What is the maximum duration for using intranasal steroids (INS)?

Duration of Intranasal Steroid Use

Intranasal corticosteroids can be used safely for long-term, continuous daily use without a specific maximum duration, as long-term use has not been shown to cause systemic adverse effects or require routine discontinuation. 1

Initial Treatment Duration

• Minimum treatment duration should be 8 to 12 weeks to allow adequate time for symptomatic relief and to properly assess therapeutic benefit 1
• Full benefit may not be evident for 2 weeks after initiation, so patients must be counseled to continue therapy during this period 1
• For seasonal allergic rhinitis with predictable patterns, initiation before symptom onset and continuation throughout the entire allergen exposure period is most effective 2

Long-Term Safety Profile

The evidence strongly supports indefinite use when clinically indicated:

• Long-term use does not affect systemic cortisol levels or hypothalamic-pituitary-adrenal axis function 1
• No increased risk of lens opacity, elevated intraocular pressure, glaucoma, or other ocular symptoms with prolonged use 1
• Studies in adults and children show no clinically significant systemic side effects when used at recommended doses 1, 3
• Newer generation intranasal steroids (fluticasone furoate, mometasone furoate) can be used safely without increased risk of IOP elevation even with prolonged use 4

Pediatric Considerations

• Intranasal corticosteroids should be used at the lowest effective dose in children but can be continued long-term when needed 2
• Fluticasone propionate, mometasone furoate, and budesonide show no effect on growth at recommended doses compared to placebo, even at up to twice the recommended doses 1, 3
• Growth suppression has only been reported with beclomethasone dipropionate at doses exceeding recommendations 1
• Nasal mucosa biopsies from patients treated continuously for 1 to 5 years showed no evidence of atrophy 1

Monitoring Requirements

While long-term use is safe, specific monitoring is recommended:

• Periodically examine the nasal septum to detect mucosal erosions that may precede septal perforation (rare complication) 1, 2
• Patients on long-term therapy should consult their physicians to determine if regular ophthalmic monitoring is appropriate 1
• Proper administration technique (directing spray away from septum) minimizes local side effects like epistaxis and nasal irritation 1

When to Reassess Treatment

• If no improvement after 3-4 weeks of appropriate therapy, refer to specialist for further evaluation 3
• For chronic rhinosinusitis, if no improvement after 3 months, consider adding short course of oral corticosteroids or proceeding to CT imaging and surgical evaluation 2
• Treatment decisions should be individualized based on degree of symptom relief, but there is no predetermined maximum duration requiring discontinuation 1

Critical Distinction from Topical Decongestants

Unlike topical decongestants, intranasal corticosteroids do not cause rhinitis medicamentosa and are safe for continuous daily use 2, 3

• Topical decongestants must be limited to maximum 3 days due to rebound congestion risk 1, 2, 3
• Intranasal corticosteroids can and should be continued as long as patients are exposed to allergens or have ongoing inflammation 3
• Continuous daily use is more effective than as-needed use for all rhinological conditions 3

Common Pitfalls to Avoid

• Do not discontinue intranasal corticosteroids when symptoms improve - continued use maintains symptom control 3
• Patients must understand this is maintenance therapy, not rescue therapy like decongestants 1
• Ensure proper administration technique is taught, as improper use increases local side effects and reduces efficacy 1
• Most common adverse event with long-term use is epistaxis (generally mild), occurring in 4-8% over short periods and up to 20% over one year 1, 2, 5