What non-steroidal nasal spray alternatives are available for allergic rhinitis patients experiencing nose bleeds due to nasal corticosteroids (steroids)?

From the Guidelines

For allergic rhinitis with nosebleeds from nasal steroids, consider switching to non-steroidal nasal sprays such as azelastine (Astelin), olopatadine (Patanase), or ipratropium bromide (Atrovent). These options are preferred due to the potential for nasal tissue thinning and bleeding associated with long-term steroid use, as noted in studies such as 1. Azelastine and olopatadine are antihistamine nasal sprays typically used twice daily, while ipratropium bromide helps control nasal secretions and is used 2-3 times daily.

Key Considerations

• Saline nasal sprays or rinses are also excellent non-medicated options that can be used multiple times daily to moisturize the nasal passages, reduce irritation, and wash away allergens.
• When using any nasal spray, direct it toward the outer wall of the nostril rather than the septum to minimize irritation, as advised in 1.
• If you continue experiencing nosebleeds, temporarily discontinue the spray and consult your healthcare provider.
• These non-steroidal options work differently than corticosteroids - antihistamines block histamine receptors directly rather than suppressing the broader inflammatory response, while saline simply moisturizes and cleanses without medication.

Mechanism and Efficacy

• The mechanism by which corticosteroids relieve symptoms of allergic rhinitis is through their anti-inflammatory activity, as discussed in 1.
• Intranasal antihistamines, such as azelastine, have been shown to be effective in reducing symptoms of allergic rhinitis, including sneezing, itching, and rhinorrhea, as noted in 1.
• Ipratropium bromide is effective in reducing rhinorrhea but has minimal effects on nasal congestion or other nasal symptoms, as mentioned in 1.

Safety and Side Effects

• Local side effects associated with intranasal corticosteroids, such as nasal irritation and bleeding, are typically minimal but can occur, as reported in 1.
• Nasal septal perforation is rarely reported with long-term use of intranasal corticosteroids, emphasizing the importance of proper use and monitoring, as advised in 1.

From the FDA Drug Label

Nasal Spray showed significant improvement compared to placebo in the two primary efficacy variables- the Total Symptom Complex (TSC) and the Major Symptom Complex (MSC). The results for the MSC are shown in Table 1 as the mean change from Baseline in the average of individual symptoms of nose blows, sneezes, runny nose/sniffles, itchy nose, and watery eyes as assessed by patients on a 0-5 categorical scale. There were no findings on nasal examination in an 8-week study that suggested any adverse effect of azelastine on the nasal mucosa

Azelastine (IN) Nasal Spray is a non-steroidal nasal spray that can be used to treat allergic rhinitis. The drug label shows that azelastine nasal spray significantly improved symptoms of allergic rhinitis, including runny nose, sneezing, itchy nose, and nasal congestion.

• The studies did not specifically address the issue of nose bleeds from nasal steroids.
• However, the label does mention that there were no adverse effects on the nasal mucosa found in an 8-week study, which may suggest that azelastine nasal spray could be a safer alternative for patients experiencing nose bleeds from nasal steroids 2.

From the Research

Allergic Rhinitis Treatment Options

• Allergic rhinitis is a common chronic disease that can be treated with various medications, including nasal steroids and non-steroidal nasal sprays 3.
• Nasal steroids are often used as a first-line treatment for allergic rhinitis, but they can cause side effects such as nose bleeds in some patients.

Non-Steroidal Nasal Spray Options

• Azelastine nasal spray is a non-steroidal option that has been shown to be effective in treating allergic rhinitis, with a rapid onset of action and a good safety profile 4, 5, 6.
• Azelastine nasal spray has been compared to nasal steroids and has been found to have a faster onset of action and a better safety profile, with at least comparable efficacy to fluticasone propionate 4.
• Combination therapy with azelastine and fluticasone propionate has been shown to be effective in reducing patient-reported symptom scores in patients with allergic rhinitis, and may be considered as a second-line therapy for patients who do not respond to monotherapy 7.

Benefits of Azelastine Nasal Spray

• Azelastine nasal spray has a rapid onset of action, with benefits seen in as little as 15 minutes 5.
• Azelastine nasal spray has a long duration of activity, lasting up to 12-24 hours 6.
• Azelastine nasal spray is effective in alleviating nasal congestion, a symptom that is often difficult to treat with oral antihistamines 4, 6.
• Azelastine nasal spray has a good safety profile, with common side effects including bitter taste, drowsiness, and headache 4, 5, 6.