What are the recommended nasal sprays for allergic rhinitis?

Nasal Sprays for Allergic Rhinitis

Intranasal corticosteroids are the most effective first-line treatment for allergic rhinitis due to their superior effectiveness in controlling symptoms including sneezing, itching, rhinorrhea, and nasal congestion. 1

Types of Nasal Sprays for Allergic Rhinitis

Intranasal Corticosteroids

• First-line therapy for allergic rhinitis with the strongest evidence for effectiveness
• FDA-approved options include:
  • Fluticasone propionate (Flonase): Approved for ages ≥4 years 2
  • Mometasone furoate (Nasonex): Approved for ages ≥2 years, 1 spray per nostril daily for ages 2-11,2 sprays per nostril daily for ages ≥12 2
  • Budesonide: Approved for ages ≥6 years 1
  • Ciclesonide (Omnaris): Approved for ages ≥6 years, 2 sprays per nostril daily 2
  • Fluticasone furoate (Veramyst): Approved for ages ≥2 years 2

Intranasal Antihistamines

• Second-line therapy or for combination with corticosteroids
• More effective than oral antihistamines for nasal congestion 1
• Example: Azelastine
  • Dosing: 1-2 sprays per nostril twice daily for adults and children ≥12 years; 1 spray per nostril twice daily for children 5-11 years 3
  • Common side effects: Bitter taste, potential sedation 2

Other Nasal Spray Options

• Ipratropium bromide: Specifically effective for rhinorrhea 1
• Cromolyn sodium: Safe but less effective than corticosteroids 4
• Topical decongestants: Should be limited to short-term use (<3 days) to avoid rhinitis medicamentosa (rebound congestion) 2, 1

Treatment Algorithm

1. Start with intranasal corticosteroid spray as first-line therapy

   • Once-daily dosing is as effective as twice-daily dosing 5, 6
   • Begin seeing effects within 3-7 days 6

2. If symptoms persist:

   • Add intranasal antihistamine (combination therapy provides >40% relative improvement versus monotherapy) 1
   • OR add ipratropium bromide if rhinorrhea is the predominant symptom 1

3. For severe congestion:

   • Consider adding a topical decongestant for ≤3 days only 1

4. For inadequate response to pharmacologic therapy:

   • Consider immunotherapy (sublingual or subcutaneous), which is the only disease-modifying treatment option 1

Clinical Pearls and Pitfalls

• Proper technique is essential: Instruct patients to aim the spray away from the nasal septum to minimize risk of epistaxis
• Regular use is more effective than as-needed use for persistent symptoms 2
• Morning dosing of once-daily intranasal corticosteroids is effective for controlling symptoms throughout the day 6
• Avoid first-generation oral antihistamines due to sedating effects and performance impairment 2, 1
• Avoid long-term use of topical decongestants as this can lead to rhinitis medicamentosa 2, 4
• Fluticasone propionate has been shown to effectively relieve sinus pain and pressure associated with allergic rhinitis 7
• Consider patient age when selecting appropriate nasal spray, as age restrictions vary by product 2, 1

Special Considerations

• For children: Lower doses are typically recommended; mometasone and fluticasone furoate are approved for children as young as 2 years 2, 1, 8
• For pregnant patients: Intranasal corticosteroids generally have good safety profiles but individual risk-benefit assessment is needed
• For patients with comorbid asthma: Consider treatments that address both conditions, such as intranasal corticosteroids 1

Intranasal corticosteroids remain the cornerstone of treatment for allergic rhinitis, with the combination of intranasal corticosteroid and intranasal antihistamine providing the most effective symptom relief for moderate to severe cases.