What are the recommended intranasal corticosteroids (INCS) for treating allergic rhinitis or chronic rhinosinusitis?

Intranasal Corticosteroids for Allergic Rhinitis and Chronic Rhinosinusitis

Intranasal corticosteroids are the most effective medication class for controlling symptoms of allergic rhinitis and should be recommended as first-line therapy for patients whose symptoms affect their quality of life. 1, 2

Available Intranasal Corticosteroids

The following intranasal corticosteroids are currently available:

• Fluticasone propionate (Flonase)
• Fluticasone furoate
• Mometasone furoate
• Budesonide
• Beclomethasone dipropionate
• Triamcinolone acetonide
• Flunisolide 3

Efficacy and Indications

Intranasal corticosteroids effectively control all four major symptoms of allergic rhinitis:

• Nasal congestion
• Rhinorrhea (runny nose)
• Sneezing
• Nasal itching 1

They are also effective for:

• Seasonal allergic rhinitis
• Perennial allergic rhinitis
• Certain forms of non-allergic rhinitis
• Chronic rhinosinusitis with or without nasal polyps 1, 4

Comparative Efficacy

• When comparing available intranasal corticosteroids, the overall clinical response does not vary significantly between products despite differences in topical potency, lipid solubility, and binding affinity 1
• Intranasal corticosteroids are more effective than:
  • Oral antihistamines
  • Nasal antihistamines
  • Leukotriene receptor antagonists
  • Nasal cromolyn sodium 1, 2

Dosing Considerations

• Most intranasal corticosteroids are approved for once-daily dosing
• Fluticasone propionate has been shown to be effective both with regular daily use and as-needed use, though regular use is generally more effective 1, 5
• For children, lower doses are typically recommended, with mometasone and fluticasone furoate approved for children as young as 2 years 2

Special Populations

Children

• Mometasone furoate has been studied in children 3-12 years and shown to be effective 6
• Fluticasone propionate is FDA-approved for children ≥4 years of age 2
• Use the lowest effective dose in children to minimize potential systemic effects 1

Pregnant Patients

• Intranasal corticosteroids generally have good safety profiles but require individual risk-benefit assessment 2

Side Effects and Safety

• Local side effects are minimal but may include:

  • Nasal irritation
  • Dryness
  • Burning and stinging
  • Sneezing
  • Headache
  • Epistaxis (in 5-10% of patients) 3

• Important safety considerations:

  • Direct sprays away from the nasal septum
  • Periodically examine the nasal septum to ensure no mucosal erosions
  • Nasal septal perforations are rare but possible 1
  • When used at recommended doses, intranasal corticosteroids are not generally associated with clinically significant systemic side effects 1

Combination Therapy

For patients with inadequate response to intranasal corticosteroid monotherapy, consider:

• Combination of intranasal corticosteroid and intranasal antihistamine (most effective combination for moderate-severe symptoms) 2
• Addition of oral antihistamine (may provide greater relief of pruritus in some patients) 1
• Combination of nasal corticosteroid and ipratropium bromide (more effective than either treatment alone) 2

Common Pitfalls to Avoid

• Failing to identify comorbidities like asthma, atopic dermatitis, sleep-disordered breathing, conjunctivitis, rhinosinusitis, and otitis media 2
• Using topical decongestants for more than 3 days (risk of rhinitis medicamentosa/rebound congestion) 2
• Using first-generation antihistamines (sedating effects) 2
• Not providing proper instructions on nasal spray technique
• Not using intranasal corticosteroids consistently when prescribed for regular use

Intranasal corticosteroids remain the cornerstone of treatment for allergic rhinitis and chronic rhinosinusitis due to their superior efficacy in controlling nasal symptoms and their favorable safety profile when used appropriately.