Intranasal Steroids in Rhinological Conditions
Intranasal corticosteroids are the most effective first-line medication class for controlling symptoms across multiple rhinological conditions, including allergic rhinitis, non-allergic rhinitis, chronic rhinosinusitis, and nasal polyposis. 1, 2
Allergic Rhinitis
Primary Treatment Recommendation
Intranasal corticosteroids should be the initial monotherapy for moderate to severe allergic rhinitis, as they provide superior symptom control compared to oral antihistamines for all nasal symptoms including congestion, rhinorrhea, sneezing, and nasal itching. 1, 3
These agents relieve both early and late-phase allergic responses, with studies demonstrating almost complete prevention of late-phase symptoms when used continuously. 4, 5
The therapeutic effect begins within 3-12 hours, but several days of continuous daily use are required to achieve full effectiveness, so patients must understand this is not an immediate-relief medication. 2
Combination Therapy Considerations
For patients aged 12 years or older with moderate to severe seasonal allergic rhinitis, the combination of intranasal corticosteroid plus intranasal antihistamine (such as fluticasone propionate 200 mcg plus azelastine 548 mcg as a single spray) may be recommended for initial treatment, providing greater symptom reduction than either agent alone. 1
The absolute symptom improvements with combination therapy represent greater than 40% relative improvement compared to monotherapy with either agent alone. 1
However, this combination approach is a weak recommendation, and monotherapy with intranasal corticosteroid remains highly effective for most patients. 1
Comparison to Other Agents
Intranasal corticosteroids are significantly more effective than montelukast (a leukotriene receptor antagonist) for nasal symptom reduction, with clinically meaningful differences in symptom scores. 1
While leukotriene receptor antagonists may be considered in patients who cannot tolerate intranasal steroids or those with concurrent mild persistent asthma, they should not be preferred over intranasal corticosteroids for rhinitis control. 1
Non-Allergic Rhinitis
Intranasal corticosteroids are effective for non-allergic rhinitis, including vasomotor rhinitis and other non-allergic inflammatory conditions. 1, 2
For rhinorrhea-predominant non-allergic rhinitis, adding intranasal ipratropium bromide to intranasal corticosteroids provides additive benefit specifically for controlling rhinorrhea, though ipratropium has no effect on other symptoms like congestion. 1
Chronic Rhinosinusitis
Role as Adjunctive Therapy
Intranasal corticosteroids should be used as adjunctive therapy to antibiotics in acute bacterial sinusitis and as primary anti-inflammatory therapy in chronic rhinosinusitis, providing modestly beneficial effects when added to antibiotic treatment. 6
Although intranasal corticosteroids may not directly reach the interior of paranasal sinuses, their anti-inflammatory effects and documented efficacy in relieving nasal congestion make them reasonable adjunctive therapy. 6
Combination with Saline Irrigation
- Intranasal corticosteroids should be used in conjunction with saline nasal irrigation for enhanced effectiveness in chronic sinusitis. 6
Post-Surgical Management
- Intranasal corticosteroids must be continued postoperatively in patients who undergo endoscopic sinus surgery to prevent recurrence and maintain symptom control. 2, 6
Nasal Polyposis
First-Line Medical Management
Intranasal corticosteroids are effective in improving sense of smell and reducing nasal congestion in nasal polyposis, with twice-daily dosing superior to once-daily dosing. 1
The treatment of nasal polyps is challenging, particularly in patients with concurrent asthma and aspirin-exacerbated respiratory disease (AERD), who have worse outcomes overall. 1
Severe Polyposis Protocol
For severe nasal polyposis, initiate a short course of oral prednisone (5-7 days) to reduce symptoms and polyp size, then maintain control with subsequent daily intranasal corticosteroids. 1, 6
This approach provides rapid initial improvement followed by sustained benefit from topical therapy. 1
Adjunctive Leukotriene Modifiers
Leukotriene modifiers (montelukast, zafirlukast, zileuton) as add-on therapy to intranasal corticosteroids have shown subjective improvement in nasal polyp symptoms. 1
After sphenoidal ethmoidectomy, montelukast showed equivalent recurrence rates and rescue medication requirements compared to nasal beclomethasone. 1
Safety Profile and Administration
Systemic Safety
- When used at recommended doses, intranasal corticosteroids are not associated with clinically significant systemic side effects, including no consistent effects on the hypothalamic-pituitary-adrenal axis, ocular pressure, cataract formation, or bone density in adults. 1, 7, 2
Pediatric Growth Considerations
Fluticasone propionate, mometasone furoate, and budesonide show no effect on growth at recommended doses in children, even at up to twice the recommended doses. 1, 7
Growth suppression has been reported only with long-term use of beclomethasone dipropionate exceeding recommended doses or when administered to toddlers. 1, 7
Children aged 4-11 years should use 1 spray per nostril once daily for up to 2 months per year before checking with a physician, while those 12 years and older may use up to 2 sprays per nostril daily for up to 6 months before reassessment. 8
Local Side Effects and Prevention
Local side effects (nasal irritation, bleeding, septal perforation) are rare and can be avoided with proper administration technique. 1, 7
Patients must be instructed to direct sprays away from the nasal septum to prevent repetitive direct application that could cause mucosal erosion. 7, 2, 6
The nasal septum should be periodically examined to ensure no mucosal erosions are present. 7, 2, 6
Preparations containing propylene glycol and benzalkonium chloride may cause local irritation or ciliary dysfunction. 1, 7
Critical Practice Points
Continuous vs. As-Needed Use
Continuous daily use is more effective than as-needed use for all rhinological conditions. 2
Patients should continue intranasal corticosteroids daily as long as they are exposed to allergens or have ongoing inflammation, not just when symptoms are present. 2, 8
Common Pitfalls to Avoid
Do not use topical decongestants (such as oxymetazoline) for more than 3 days, as they cause rhinitis medicamentosa; intranasal corticosteroids do not have this limitation and can be used long-term. 7, 6
Do not discontinue intranasal corticosteroids when symptoms improve—continued use maintains symptom control. 8
Failure to use proper spray technique reduces efficacy and increases side effects; ensure patients understand correct administration with the nozzle directed laterally away from the septum. 6