What intranasal corticosteroid (INCS) to use for sinus congestion?

Intranasal Corticosteroid Selection for Sinus Congestion

For sinus congestion, use mometasone furoate 200 mcg twice daily or fluticasone propionate 200 mcg once daily, as both are equally effective intranasal corticosteroids with the strongest evidence base for symptom relief. 1

Evidence-Based Recommendations

First-Line Options

The European Position Paper on Rhinosinusitis (EPOS 2020) provides the highest quality evidence for intranasal corticosteroid selection:

• Mometasone furoate nasal spray (MFNS) 200 mcg twice daily demonstrated significant reduction in total symptom scores and nasal congestion compared to placebo in multiple large trials 1
• Fluticasone propionate nasal spray (FPNS) 200 mcg once daily showed comparable efficacy with significant improvement in congestion, facial pain, and overall symptom scores 1

Both agents are FDA-approved and available as generic formulations, making them accessible and cost-effective options 2, 3

Comparative Efficacy

All intranasal corticosteroids are similarly effective when used at equipotent doses - the choice between specific agents is less important than ensuring proper administration and adherence 1. Key evidence includes:

• Studies directly comparing MFNS and FPNS found no significant differences in efficacy for nasal congestion relief 1
• Both agents significantly reduced major symptom scores including congestion, with effect sizes favoring active treatment over placebo (p<0.05) 1
• FPNS demonstrated superiority over oral antihistamines (loratadine) for nasal obstruction, making intranasal corticosteroids the preferred first-line therapy 4

Dosing Considerations

For adults with moderate-to-severe congestion:

• Start with higher doses: MFNS 200 mcg twice daily or FPNS 200 mcg once daily 1
• Once symptoms controlled, may reduce to maintenance dosing (FPNS 100 mcg once daily) 2
• Maximum duration without physician consultation: 6 months of continuous use 2

For children ages 4-11 years:

• Use lower doses: FPNS 100 mcg once daily (as effective as 200 mcg in pediatric trials) 5
• Maximum duration: 2 months per year before consulting physician due to potential growth effects 2, 5

Clinical Advantages of Intranasal Corticosteroids

Superior Symptom Control

Intranasal corticosteroids are the most effective medication class for controlling all four major symptoms of rhinitis, including nasal congestion 1. They provide:

• Greater reduction in congestion compared to oral antihistamines alone 1, 4
• Relief of sinus pain and pressure in addition to congestion 6
• Benefit for both allergic and some forms of nonallergic rhinitis 1

Safety Profile

When used at recommended doses, intranasal corticosteroids have minimal systemic effects 7:

• No clinically significant effects on hypothalamic-pituitary-adrenal axis 7, 8, 5
• No effects on ocular pressure or bone density in adults 7
• Local side effects (nasal irritation, bleeding) occur in <5% of patients and can be minimized with proper technique 7
• Unlike oral decongestants, no risk of insomnia, palpitations, or blood pressure elevation 1, 7
• Unlike topical decongestants, no risk of rhinitis medicamentosa with long-term use 1, 7

Critical Administration Technique

Proper spray technique is essential for efficacy and safety:

• Direct spray away from nasal septum toward lateral nasal wall to prevent septal irritation and rare perforation 1, 7
• Prime pump before first use and after periods of non-use 2
• Use consistently once or twice daily rather than as-needed for optimal effect 1
• Full therapeutic benefit may take 4-7 days, though some improvement occurs within 3 days 1, 8

Common Pitfalls to Avoid

Do not expect immediate decongestant effect - unlike topical decongestants that work within minutes, intranasal corticosteroids require several days for maximal benefit 1. Consider short-term (3-day) topical decongestant to facilitate initial delivery if severe congestion present 1

Do not discontinue prematurely - patients often stop treatment when symptoms improve, but continued use is necessary for sustained relief during allergen exposure 2

Do not use systemic corticosteroids as first-line - intranasal corticosteroids should always be tried before considering oral steroids for rhinitis 1

Special Clinical Scenarios

Acute Post-Viral Rhinosinusitis

For sinus congestion in the context of acute rhinosinusitis (symptoms 5-12 days):

• MFNS 200 mcg twice daily or FPNS 200 mcg once daily reduces symptom duration and severity 1
• Effect size is modest but statistically significant compared to placebo 1
• Can be used with or without antibiotics (though antibiotics not recommended for post-viral disease) 1

Chronic Rhinosinusitis

For persistent congestion beyond 12 weeks:

• Intranasal corticosteroids remain first-line medical therapy 1
• Higher doses (FPNS 400 mcg twice daily) may be considered for refractory cases 9
• Specialist consultation warranted if no improvement after appropriate trial 1