How long should intranasal steroids (INS) be used to treat allergic rhinitis?

Duration of Intranasal Steroid Use for Allergic Rhinitis

Intranasal corticosteroids (INS) can be used continuously for the entire duration of allergic rhinitis symptoms, with no specific time limitation when used at recommended doses. 1

Efficacy and Usage Patterns

Intranasal corticosteroids are the most effective medication class for controlling the four major symptoms of allergic rhinitis: sneezing, itching, rhinorrhea, and nasal congestion. They are particularly valuable for treating more severe allergic rhinitis and certain forms of nonallergic rhinitis. 1

Usage patterns can be:

• Continuous use: Most effective approach for persistent symptoms
• As-needed use: Can provide significant relief compared to placebo but may not be as effective as continuous use 1, 2

A well-controlled trial showed that as-needed use of intranasal fluticasone propionate demonstrated better scores in activity, sleep, practical, and overall domains compared to loratadine used as needed. 3 However, the efficacy of as-needed INS at approximately 50% of corticosteroid exposure is comparable to regular use in improving nasal symptoms and quality of life. 2

Onset and Duration of Action

• Onset: Therapeutic effect occurs within 12 hours and as early as 3-4 hours in some patients 1
• Optimal effect: May take several days to reach full effectiveness 4
• Duration: Can be used continuously throughout the allergy season or year-round for perennial allergic rhinitis 1, 4

Safety Considerations

When used at recommended doses, intranasal corticosteroids are not generally associated with clinically significant systemic side effects. 1

Adults

• Local side effects are minimal but may include nasal irritation and bleeding
• Patients should direct sprays away from the nasal septum
• Periodic examination of the nasal septum is recommended to check for mucosal erosions 1

Children

• Should be used at the lowest effective dose
• Growth suppression is a sensitive indicator of excessive corticosteroid effect
• Studies have shown minimal systemic effects on the HPA axis 1

Comparison with Other Treatments

Intranasal corticosteroids are superior to:

• Oral antihistamines for nasal symptoms 1
• Oral leukotriene receptor antagonists (strong recommendation) 1
• Intranasal chromones 1

Common Pitfalls and Caveats

1. Nasal patency: Because a patent nasal airway is necessary for optimal delivery, use of a nasal decongestant spray may be necessary for several days when intranasal corticosteroids are introduced 1

2. Decongestant use: Topical decongestants should only be used short-term (no more than 3-5 days) to avoid rhinitis medicamentosa 1, 5

3. Technique matters: Improper administration technique can reduce efficacy and increase side effects 5

4. Continuous vs. intermittent use: While as-needed use can be effective, continuous use provides better symptom control for persistent allergic rhinitis 1, 2

5. Monitoring: The nasal septum should be periodically examined in patients on long-term therapy to check for mucosal erosions 1

In conclusion, intranasal corticosteroids remain the most effective treatment for allergic rhinitis and can be used for the entire duration of symptoms without specific time limitations when used at recommended doses. Their excellent safety profile allows for continuous long-term use in both seasonal and perennial allergic rhinitis.