What are the side effects of intranasal steroids (INS) for allergic rhinitis?

Side Effects of Intranasal Steroids for Allergic Rhinitis

Intranasal corticosteroids when given in recommended doses are not generally associated with clinically significant systemic side effects. 1

Local Side Effects

• Nasal irritation and bleeding are the most common local side effects but are relatively rare and can be minimized with proper administration technique 1
• Burning or stinging sensations, especially with propylene glycol-containing solutions 1
• Blood-tinged secretions may occur in some patients 1, 2
• Nasal septal perforations are extremely rare but have been reported with long-term use 1
• Preparations containing propylene glycol and benzalkonium chloride may result in local irritation or ciliary dysfunction 1
• Bad taste or smell may be experienced by some users 2
• Dry or irritated nose or throat 2, 3
• Sneezing after administration 2, 3

Systemic Side Effects

• Studies in both children and adults have failed to demonstrate any consistent, clinically relevant systemic effects from intranasal corticosteroids when used at recommended doses 1
• No significant effects on the hypothalamic-pituitary-adrenal (HPA) axis 1
• No significant effects on ocular pressure or cataract formation 1
• No significant effects on bone density in adults 1

Special Considerations for Children

• Growth effects are a potential concern in children 1, 2
• Studies with intranasal fluticasone propionate, mometasone furoate, and budesonide have shown no effect on growth at recommended doses compared with placebo 1
• Growth suppression has been reported only with:
  • Long-term use of beclomethasone dipropionate that exceeded recommended doses 1
  • Administration to toddlers 1
• Newer agents (mometasone furoate and fluticasone propionate) may have less potential for systemic effects during prolonged use in children 4

Proper Administration to Minimize Side Effects

• Direct sprays away from the nasal septum to prevent repetitive direct application 1
• The nasal septum should be periodically examined to ensure there are no mucosal erosions 1
• Unlike topical decongestants, intranasal corticosteroids do not cause rebound congestion (rhinitis medicamentosa) and can be used for extended periods 5, 2

When to Stop Use and Seek Medical Attention

• If severe or frequent nosebleeds occur 2, 6
• If a constant whistling sound develops (may indicate septal damage) 2, 6
• If symptoms do not improve within 7 days or new symptoms develop 2, 6
• If the user has or comes into contact with someone who has chickenpox, measles, or tuberculosis 2, 6
• If an allergic reaction occurs (sudden swelling of face or tongue, rash, wheezing, or feeling faint) 2
• If new changes to vision develop after starting the medication 2, 6

Advantages Over Other Allergic Rhinitis Treatments

• Unlike first-generation antihistamines, intranasal corticosteroids do not cause drowsiness 2, 7
• Unlike oral decongestants, they do not cause insomnia, loss of appetite, irritability, or palpitations 1
• Unlike topical decongestants, they can be used long-term without risk of rhinitis medicamentosa 1, 5

Intranasal corticosteroids remain the most effective medication class for controlling all symptoms of allergic rhinitis, with a favorable safety profile when used as directed 1, 5, 3.