Prednisone Course for Allergic Rhinitis
A short course of oral prednisone (5-7 days) may be used only for very severe or intractable allergic rhinitis symptoms that are unresponsive to intranasal corticosteroids and other standard therapies, but intranasal corticosteroids should always be tried first and oral corticosteroids should not be used for routine management. 1, 2
When to Consider Oral Prednisone
- Oral prednisone is reserved exclusively for patients with extremely severe nasal symptoms that significantly impact quality of life and have failed to respond to intranasal corticosteroids, antihistamines, and other standard treatments 2
- A 5-7 day course is the recommended duration when oral corticosteroids are deemed necessary 1
- Oral corticosteroids should not be administered as therapy for chronic rhinitis except in rare cases of severe intractable symptoms 3, 2
Critical Contraindications and Warnings
- Single administration of parenteral (injectable) corticosteroids is discouraged, and recurrent administration of parenteral corticosteroids is absolutely contraindicated due to greater potential for long-term side effects 1, 2
- Potential for adrenal suppression must be considered in any patient receiving oral corticosteroids 2
- Avoid abrupt withdrawal of therapy after use 4
Dosing Considerations (When Indicated)
- Initial dosage may vary from 5-60 mg per day depending on disease severity, though dosage requirements must be individualized 4
- Administer in the morning prior to 9 AM to minimize suppression of the hypothalamic-pituitary-adrenal axis, as maximal adrenal cortex activity occurs between 2 AM and 8 AM 4
- Take with food or milk to reduce gastric irritation 4
- When discontinuing after long-term use, withdraw gradually rather than abruptly 4
Preferred First-Line Treatment Algorithm
Before ever considering oral prednisone, the following stepwise approach should be exhausted:
Step 1: Intranasal corticosteroids (fluticasone, mometasone, budesonide, triamcinolone) are the most effective medication class for controlling all four major symptoms of allergic rhinitis (sneezing, itching, rhinorrhea, nasal congestion) and should be the initial treatment 1, 3, 2, 5, 6
Step 2: For moderate to severe seasonal allergic rhinitis, combine intranasal corticosteroid with intranasal antihistamine (azelastine, olopatadine) for greater efficacy than either alone 3, 5
Step 3: Add second-generation oral antihistamines (cetirizine, fexofenadine, loratadine, desloratadine) if needed 3, 2, 5
Step 4: Consider leukotriene receptor antagonists (montelukast), though these are generally less effective than intranasal corticosteroids 3, 2
Step 5: Only after failure of the above treatments should a short 5-7 day course of oral prednisone be considered 1, 2
Common Pitfalls to Avoid
- Using oral corticosteroids before adequately trialing intranasal corticosteroids at appropriate doses for sufficient duration 1, 3
- Administering injectable depot corticosteroids, which carry significantly higher risk of long-term adverse effects 1, 2
- Prescribing repeated courses of oral corticosteroids for chronic management 3, 2
- Failing to counsel patients on proper intranasal corticosteroid technique (spray should be directed away from nasal septum to prevent mucosal erosions) 1, 3