. Patients with intermittent symptoms that occur seasonally may only require treatment for a few months of the year, while others may require long-term treatment.

For severe symptoms occurring seasonally (eg in spring) and related to pollen exposure, consider starting an intranasal corticosteroid at least 2 weeks before the onset of the pollen season to avoid the priming effect of initial re-exposure to the allergen.

¹ Based on lack of available clinical data, the manufacturer does not recommend decreasing the initial dose of ciclesonide.Return