Are nasal steroids, such as budesonide (corticosteroid) and fluticasone (corticosteroid), safe to use during pregnancy?

Nasal Steroids During Pregnancy

Direct Recommendation

Modern intranasal corticosteroids, including budesonide and fluticasone, are safe to use during pregnancy at recommended doses and should be continued or initiated when clinically indicated for allergic rhinitis or chronic rhinosinusitis. 1, 2

Safety Profile and Evidence

Overall Safety Data

• A meta-analysis demonstrates that intranasal corticosteroids during pregnancy do not increase the risk of major malformations, preterm delivery, low birth weight, or pregnancy-induced hypertension. 1, 2

• Although most intranasal corticosteroids carry an FDA Pregnancy Category C rating, gestational risk has not been confirmed in human observational data. 1

• Large population-based studies from Swedish registries (covering ~99% of pregnancies) showed no increased risk of congenital malformations with inhaled budesonide use in early pregnancy—the malformation rate was 3.8% versus 3.5% in the general population. 3

• The number of orofacial clefts after budesonide exposure was similar to expected rates in the normal population (4 children versus 3.3 expected). 3

Specific Agent Recommendations

If initiating intranasal corticosteroid therapy during pregnancy, budesonide is the preferred choice because it has:

• FDA Pregnancy Category B classification 1, 4
• The most extensive human safety data compared to other intranasal corticosteroids 1, 2, 5
• Negligible systemic absorption with intranasal administration 1

If a patient is already well-controlled on another intranasal corticosteroid before pregnancy (fluticasone propionate, mometasone, or beclomethasone), it is reasonable to continue that same agent rather than switching, as no substantial difference in efficacy and safety has been demonstrated among available intranasal corticosteroids. 1, 2

Agents with Adequate Safety Data

The following intranasal corticosteroids have reassuring safety profiles during pregnancy:

• Budesonide (most data, Category B) 1, 2, 5, 6
• Fluticasone propionate (adequate accumulated data) 1, 6
• Fluticasone furoate (no significant association with congenital malformations) 6
• Mometasone (considered safe at recommended doses) 1, 2, 6
• Beclomethasone (more accumulated data than some newer agents) 1, 7

Agent to Avoid

• Intranasal triamcinolone has been associated with respiratory tract defects in offspring and should be avoided during pregnancy. 6

Dosing Principles

• Administer intranasal corticosteroids at the lowest effective dose throughout pregnancy. 1, 2

• Use recommended therapeutic doses only—do not exceed standard dosing. 1, 6

Clinical Context and Indications

When to Use Nasal Steroids in Pregnancy

• Continue nasal corticosteroids for chronic rhinitis and chronic rhinosinusitis maintenance during pregnancy. 1, 8

• Modern nasal corticosteroids (budesonide, fluticasone, mometasone) should be continued because they are safe for chronic rhinosinusitis maintenance at recommended doses. 1

• Intranasal corticosteroids may be used during pregnancy because of their favorable safety and efficacy profile. 1

What NOT to Use

• Off-label use of budesonide irrigations or corticosteroid nasal drops is not recommended during pregnancy. 1

• Oral decongestants should be strictly avoided during the first trimester due to potential teratogenicity. 4

• Oral corticosteroids should be avoided during the first trimester (greatest risk of teratogenicity), though short bursts may be considered after the first trimester for severe conditions, especially asthma exacerbations. 1, 8

Maternal Monitoring Considerations

While intranasal corticosteroids have negligible systemic absorption, be aware of potential maternal effects with any corticosteroid use:

• Monitor for hyperglycemia and screen for gestational diabetes if using any corticosteroid therapy, particularly with prolonged use. 2, 8

• Watch for hypertension and increased preeclampsia risk with prolonged corticosteroid exposure. 2, 8

• These risks are primarily associated with systemic (oral) corticosteroids rather than intranasal formulations, but awareness is prudent. 8

Common Pitfalls to Avoid

• Do not withhold necessary intranasal corticosteroid therapy due to unfounded pregnancy concerns—untreated rhinitis can worsen asthma control, which poses greater maternal and fetal risks than the medication itself. 1

• Do not switch a well-controlled patient from their current intranasal corticosteroid to budesonide unless there is a specific concern—continuity of effective therapy is reasonable. 1, 2

• Do not confuse intranasal corticosteroids with oral corticosteroids—the safety profiles differ significantly due to minimal systemic absorption with nasal administration. 1

• Avoid the misconception that all medications should be stopped in pregnancy—suboptimal treatment of maternal conditions may be more harmful to the fetus than appropriate medication use. 5